Download Scapular winging (R)

Scapular winging
Classification
A.
Primary
a. Neurological
i. Accessory nerve
ii. Long thoracic nerve
iii. Dorsal scapular nerve
b. Osseous
i. Osteochondromas
ii. Malunion
c. Soft tissue
i. Contractures
ii. Muscle avulsion
iii. Muscle agenesis
iv. Bursitis
B.
Secondary to shoulder pathology
C.
Voluntary
Evaluation
Observe first from behind with arms at side.
Look for a static deformity, atrophy of the
trapezius,
medial
border
of
scapula
(rhomboids).
Observe during forward elevation, for
scapulothoracic
rhythm
and
dynamic
deformity.
Palpate for crepitus.
Then test for winging during resisted motion.
Accessory palsy
The spinal accessory nerve emerges from the
sternocleidomastoid muscle to run across the
posterior triangle and enter the trapezius (the
cervical plexus nerves enter the posterior
triangle behind SCM). It contains segments
from C1-5. The trapezius is also innervated by
cervical plexus nerves C3-4 which supply
proprioception and occasionally some motor
function.
Injury can be caused by blunt trauma, traction
or penetrating trauma. Surgical misadventure
can occur during biopsy of nodes in the
posterior cervical triangle.
After injury the patient’s shoulder is depressed
and the scapula is translated laterally with the
inferior angle rotated laterally.
The patient tries to compensate for this by
increased use of the rhomboids and levator
scapulae, which can be lead to painful spasm.
On examination there is trapezius wasting,
inability to shrug and weakness on elevation
and abduction of the arm. The diagnosis can
be confirmed by EMG studies.
Initial treatment consists of physiotherapy to
maintain a full range of shoulder movement,
thus preventing a frozen shoulder.
Surgical treatment, in the event of no recovery,
can be grouped into three options:
1.
2.
3.
Scapulothoracic fusion
Static fascial slings
Dynamic transfers
Scapulothoracic fusions lead to a drastic
decrease in shoulder ROM, and fascial slings
stretch out over a period of a couple of years.
Thus, dynamic transfers are preferred.
The preferred procedure is the Eden-Lange
transfer (remember as the NZ transfer), which
consists of transferring the insertions of the
levator and rhomboids with attached bone
blocks laterally (By around 5cm). Bigliani
reported good or excellent results in 87% of the
23 patients in his series.
Serratus anterior winging
The long thoracic nerve (C5-7) originates from
the roots of the brachial plexus, and runs down
the medial wall of the axilla, anterior to the mid
axillary line to innervate serratus anterior.
Damage is usually due to blunt trauma or
stretching, and has been reported in almost all
sports. Brachial neuritis also commonly affects
this nerve. Prolonged bed rest has been
reported to trigger dysfunction of the nerve.
When the LTN is injured, the scapula assumes
a position of superior elevation and the inferior
angle rotates medially.
Patients complain of pain from other muscles
which are in spasm from trying to compensate
for the actions of serratus.
Pushing against a wall and attempted elevation
above the head magnify symptoms.
Initial treatment consists of ROM exercises.
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Most injuries of the LTN recover within a year.
If there is no recovery and symptoms warrant
it a muscle transfer can be performed. The one
most commonly employed is the MarmorBechtol transfer, which uses the sternocostal
head of pectoralis major, prolonged by a 7 inch
tube of fascia lata, passed through a foramen
created at the inferior angle of the scapula.
This operation has success rates of 70-90% in
the literature.
Rhomboid major and minor winging
These muscles are innervated by the dorsal
scapular nerve (C5) which runs deep to levator,
on serratus posterior superior.
Palsy of these muscles is a rare cause of
winging.
The clinical picture is similar to that seen in
trapezius palsy, with the shoulder slightly
depressed, the scapula laterally translated and
the inferior angle rotated laterally.
Treatment is nonsurgical with trapezius
strengthening exercises in most cases.
Occasionally a fascial sling operation is used to
connect the lower border of the scapular to the
spinal muscles and latissimus dorsi.
Secondary winging
Contractural winging
Contractures around the glenohumeral joint
produce a secondary winging as the patient
attempts to place the arm in the desired
position.
One example is seen in obstetric brachial
plexus palsy when the arm can assume an
adducted and internally rotated posture.
When attempting to abduct and externally
rotate the arm, the superior corner of the
scapula can project away from the chest wall at
the upper margin of the trapezius, producing
the “scapular sign of Putti”.
Contractural winging can also occur with
deltoid fibrosis, which may occur secondary to
multiple deltoid injections.
Glenohumeral pathology
Secondary scapular winging may occur with
frozen shoulder, instability and impingement.
Patients with painful shoulders may reflexively
limit glenohumeral motion and attempt to
compensate with increased scapulothoracic
motion. This fatigues the periscapular muscles,
and weakening of the muscles leads to fatigue.
Osseous problems
Osteochondromas are the commonest tumours
of the scapula, and if found on the deep surface
of the scapula may produce a fixed winging
and scapular crepitus.
EMG findings are normal; XR and CT scans
demonstrate the abnormality.
Treatment is resection of the abnormal bone.
Muscular problems
Agenesis of various parascapular muscles may
occur e.g. in Poland syndrome, but is usually
not a functional problem.
Avulsion of the serratus has been reported, and
surgical reattachment is indicated.
Bursal origin
Rarely the scapulothoracic articulation can be
affected by a bursitis. This causes a painful
impairment of scapulothoracic rhythm, and can
be addressed with NSAIDs or surgical
bursectomy.
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