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Home , Winged scapula

Scapular Winging

John E. Kuhn, MD, Kevin D. Plancher, MD, and Richard J. Hawkins, MD, FRCS(C)

Abstract

Scapular winging, one of the more common scapulothoracic disorders, is caused (including surgical biopsy of lymph by a number of pathologic conditions. It can be classified as primary, secondary, nodes in the posterior cervical trian- or voluntary. Primary scapular winging may be due to neurologic , patho- gle3,4 and radical neck dissection).1 logic changes in the bone, or periscapular soft-tissue abnormalities. Secondary After injury to the spinal acces- scapular winging occurs as a result of glenohumeral and subacromial conditions sory nerve, the patient assumes a and resolves after the primary pathologic condition has been addressed. Volun- position with the depressed tary scapular winging is not caused by an anatomic disorder and may be associ- and the translated laterally ated with underlying psychological issues. The evaluation and treatment of these with the inferior angle rotated later- three types are discussed. ally (Fig. 1, A). Patients will attempt J Am Acad Orthop Surg 1995;3:319-325 to compensate for this deformity by using muscles of the , including the levator scapulae and the rhomboids. This strain may lead Scapular winging is one of the most smooth rhythm may become evident to disabling pain and muscle spasm.5 common abnormalities of the scapu- with dynamic testing. The examiner Patients can also have pain due to lothoracic articulation. Winging may must also look for winging with secondary effects of winging, includ- be described as primary, secondary, resisted motion, such as may occur ing adhesive capsulitis, subacromial or voluntary (Table 1). Primary when the patient pushes against a impingement, and radiculitis from scapular winging is caused by wall or resists forward elevation traction on the brachial plexus. On anatomic disorders that directly affect with the arms at 30, 90, and 150 examination, patients will have the scapulothoracic articulation. Sec- degrees. Static, dynamic, or resisted wasting, will be unable to ondary scapular winging usually winging may be graded subjectively shrug the shoulder, and will have accompanies some glenohumeral dis- as mild, moderate, or severe. associated weakness on forward ele- order and should resolve once that disorder has been addressed. Volun- tary winging may have psychological Primary Scapular Winging overtones and is quite rare. Dr. Kuhn is Lecturer, Division of Sports Medi- cine, Section of Orthopaedic Surgery, University Neurologic Origin of Michigan Medical Center, Ann Arbor. Dr. Plancher is Assistant Professor, Albert Einstein Evaluation Trapezius Winging College of Medicine, New York; Attending Sur- The spinal , which geon, Montefiore Medical Center, New York; and Patients with scapular winging provides the only innervation to the Hand Consultant, Steadman-Hawkins Clinic, 1 Vail, Colo. Dr. Hawkins is Clinical Professor, should be first observed at rest with trapezius muscle, is located in the Department of Orthopedics, University of Col- the arms at the sides. A static defor- subcutaneous tissue on the floor of orado Medical School, Denver, and Orthopaedic mity should be sought, as well as the posterior cervical triangle. Its Consultant, Steadman-Hawkins Clinic, Vail. muscle atrophy. The patient is then superficial location makes it suscep- Reprint requests: Dr. Kuhn, The University of asked to elevate his arms in the for- tible to injury, which can result in Michigan Shoulder Group, 24 Frank Lloyd ward plane, and the scapulae are significant deformity as well as Wright Drive, Box 363, Ann Arbor, MI 48106- observed in relation to the chest painfully disabling alterations in 0363. 2-4 wall. The scapulothoracic rhythm scapulothoracic function. Injury Copyright 1995 by the American Academy of and the presence of crepitus should can be caused by blunt trauma,4,5 Orthopaedic Surgeons. be noted; alterations in the normally traction,4 or penetrating trauma

Vol 3, No 6, November/December 1995 319 Scapular Winging

are unlikely to benefit from contin- scapulae substitutes for the upper third of Table 1 ued conservative treatment, and the trapezius; the rhomboideus major, Classification of Scapular surgery can be offered. Historically, for the middle third; and the rhom- Winging a variety of surgical procedures have boideus minor, for the lower third. By been described for the treatment of moving these muscle insertions laterally, Primary spinal accessory nerve .2,9,10 their mechanical advantage is improved, Neurologic origin These can be divided into static and and winging is diminished or eliminated. Spinal accessory nerve (trapezius palsy) dynamic procedures. Static stabiliza- The surgical technique involves 9 tion includes scapulothoracic fusion two incisions. The first is along the (serratus anterior palsy) and any of the many operations that medial scapular border, and the sec- tether the scapula to the spine.2 The ond is over the spine of the scapula. (rhomboideus palsy) dynamic procedures all involve some The levator scapulae, rhomboideus Osseous origin form of muscle transfer.5,10,11 Because minor, and rhomboideus major are Osteochondromas scapulothoracic fusions represent a detached from their origins, taking a Fracture malunions huge undertaking and may limit small portion of insertional bone Soft-tissue origin motion significantly, and because fas- from the medial scapula. The rhom- Contractural winging cial-sling suspensions tend to fail, boid muscles are advanced laterally Muscle avulsion or agenesis causing recurrence of winging in 2 to under the infraspinatus and are Scapulothoracic bursitis 5 Secondary 3 years, dynamic muscle transfers secured with suture, which is passed Voluntary have become the procedure of choice through drill holes placed 5 cm lateral for persistent trapezius winging.5,10-13 to the medial border of the scapula. The muscle-transfer operation per- The levator scapulae is passed 5 cm haps most commonly performed for laterally, subcutaneous to the second vation and abduction of the arm. The trapezius paralysis is the Eden-Lange incision, and is sutured to the scapu- diagnosis can be confirmed by elec- procedure,5,12,13 in which the levator lar spine through drill holes. Postop- tromyographic (EMG) examination. scapulae, rhomboideus minor, and eratively, a sling is used for 6 weeks, Treatment depends on the dura- rhomboideus major muscles are trans- after which passive and then active tion and severity of symptoms. An ferred laterally (Fig. 2). The levator range-of-motion exercises are used. initial treatment regimen including is helpful to main- tain glenohumeral motion and pre- vent adhesive capsulitis. In patients in whom spinal accessory nerve injury is due to blunt trauma, serial EMG examinations may be per- formed at 6-week intervals to follow the returning function of the nerve. This is usually not begun until 3 months after the injury, because denervation changes in the muscle may not be manifest before that time. In nerve due to pene- trating trauma, or when there is no evidence of nerve function on EMG analysis, neurolysis and/or nerve grafting can be considered.3,6-8 The results of these procedures have been variable. If neurolysis is per- formed, the success rate seems to be improved if the procedure is done AB within 6 months of the injury.5 Fig. 1 Position of the scapula with primary scapular winging due to trapezius palsy (A) and Patients who have had debilitat- serratus anterior palsy (B). ing symptoms for more than 1 year

320 Journal of the American Academy of Orthopaedic Surgeons John E. Kuhn, MD, et al

nerve originates from the ventral degrees, which will magnify the rami of the C5, C6, and C7 cervical degree of winging. Pain may be nerves and travels beneath the increased with this maneuver and brachial plexus and clavicle over the when the head is tilted toward the first . The nerve then travels along contralateral shoulder. the lateral aspect of the chest wall Electromyography is recom- superficially, making it susceptible mended to confirm the diagnosis. to injury. Blunt trauma or stretching Electromyographic examinations at of this nerve is particularly common 3-month intervals have also been in athletes and has been reported in recommended to follow nerve 22,24 almost every sport.14-16 Repetitive recovery. industrial use of the shoulder has Range-of-motion exercises to also been implicated as a cause of ser- prevent adhesive capsulitis of the ratus anterior paralysis.17 Penetrat- shoulder should be implemented ing trauma will rarely cause injury to immediately on diagnosis. Many this nerve, although surgical proce- types of braces and orthotic devices 20 dures such as radical mastectomy, have been developed. They may first-rib resection, axillary lymph- have some role, but often their cum- node dissection, and transaxillary bersome nature overshadows symp- 22 sympathectomy have been impli- tom relief. Most injuries of the long cated as sources of injury to the long thoracic nerve recover sponta- 15,17,20,22,25 thoracic nerve.16 neously within 1 year, but 26 The long thoracic nerve can also recovery may take up to 2 years. be affected by nontraumatic events, There is little data in the literature including positioning during anes- regarding the results of neurolysis, thesia,17 the sequelae of viral ill- nerve grafting, or nerve repair of an ness,18 inoculations,19 and injured long thoracic nerve. Never- Fig. 2 Eden-Lange dynamic transfer, used affecting the brachial plexus or the theless, penetrating injuries should 5 to treat trapezius paralysis. The levator long thoracic nerve alone.20,21 Even be treated with nerve exploration scapulae, rhomboideus minor, and rhom- and early repair. Neurorrhaphy may boideus major muscles are detached from prolonged bed rest has been their origins (inset), taking a small portion of reported to trigger dysfunction of be indicated when the lesion can be 22 insertional bone from the medial scapula. the long thoracic nerve, particularly localized. Patients with persistent The rhomboid muscles are advanced later- impairment of the serratus anterior ally under the infraspinatus and are secured if the arm is abducted while prop- with suture, which is passed through drill ping up the head to read.17,22 Since are often able to compensate, and holes placed 5 cm lateral to the medial bor- the long thoracic nerve has its ori- most do not require surgical recon- der of the scapula. The levator scapulae is struction.22 For patients who have passed 5 cm laterally and is sutured to the gin at C7, patients with C7 radicu- scapular spine through drill holes. lopathy may also manifest serratus had symptomatic serratus winging anterior weakness and scapular for more than 1 year and whose winging.23 EMG studies show total denerva- With an injury to the long thoracic tion, surgical options may be offered 5 Bigliani et al recently reported nerve, the scapula assumes a posi- to alleviate pain and improve func- their results with this procedure. tion of superior elevation and tion. Of 23 patients with trapezius wing- medial translation, and the inferior Like the surgical treatments for ing, 87% had good or excellent pole is rotated medially (Fig. 1, B). trapezius winging, the operations for results. Significant improvement in Patients will complain of pain as the serratus paralysis can be classified pain was seen in 91% of these other periscapular muscles try to into three types: scapulothoracic 9 7 patients, and 87% demonstrated an compensate for the serratus weak- fusions, fascial sling suspensions, improvement in function. ness. More severe pain may indicate and muscle transfers. A variety of acute brachial plexus neuritis or Par- muscle-transfer operations have Serratus Anterior Winging sonage-Turner syndrome, which been described; these include the use Palsy of the serratus anterior mus- may affect the long thoracic nerve of the pectoralis minor, the pec- cle can also cause painful, disabling alone.21 The patient will have diffi- toralis major, the sternocostal head scapular winging. The long thoracic culty with arm elevation above 120 of pectoralis major, the clavicular

Vol 3, No 6, November/December 1995 321 Scapular Winging head of the pectoralis major, the teres major, the rhomboid muscles, and combinations of these muscles. Scapulothoracic fusions for serra- tus winging have been discouraged by some,20 primarily because of the associated inherent loss of motion, as well as the magnitude of the surgery. Pain relief, however, is a reasonable expectation.9 Complica- tions of scapulothoracic fusions are many and include nonunion and .9 For these reasons, as well as the limited expectations with regard to motion, scapulotho- B racic fusions have been generally A reserved for salvage operations after failure of other techniques and for treating patients with paralysis of other shoulder girdle muscles in addition to the serratus anterior.24 Although controversial, a primary scapulothoracic fusion may also be considered for the laborer with disabling serratus winging who places heavy demands on the shoulder.26 Fascial-sling suspensions to cor- rect serratus winging have been advocated by some.7,27 However, there are significant concerns about sling failure and recurrence of wing- C ing.10 For these reasons, muscle D transfers for dynamic scapular stabi- lization have gained broader accep- tance. Fig. 3 Marmor-Bechtol transfer of the ster- nocostal head of the pectoralis major, used Of the variety of muscle transfers to treat serratus anterior paralysis.28 A, With that have been described, transfer of the patient in the lateral decubitus position, the sternocostal head of the pec- an incision is made, crossing the from the pectoralis major muscle anteriorly to the toralis major with a fascia lata graft inferior tip of the scapula. B, The ster- extension28 (Fig. 3) is probably the nocostal head of the pectoralis major is most popular.22,24,25,29 In this tech- released from its insertion on the bicipital groove of the humerus, leaving the clavicu- 24,28,29 nique, the patient is placed in lar head intact. C, A graft of fascia lata mea- the lateral decubitus position with suring 7 by 2 inches is harvested from the use of a beanbag, and the involved ipsilateral leg and sutured into a 7-inch-long tube. Graft is then sutured to the distal por- arm and forequarter are prepared tion of the freed pectoralis tendon. D, A and draped. An incision is made, foramen is made in the inferior angle of the crossing the axilla from the pectoralis scapula. E, The graft is inserted through this foramen and sutured to itself under moder- major muscle anteriorly to the infe- ate tension. rior tip of the scapula. The ster- nocostal head of the pectoralis major E is released from its insertion on the bicipital groove of the humerus,

322 Journal of the American Academy of Orthopaedic Surgeons John E. Kuhn, MD, et al leaving the clavicular head intact. A and laterally by the unopposed ser- Because muscle function is not graft of fascia lata measuring 7 by 2 ratus anterior muscle.27 With weak- impaired, affected patients may not inches is harvested from the ipsilat- ness of the rhomboid muscles, the be symptomatic. eral leg and sutured into a 7-inch- winging is accentuated when the long tube. This graft is then sutured arm is slowly lowered from the for- Muscular Origin to the distal portion of the freed pec- ward elevated position. The inferior Muscle abnormalities that cause toralis tendon. After the inferior bor- angle of the scapula is pulled later- winging include traumatic ruptures der of the scapula has been exposed, ally and dorsally.30 The patient will and congenital absence of periscapu- a foramen is made in the inferior also have difficulty pushing the lar muscles. In patients with serra- angle. The graft is inserted through backward against resistance tus anterior muscle avulsion, this defect and sutured to itself under with the hands on the . significant trauma has occurred, moderate tension. Postoperatively, Treatment of rhomboideus wing- which pulls the muscle insertion the arm is placed in a sling, and pas- ing consists of trapezius-strength- from the medial border of the 17,32-34 14 sive motion is started after 4 weeks. ening exercises. Although no scapula. Fiddian and King Active motion is begun at 6 weeks muscle-transfer operations have reported the case of a patient in and strengthening at 12 weeks. been described for rhomboideus whom serratus anterior division Although there are few large series in palsy, the patient with significant occurred during thoracotomy, the literature, results with this tech- symptoms for whom conservative which produced symptomatic wing- nique have been encouraging, with therapy has proved a failure may be ing. In this situation, early nerve- 70% to 91% success rates, defined on helped by a fascial-sling operation, conduction studies may be normal, the basis of normal shoulder motion as described by Dickson.7,27 In this and magnetic resonance imaging and a significant reduction in pain operation, two fascia lata grafts are should be considered to assist in the and winging.16,24,25,29 tubularized and used to connect the diagnosis. Surgical reattachment is lower vertebral border of the recommended in all cases, and excel- 17,32,34 Rhomboideus Major and Rhomboideus scapula to the spinal muscles and the lent results can be expected. Minor Winging inferior angle of the scapula to the However, the combination of ad- Weakness of the greater and fibers of the latissimus dorsi. This vanced age and systemic lesser rhomboid muscles is a rare procedure is thought to be useful in may be a contraindication to sur- 33 source of scapular winging. These stabilizing the scapula and partially gery. muscles are innervated by the dorsal arresting the high thoracic scoliosis Congenital absence of the serra- 35 36 scapular nerve, which takes its ori- that may occur with rhomboideus tus anterior, the trapezius, and gin from the C5 nerve root. The dor- and levator scapulae paralysis.27 the rhomboideus major and trapez- 36 sal scapular nerve passes deep to or, ius muscles have all been reported in some patients, through the levator Osseous Origin as causes of scapular winging. scapulae on its way to the rhomboid Osteochondromas, the most Patients with these congenital anom- muscles. A C5 or an common scapular tumors, can be a alies seem to function very well 36 injury to the dorsal scapular nerve cause of “pseudowinging.”14 Rib osteo- without treatment. may produce rhomboid weakness chondromas may also cause the and scapular winging.30 Patients deformity.14 This type of winging is Bursal Origin may complain of pain along the structural and may be associated The articulation between the medial border of the scapula. The with scapular crepitus. The winging scapula and the thorax is character- winging produced by rhomboideus may not change when the position ized by bursae, which in rare cir- palsy at rest is usually minimal but of the arm is varied. The EMG find- cumstances may become inflamed, may appear similar to trapezius ings will be normal in patients with causing scapular crepitus and pain. winging, with the shoulder slightly such osteochondromas; however, In one study,37 winging was identi- depressed, the scapula laterally the lesion can be identified on radio- fied in 50% of patients with a symp- translated, and the inferior angle graphs obtained tangential to the tomatic snapping scapula and no rotated laterally. plane of the scapula or on computed bone abnormalities. This type of On , atro- tomograms. Winging is alleviated winging is presumably related to phy may be evident along the with resection of the abnormal bone. subscapular bursitis. With treat- medial border of the scapula. Dur- Malunions of scapular fractures ment of the bursitis, either by ing arm elevation, the inferior angle have also been implicated as a nonoperative means or surgical bur- of the scapula is pulled downward source of primary winging.31 sectomy, the winging resolves.

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Asymptomatic scapulothoracic muscle is thought to be either con- to improve until the primary prob- crepitus also exists but is usually not genital41 or related to a history of lem is addressed.38 Nevertheless, in associated with scapular winging. injections,42 and is almost always every patient with secondary scapu- associated with scapular winging.42 lar winging, a scapular rehabilita- Common disorders involving the tion program should be added to the Secondary Scapular glenohumeral joint can also be a treatment of the primary gleno- Winging cause of secondary scapular winging. humeral disorder to facilitate re- The mechanism is thought to be due covery. Secondary scapular winging orig- to reflex muscle spasm provoked by inates from disorders of the some painful condition in the gleno- glenohumeral joint that produce humeral or subacromial area.40 Voluntary Scapular abnormal scapulothoracic dynam- Winging has been associated with Winging ics. This phenomenon has not been tears,40 nonunion of thoroughly investigated in the pub- acromion fractures,15 malunion of Voluntary scapular winging is very lished literature. clavicular fractures,14 fractures of the rare.14,15,38,43 In fact, the largest series A thorough evaluation of the glenoid,14 osteonecrosis of the is Rowe’s report of four cases.43 The patient with secondary scapular humeral head,15 acromegalic ar- patients were reassured and in- winging will usually, but not always, thropathy of the shoulder,14 acromio- structed on the normal muscle-firing identify the source as a glenohumeral clavicular joint disorders,14,38 and patterns of the shoulder, with or subacromial disorder.38 When shoulder instability.14,38 In our prac- “instructions not to tighten or con- examining any patient with a shoul- tice, we have observed secondary tract their shoulder muscles when der condition, secondary scapular scapular winging in patients with elevating the arm.” All four recov- winging should be sought with the adhesive capsulitis, the impingement ered after this coaching. In another shoulder at rest, with dynamic for- syndrome, anterior shoulder instabil- report, Gregg et al15 described ward elevation, and with resisted for- ity, posterior shoulder instability, asymptomatic bilateral voluntary ward elevation. One would expect a and multidirectional shoulder insta- scapular winging in an orthopaedic patient with secondary scapular bility. We have also encountered sec- resident. It is important to appreciate winging to have normal findings on ondary impingement due to subtle that patients with voluntary scapular EMG and nerve-conduction exami- shoulder instability in throwing ath- winging who seek medical attention, nations of the long thoracic nerve and letes. like patients with voluntary subluxa- , the spinal Winging frequently accompanies tion of the shoulder, may have unad- accessory nerve and trapezius mus- the asynchronous shoulder motion dressed psychological issues that cle, and the dorsal scapular nerve and seen in patients with voluntary pos- complicate their care. rhomboid muscles. terior shoulder subluxation. If the In contractural winging, contrac- scapula is forcibly held against the tures about the glenohumeral joint chest wall, preventing winging, the Summary produce secondary scapular winging. patient may have difficulty sublux- Patients with obstetric shoulder ating the shoulder. A variety of disorders can cause trauma may develop Patients with painful scapular winging. An understand- due to unbalanced muscle forces with may reflexively limit glenohumeral ing of these disorders and an appre- the humerus abducted and internally motion. This forces the periscapular ciation of the physical examination rotated relative to the scapula. When muscles to work in excess, because findings will prevent misdiagnosis the arm is forcibly adducted to the scapulothoracic motion must in- and assist in directing treatment. chest wall and externally rotated, the crease to compensate for the limited For most patients, conservative superior corner of the scapula projects glenohumeral motion. With fatigue treatment, which includes scapular away from the chest wall at the upper of the periscapular muscles, particu- rehabilitation emphasizing range of margin of the trapezius, producing larly the serratus anterior, trapezius, motion and periscapular muscle the “scapular sign of Putti.”39 and rhomboid muscles, secondary strengthening, will alleviate symp- Contractural winging can also scapular winging occurs. As has toms. If symptoms persist despite occur with fibrosis of the deltoid.40 been shown,38,40 treatment of the pri- adequate time and conservative This type of winging decreases when mary glenohumeral disorder will treatment, one should consider the the arm is raised and increases when alleviate the scapular winging; con- surgical options, which are capable it is lowered. Fibrosis of the deltoid versely, scapular winging is unlikely of resolving pain and winging.

324 Journal of the American Academy of Orthopaedic Surgeons John E. Kuhn, MD, et al

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