Scapular Winging 907.4

 

synonyms:

Scapular Winging ICD-9

  • 907.4 (Late effect of injury to peripheral nerve of shoulder girdle and upper limb)

Scapular Winging Etiology / Epidemiology / Natural History

  • Most commonly associated with Parsonage-Turner Syndromecausing medial scapular winging.
  • May occur after lymph node biopsy.
    -Axillary node dissection = long thoracic nerve injury = serratus anterior dysfunction medial scapular winging.
    -Cervical node dissection = spinal accessory nerve injury = trapezius dysfunction = lateral scapular winging.

Scapular Winging Anatomy

  • Lateral scapular winging is related to spinal accessory nerve palsy causing Trapeziusdysfunction.
  • Medial scapular wingning is relaed to long thoracic nerve palsy causing serratus anterior dysfunction.
  • Rhomboids(dorsal scapular nerve) can also cause winging

Scapular Winging Clinical Evaluation

  • May cause disabling pain, decrease in active flexion, abduction and cosmetic deformity.
  • Can be clinically tested by having the pt push forward against a wall. Inferior pole will rotate medially in medial scapular winging. Rotates laterally in lateral scapular winging.

Scapular Winging Xray / Diagnositc Tests

  • EMG indicated to evaluate for denervation of affected muscles.

Scapular Winging Classification / Treatment

  • Medial scapular winging [MSALT]
    • inferior pole is rotated medially caused by dysfunction of the serratus anterior(long thoracic nerve).  
    • The upper division of the long thoracic nerve can be tested by having supine pt move their shoulder forward (protraction) separating it from the bed.  Strength can be graded by resisting the protraction with the examiners hand.  (Bertelli JA, JBJS AM 2005;87:993-998)
    • RX=physical therapy. Consider pectoralis major transfer if fails prolonged physical therapy.
  • Lateral scapular winging [LTSA]
    • inferior angle rotated laterally; caused by dysfunction of the Trapezius(spinal accessory nerve.
    • RX=physical therapy. Surgical treatment = lateral transfer of the Rhomboid major/minor and levator scapulae(Eden-Lange procedure) has become the procedure of choice for persistent trapezius winging (Romero J JBJS 2003;85Br:1141). Alternative=scapulothoracic fusion.  However fusion has a higher incidence of failure, a significant limitation of motion, and a larger surgical dissection
  • Rhomboids(dorsal scapular nerve) can also cause winging; rare.

Scapular Winging Associated Injuries / Differential Diagnosis

Scapular Winging Complications

  • Pneumothorax
  • Nonunion (patients treated with scapulothoracic fusion)
  • Rib stress fracture (patients treated with scapulothoracic fusion)
  • Pain
  • Painfull hardware ((patients treated with scapulothoracic fusion, most require hardware removal)

Scapular Winging Follow-up Care

  • 75% excellent, 17% fair, and 8% poor outcomes for Eden-Lange procedure (Romero J JBJS 2003;85Br:1141).
  • Scapulothoracic Fusion: Mean Active elevation preop=80°, post-op = 98°. 100% patient satisfaction and ability to perform daily activities. (Jeon IH, JSES 2005;14:400)

Scapular Winging Review References

  • Kuhn JE, Plancher KD, Hawkins RJ, Scapular Winging, JAAOS, Vol. 13, No.6, Nov/Dec 1995, pp 319-325
  • Fiddian NJ, CORR 1984;185:236

 

 

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