Winging of the Scapula


Article Author:
Sharon Park


Article Editor:
Jordan Ramage


Editors In Chief:
Susan Jeno
Renato Vilella
Sarah Fabiano


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
9/20/2019 7:16:20 PM

Introduction

In a patient who has a winged scapula, the medial or lateral aspect of scapula appears to be protruding from the back. As the name of the condition implies, it can create a winged appearance. This abnormal position of the scapula can lead to many physical functional disabilities such as pain, decreased strength, and range of motion disruptions. The ranges of motion that are typically abnormal are abduction and flexion of the affected upper extremity.

Etiology

The most common etiology of a winged scapula is usually due to damage or impaired innervation to the serratus anterior muscle. The nerve that innervates this muscle is the long thoracic nerve. Sometimes, this nerve can be damaged or impinged, leading to malfunction of the serratus anterior muscle. Some patients may also complain of an inability to raise the affected arm above their head. This dysfunction results in the medial border of the scapula giving a winged-like appearance. The reason the impingement or damage of this nerve leads to the winged appearance is that the serratus anterior muscle attaches to the medial aspect of the scapula and hold it against the posterior rib cage. Less commonly, the scapula can wing laterally due to damage to the trapezius or rhomboid muscles, which are innervated by the spinal accessory nerves and dorsal scapular nerve, respectively. The scapula will move laterally due to unopposed muscle strength attributed to the trapezium or rhomboid paralysis or weakness; this occurs because the function of the trapezius muscle is to elevate, retract and rotate the scapula.

Epidemiology

One patient population that is noted to present with scapular winging are women who have undergone chest surgery, as in the case of breast cancer patients who have undergone a radical mastectomy.[1] During the procedure, the long thoracic nerve can suffer damage due to the nerve's proximity to the other involved structures. Specifically, mastectomies that involve resection of the axillary lymph nodes are at higher risk as the long thoracic nerve lies near the axillae and is at risk of being damaged during the lymph node resection.

Another relatively common cause is trapezius muscle paralysis which may occur during neck dissection leading to injury to the spinal accessory nerve. Paralysis of the serratus anterior muscle has been well documented in many sporting events and during certain occupations (car mechanics, carpenters, laborers, etc.)

Pathophysiology

A primary winged scapula is due to an injury to the nerve, changes in the bone of the scapula, or because of periscapular soft tissue abnormalities. Remember, the serratus anterior muscle attaches to the medial aspect of the scapula and attaches it to the rib cage. If it loses innervation by the long thoracic nerve, then it can no longer provide stability to the scapula which leads to medial scapular winging. Again, lateral scapular winging is due to damage to the trapezius or rhomboid muscles. The scapula will move laterally due to unopposed muscle strength attributed to the trapezium or rhomboid paralysis or weakness. The trapezius is solely innervated by the spinal accessory nerve which crosses the posterior cervical triangle superficially where it can be damaged during occipital lymph node biopsy. The rhomboid muscles are innervated by the dorsal scapular nerve.

A secondary winged scapula occurs due to glenohumeral and subacromial conditions and should resolve after addressing the pathological condition causing the winging. A winged scapula caused by trauma is uncommon.

Irrespective of the cause of winging of the scapula, the condition is disabling and can affect the function of the ipsilateral shoulder and arm. In addition, winging of the scapula also leads to significant cosmetic deformity.

History and Physical

Classically, patients present and pain and weakness related to movements involving the scapula. The classic findings are a difficulty with elevating the arm above the head and lifting objects.[2] Due to multiple different etiologies of a winged scapula, the histories gathered from presenting patients may differ. In one study, the pain was not associated with every case whereas fatigue was a significant characteristic.[3] On physical exam, providers should be able to recognize deformation of the back due to a protrusion of the medial portion of the scapula which is not anchored against the rib cage. Due to this muscle pathology, the movement involving upward rotation, abduction, and there is a limitation of elevation of the scapula due to weakness or pain. One clinical test that providers can use to assess patients is to have the patient face a wall and stand with the affected arm out in front of their body, parallel to the floor. The patient should then be instructed to push against the wall with the palm of their hand on the affected side. A protrusion of the medial portion of the scapula should then be apparent.

In most cases, winging of the scapula is not seen immediately but may take weeks to become obvious.

Evaluation

In most cases, the practitioner can evaluate scapular winging with a proper history and physical examination. Electrodiagnostic testing can help to establish the underlying neuromuscular pathology. Furthermore, neuromuscular ultrasound can be used not only to establish the muscular pathology, but also the neurologic causes of the muscle pathology. Ultrasound can be used to provide for a painless and radiation-free method of imaging that can be used to evaluate for winging of the scapula.[4] More specific methods for scapular winging evaluation include electromyography and nerve conduction studies. These studies are sensitive and specific in determining the exact nerve involved in the pathology as well as the location of the damage by recording the electrical activity produced by muscles and evaluating how fast an impulse moves through a specific nerve.[5] The benefit of these measures of evaluation is that early diagnosis and early treatment can help prevent more severe shoulder dysfunction.

Treatment / Management

Management of winged scapula is primarily achieved utilizing conservative measures such as pain control and physical therapy. Physical therapy helps to preserve the range of motion of the affected extremity as well as prevent possible complications such as adhesive capsulitis. Most people who have scapular winging and receive early treatment can achieve full recovery. In many cases, patients learn to compensate for the serratus anterior palsy by utilizing the trapezius muscle. With conservative therapy, the recovery may take months or years. If no recovery has occurred within this time, it is unlikely that the patient will recover.

Surgical procedures to manage scapular winging include scapulothoracic arthrodesis and scapulopexy without arthrodesis. In these procedures, the scapula is fused to the third to sixth ribs to prevent potential dyskinesis and winging. Muscle transfer is also an option in some patients where the sternal head of the pectoralis major is transferred to the inferior angle of the scapula. However, this procedure is not recommended for athletes or individuals involved in heavy labor.

Unlike serratus anterior muscle palsy which can recovery with conservative management, paralysis of the trapezius rarely improves with such treatment. While pain may improve with exercise, the neck asymmetry does not. In many cases, exploration and nerve repair yields better results. In young healthy individuals, lateral transfer of the levator scapula and rhomboid muscles to the scapula has proven durable and effective. Finally, some patients may benefit from botulinum toxin, but the therapy is temporary and prohibitively expensive in the long run.

Differential Diagnosis

Those presenting with signs and symptoms of scapular winging can present similarly to other pathologies of the upper extremities and scapula. The pain and associated weakness and discomfort of the upper extremity are seen in other diagnoses as well [5]. Some presentations can appear similar to rotator cuff disorders due to the limited motion and weakness with the associated arm. Glenohumeral instability is also a differential diagnosis as the patient may report instability of the shoulder. When the diagnosis is scapular winging, however, it is the instability of the scapula rather than the glenohumeral joint. Peripheral nerve disorders, cervical spine disease could also mimic scapular winging and should be ruled out. Thoracic outlet syndrome and acromioclavicular disorders might also be included in the differential, likely because the presentation of associated pain and weakness with the affected anatomy can be similar.

Prognosis

Currently, no treatment method is considered to be the first line for resolution of scapular winging. As discussed prior, the recommended treatment for initial treatment is pain control and physical therapy.[3] If treatment is not initiated early on in the progression of the condition, patients can develop subsequent issues such as adhesive capsulitis (or frozen shoulder), subacromial impingement and other pathogenesis involving the brachial plexus.

Complications

Often, when scapular winging is present due to injury to the long thoracic nerve, other nerves, and structures near the anatomy can be affected as well. The long thoracic nerve, which is usually the nerve affected in this condition and leads to scapular winging, comes off of the brachial plexus, a network of nerves formed that initiates at the lower four cervical nerve roots and the first thoracic nerve root (C5 - T1). Damage to the brachial plexus can cause neurologic problems in the upper extremities and the trunk.[6] The long thoracic nerve is a peripheral nerve that comes off of the brachial plexus. Studies have shown that during surgery, destruction of trunks of the brachial plexus can be traumatic and loss of function is associated with atrophy of the corresponding muscles.

Deterrence and Patient Education

Like many other clinical pathologies, it is best to practice preventative measures to avoid scapular winging then to try to treat it once it has manifested in symptoms. The course of clinical cases in winging of the scapula can persist for up to two years. Most patients eventually recover, but at least one-fourth may have residual pain.[7]

Enhancing Healthcare Team Outcomes

An interprofessional team providing care to a patient with scapular winging is crucial in ensuring the best health outcome of the individual. The integrated postoperative care given to the patient can determine whether the patient will make a full recovery or to what extent. When the patient is under post-operative management, all members of the interprofessional team, including the nurse and physical therapist involved in patient care, should be made aware of scapular winging as a potential complication. Thus, nurses who work closely with the patients can monitor and know what to look for to alert the medical team. The pharmacist should educate the patient on pain management and the physical therapist should recommend the relevant exercises. That way, early and effective intervention can commence before the patient presents with symptoms. Prevention of this condition will clearly lead to the best outcomes in patient care. Interprofessional care can lead to the best success in the planning and evaluation of patient progress in recovery. Collaboration is guaranteed to result in better prognosis and outcome for the patient as an integrated approach to care.[8]


  • Image 9845 Not availableImage 9845 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

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Winging of the Scapula - Questions

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Winged scapula after a mastectomy is associated with which muscle?



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Medial scapula winging is caused by weakness of which of the following muscles?



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A student complains of pain in his shoulder after final exams. He denies any injuries and is not active in sports. His exam shows medial winging of the scapula and problems with abduction greater than 120 degrees. What is the most likely diagnosis?



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A 31-year old female patient presents to the clinician with discomfort in her shoulders, and neck. She also adds that she feels fatigued. On examination, there is drooping of the shoulder. She is diagnosed with bilateral winging of the scapula. Noted in her history is recent cosmetic surgery, specifically breast augmentation. The plastic surgeon performing the surgery bilaterally transected which of the following?



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Winging of the scapula is flexion of the scapula with the medial border of the scapula protruding posteriorly from the chest wall. Which is the nerve injured?



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A post-mastectomy patient presents to the primary care provider complaining of arm dysfunction. On physical exam, she cannot abduct her arm above her shoulder, and her scapula becomes more prominent when pushing against the wall. What nerve is most likely affected in this patient?



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A 68-year-old female comes to her physician complaining of a firm, “rock-hard” mass in her right breast. She has also noticed some dimpling of the skin surrounding the mass. She denies any pain, nipple discharge, or family history of similar symptoms. After appropriate diagnostic workup, she is subsequently diagnosed with invasive ductal carcinoma of the right breast. She is scheduled for a right mastectomy with axillary lymph node dissection. During her preoperative consult, the surgeon details possible risks associated with the procedure. One of the major risks includes the inability to do which of the following actions?



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A 42-year-old male presents to a family medicine clinic complaining of right medial shoulder pain and discomfort for the past two months. He works as an electrician and has sustained repeated minor trauma to his shoulder throughout the past three months. Vital signs are stable. He also has weakness with overhead motion. Physical exam shows that the patient has lateral winging of the scapula. What is the best diagnostic test to analyze the injured muscle?



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Winging of the Scapula - References

References

Pallara T,Del Buono R,Marangi GF,Langella M,Toto V,Persichetti P, Outcomes of traditional cosmetic abdominoplasty in a community setting: a retrospective analysis of 1008 patients. Plastic and reconstructive surgery. 2013 Nov     [PubMed]
Kauppila LI,Vastamäki M, Iatrogenic serratus anterior paralysis. Long-term outcome in 26 patients. Chest. 1996 Jan;     [PubMed]
LURJE A, Concerning surgical treatment of traumatic injury of the upper division of the brachial plexus (Erb's-type). Annals of surgery. 1948 Feb;     [PubMed]
Didesch JT,Tang P, Anatomy, Etiology, and Management of Scapular Winging. The Journal of hand surgery. 2018 Oct 3;     [PubMed]
Srikumaran U,Wells JH,Freehill MT,Tan EW,Higgins LD,Warner JJ, Scapular Winging: A Great Masquerader of Shoulder Disorders: AAOS Exhibit Selection. The Journal of bone and joint surgery. American volume. 2014 Jul 16;     [PubMed]
Krzesniak-Swinarska M,Caress JB,Cartwright MS, Neuromuscular ultrasound for evaluation of scapular winging. Muscle     [PubMed]
Lung K,Lui F, Anatomy, Thorax, Long Thoracic Nerve 2019 Jan;     [PubMed]
Saied GM,Kamel RM,Dessouki NR, The effect of mastectomy and radiotherapy for breast carcinoma on soft tissues of the shoulder and its joint mobility among Egyptian patients. Tanzania health research bulletin. 2007 May;     [PubMed]

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