18: Scapular Winging

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CHAPTER 18

Scapular Winging

Peter M. McIntosh, MD

Synonyms

Scapulothoracic winging

Long thoracic nerve palsy

Spinal accessory nerve palsy

Scapula alata

Alar scapula

Rucksack palsy

ICD-9 Codes

352.4 Spinal accessory nerve disorder

353.3 Neuropathy long thoracic

353.5 Neuralgic amyotrophy

354.9 Mononeuritis of upper limb, unspecified

723.4 Cervical radiculopathy NOS

724.4 Long thoracic nerve entrapment

728.87 Muscle weakness NOS

ICD-10 Codes

G54.3 Neuropathy thoracic root

G54.5 Neuralgic amyotrophy

G56.9 Mononeuritis of unspecified upper limb

G56.91 Mononeuritis of right upper limb

G56.92 Mononeuritis of left upper limb

G58.9 Nerve entrapment, unspecified

M54.12 Cervical radiculopathy

M54.13 Cervicothoracic radiculopathy

M62.81 Muscle weakness, generalized

Definition

Scapular winging refers to prominence of the vertebral (medial) border of the scapula [1]. The inferomedial border can also be rotated or displaced away from the chest wall. This well-defined medical sign was first described by Velpeau [2] in 1837. It is associated with a wide array of medical conditions or injuries that typically result in dysfunction of the scapular stabilizers and rotators and, ultimately, glenohumeral and scapulothoracic biomechanics.

Fiddian and King [1] classified scapular winging as either static or dynamic after examination of 25 patients with 23 different causes of scapular winging. Static winging is attributable to a fixed deformity in the shoulder girdle, spine, or ribs; it is characteristically present with the patient’s arms at the sides. Dynamic winging is ascribed to a neuromuscular disorder; it is produced by active or resisted movement and is usually absent at rest. Scapular winging has also been classified anatomically according to whether the etiology of the lesion is related to nerve, muscle, bone, or joint disease (Table 18.1).

Table 18.1

Etiology of Scapular Winging

Characteristic Nerve Muscle Bone Joint
Site of lesion LTN [3]
SAN [4]
DSN
C5-C7 nerve root lesion
Brachial plexus lesion [5]
SA
T
R
Scapula
Clavicle
Spine
Ribs
GHJ
ACJ
Traumatic Acute, repetitive, or chronic compression of LTN, SAN, DSN
Trauma or traction injury to LTN, nerve roots, brachial plexus [6]
Whiplash injury [7]
Direct muscle injury to SA, T, R [4,8]
Avulsion of SA, T, R
RTC disease
Sports-related injury [810]
Nonunion
Malunion
Fractures of scapula [11,12], clavicle, acromion
Glenoid fracture
ACJ dislocation
Shoulder instability
Congenital, hereditary Cerebral palsy Congenital contracture of infraspinatus muscle
Agenesis of SA, T, R
Duchenne muscular dystrophy
FSHD [13]
Fibrous bands (deltoid)
Scoliosis
Craniocleidodysostosis
Ollier disease
Sprengel deformity
Arthrogryposis multiplex congenita
Congenital posterior shoulder dislocation
Degenerative, inflammatory SLE [14]
Neuritis
Amyotrophic brachial neuralgia [5]
Guillain-Barré syndrome [15]
Toxin exposure
Infection
Myositis
Abduction-internal rotation contracture from AVN of humeral head
Arthropathy
Iatrogenic Epidural or general anesthesia
Radical neck dissection [16]
Lymph node biopsy
First rib resection [17]
Radical mastectomy
Posterolateral thoracotomy incision
Axillary node dissection
Anterior spinal surgery [18]
Postinjection fibrosis (deltoid)
Division of SA
Miscellaneous Vaginal delivery [19]
Cervical syringomyelia [20]
Chiropractic manipulation
Electrocution [21]
Scapulothoracic bursa
Enchondroma
Subscapular osteochondroma [2224]
Exostoses of rib or scapula [25]
Voluntary posterior shoulder subluxation

t0010

From Fiddian NJ, King RJ. The winged scapula. Clin Orthop Relat Res 1984;185:228-236.

ACJ, acromioclavicular joint; AVN, avascular necrosis; DSN, dorsal scapular nerve; FSHD, facioscapulohumeral muscular dystrophy; GHJ, glenohumeral joint; LTN, long thoracic nerve; R, rhomboid muscles; RTC, rotator cuff muscles; SA, serratus anterior muscle; SAN, spinal accessory nerve; SLE, systemic lupus erythematosus; T, trapezius muscle.

The scapula is a triangular bone that is completely surrounded by muscles and attaches to the clavicle by the coracoclavicular ligaments and acromioclavicular joint capsule. Motion of the scapula along the chest wall occurs through the action of the muscle groups that originate or insert on the scapula and proximal humerus. These muscles include the rhomboids (major and minor), trapezius, serratus anterior, levator scapulae, and pectoralis minor. The rotator cuff and deltoid muscles are involved with glenohumeral motion. Innervation of these muscle groups includes all the roots of the brachial plexus and several peripheral nerves. Scapular winging may be caused by brachial plexus injuries but most often is related to a peripheral nerve injury (see Table 18.1).

Injury to the long thoracic and spinal accessory nerves with weakness of the serratus anterior and trapezius muscles, respectively, is most commonly associated with scapular winging. The serratus anterior muscle originates on the outer surface and superior border of the upper eight or nine ribs and inserts on the costal surface of the medial border of the scapula. It abducts the scapula and rotates it so the glenoid cavity faces cranially and holds the medial border of the scapula against the thorax.

The serratus anterior muscle is innervated by the pure motor long thoracic nerve, which arises from the ventral rami of the fifth, sixth, and seventh cervical roots. The nerve passes through the scalenus medius muscle, beneath the brachial plexus and the clavicle, and over the first rib. It then runs superficially along the lateral aspect of the chest wall to supply all the digitations of the serratus anterior muscles [26]. Because of its long and superficial course, the long thoracic nerve is susceptible to both traumatic and nontraumatic injuries (Fig. 18.1).

f18-01-9781455775774
FIGURE 18.1 Anterolateral view of the right upper chest and shoulder showing the course of the long thoracic nerve and innervation of the serratus anterior muscles. Note the superficial location of the long thoracic nerve. (From the Mayo Foundation for Medical Education and Research. © Mayo Foundation, 2007.)

The trapezius muscle consists of upper, middle, and lower fibers. The upper fibers originate from the external occipital protuberance, superior nuchal line, nuchal ligament, and spinous process of the seventh cervical vertebra and insert on the lateral clavicle and acromion. The middle fibers arise from the spinous process of the first through fifth thoracic vertebrae and insert on the superior lip of the scapular spine. The lower fibers originate from the spinous process of the sixth through twelfth thoracic vertebrae and insert on the apex of the scapular spine. They are innervated by the pure motor spinal accessory nerve (cranial nerve XI) and afferent fibers from the second through fourth cervical spinal nerves. The root fibers unite to form a common trunk that ascends to enter the intracranial cavity through the foramen magnum. It exits with the vagus nerve through the jugular foramen, pierces the sternocleidomastoid muscle, and descends obliquely across the floor of the posterior triangle of the neck to the trapezius muscle [26]. In the posterior triangle, the nerve lies superficially, covered only by fascia and skin, and is susceptible to injury. Cadaver studies have shown considerable variations in the course and distribution of the spinal accessory nerve in the posterior triangle and in the nerve’s relationship to the borders of the sternocleidomastoid and trapezius muscles [27]. The trapezius muscle adducts the scapula (middle fibers), rotates the glenoid cavity upward (upper and lower fibers), and elevates and depresses the scapula. Overall, the trapezius muscles maintain efficient shoulder function by both supporting the shoulder and stabilizing the scapulae (Fig. 18.2).

f18-02-9781455775774
FIGURE 18.2 Lateral view of the neck showing the course of the spinal accessory nerve and innervation of the trapezius muscle. (From the Mayo Foundation for Medical Education and Research. © Mayo Foundation, 2007.)

A rare cause of scapular winging is dorsal scapular nerve palsy. The dorsal scapular nerve is a pure motor nerve from the fifth cervical spinal nerve that supplies the rhomboid and levator scapulae muscles. It arises above the upper trunk of the brachial plexus and passes through the middle scalene muscle on its way to the levator scapulae and rhomboids. The rhomboids (major and minor) adduct and elevate the scapula and rotate it so the glenoid cavity faces caudally [26].

The levator scapulae muscles originate on the transverse process of the first four cervical vertebrae and insert on the medial borders of the scapulae between the superior angle and the root of the spine. They elevate the scapulae and assist in rotation of the glenoid cavity caudally. They are innervated by the dorsal scapular nerve (emanating from the fifth cervical spinal nerve) and the cervical plexus (emanating from the third and fourth cervical spinal nerves) (Fig. 18.3).

f18-03-9781455775774
FIGURE 18.3 View of upper back showing origins and insertions of rhomboid, levator scapulae, and trapezius muscles. (From the Mayo Foundation for Medical Education and Research. © Mayo Foundation, 2007.)

Symptoms

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