winging of only one scapula indicates an injury to what nerve

Continuing Instruction Activity

In a patient who has a winged scapula, the medial (or in some cases, lateral) aspect of the scapula appears to be protruding from the back. Every bit the proper name of the condition implies, information technology can create a winged appearance. This abnormal position of the scapula can atomic number 82 to many physical functional disabilities such as pain, decreased strength, and range of motion disruptions. The ranges of motion that are most commonly afflicted are abduction and flexion of the affected upper extremity. This activity reviews the causes and presentation of winging of the scapula and stresses the role of the interprofessional team in the management of patients with this condition.

Objectives:

Depict the causes of winging of the scapula.
Review the presentation of a patient with winging of the scapula.
Outline the treatment options for winging of the scapula.
Summarize the importance of improving care coordination among the interprofessional team to provide constructive treatment to patients with winging of the scapula.

Admission free multiple option questions on this topic.

Introduction

In a patient with a winged scapula, the medial or lateral attribute of the scapula appears to be protruding from the back. Equally the name of the condition implies, information technology can create a winged advent. This abnormal position of the scapula tin 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 unremarkably due to harm or impaired innervation to the serratus inductive muscle. The nerve that innervates this muscle is the long thoracic nerve. Sometimes, this nervus can be damaged or impinged, leading to malfunction of the serratus anterior muscle. Some patients may as well 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-similar appearance. The impingement or damage of this nerve leads to the winged appearance because the serratus inductive musculus attaches to the medial attribute of the scapula and holds it against the posterior rib muzzle. Less commonly, the scapula can wing laterally due to harm 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 part of the trapezius musculus is to drag, retract and rotate the scapula.

Epidemiology

One patient population that is noted to present with scapular winging are women who accept undergone chest surgery, as in breast cancer patients who take undergone a radical mastectomy.[ane] During the process, the long thoracic nerve tin can suffer harm due to its proximity to the other involved structures. Specifically, mastectomies that involve resection of the axillary lymph nodes are at higher risk as the long thoracic nervus lies nigh the axillae and is at risk of being damaged during the lymph node resection.

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

Pathophysiology

A primary winged scapula results from an injury to the nerve, changes in the scapula bone itself, or periscapular soft tissue abnormalities. Remember, the serratus anterior musculus attaches to the medial aspect of the scapula and attaches it to the rib cage. If information technology loses innervation by the long thoracic nerve, information technology tin can no longer provide stability to the scapula, leading 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 dorsal scapular nerve innervates the rhomboid muscles.

A secondary winged scapula occurs due to glenohumeral and subacromial weather condition and should resolve after addressing the pathological status 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. Also, winging of the scapula also leads to meaning corrective deformity.

History and Physical

Classically, patients present and pain and weakness related to movements involving the scapula. The archetype findings are difficulty with elevating the arm above the head and lifting objects.[two] Due to multiple unlike etiologies of a winged scapula, the histories gathered from presenting patients may differ. In 1 study, the hurting was not associated with every case, whereas fatigue was a significant feature.[3] On physical examination, 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 confronting the rib cage. Due to this muscle pathology, the motility involving up rotation, abduction, and at that place is a limitation of elevation of the scapula due to weakness or hurting. I clinical test that providers tin employ to assess patients is to have the patient face up a wall and stand with the affected arm out in forepart of their body, parallel to the floor. The patient should and so be instructed to push button against the wall with the palm of their hand on the afflicted side. A protrusion of the medial portion of the scapula should and then be apparent.

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

Evaluation

In most cases, the practitioner tin evaluate scapular winging with a proper history and concrete test. Electrodiagnostic testing can assistance to institute the underlying neuromuscular pathology. Furthermore, neuromuscular ultrasound can be used to establish the muscular pathology and the neurologic causes of the muscle pathology. Ultrasound can be used to provide for a painless and radiation-complimentary imaging method that tin can be used to evaluate for winging of the scapula.[four] 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 and the location of the impairment by recording the electric action produced by muscles and evaluating how fast an impulse moves through a specific nerve.[5] The do good of these evaluation measures is that early diagnosis and early treatment can aid foreclose more severe shoulder dysfunction.

Treatment / Management

Management of winged scapula is primarily accomplished utilizing bourgeois measures such equally hurting command and physical therapy. Physical therapy helps to preserve the range of motion of the afflicted extremity as well equally prevent possible complications such every bit adhesive capsulitis. Almost 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 past utilizing the trapezius muscle. With conservative therapy, the recovery may take months or years. If no recovery has occurred within this fourth dimension, information technology 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 tertiary to 6th ribs to preclude 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 process is not recommended for athletes or individuals involved in heavy labor.

Unlike serratus anterior muscle palsy, which can assist recovery with conservative management, paralysis of the trapezius rarely improves with such handling. While pain may improve with do, the neck asymmetry does not. In many cases, exploration and nerve repair yields better results. In immature, healthy individuals, lateral transfer of the levator scapula and rhomboid muscles to the scapula has proven durable and constructive. Finally, some patients may benefit from botulinum toxin, simply 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 hurting and associated weakness and discomfort of the upper extremity are seen in other diagnoses too [5]. Some presentations can appear similar to rotator gage disorders due to the express motion and weakness with the associated arm. Glenohumeral instability is too a differential diagnosis as the patient may report instability of the shoulder. However, when the diagnosis is scapular winging, it is the instability of the scapula rather than the glenohumeral joint. Peripheral nerve disorders, cervical spine disease could too mimic scapular winging and should be ruled out. Thoracic outlet syndrome and acromioclavicular disorders might also be included in the differential, probable considering 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 the resolution of scapular winging. As discussed prior, the recommended treatment for initial treatment is hurting command and concrete therapy.[iii] If treatment is not initiated early on on in the progression of the status, patients can develop subsequent issues such as adhesive capsulitis (or frozen shoulder), subacromial impingement, and other pathogenesis involving the brachial plexus.

Complications

Ofttimes, when scapular winging is present due to injury to the long thoracic nervus, other nerves and structures near the anatomy can exist affected as well. The long thoracic nerve, which is commonly the nerve affected in this status and leads to scapular winging, branches from the brachial plexus, a network of nerves formed that initiates at the lower 4 cervical nerve roots and the beginning thoracic nerve root (C5 - T1). Damage to the brachial plexus can cause neurologic problems in the upper extremities and the torso.[6] The long thoracic nerve is a peripheral nerve that comes off of the brachial plexus. Studies accept shown that during surgery, the destruction of trunks of the brachial plexus tin exist traumatic, and loss of role is associated with atrophy of the corresponding muscles.

Deterrence and Patient Education

Like many other clinical pathologies, information technology is all-time to practice preventative measures to avert scapular winging and try to treat it once it has manifested in symptoms. The grade of clinical cases in winging of the scapula can persist for upward to 2 years. Nigh patients somewhen recover, just at least one-fourth may have residual pain.[7]

Enhancing Healthcare Squad Outcomes

An interprofessional healthcare squad providing care to a patient with scapular winging is crucial in ensuring the best health issue of the individual. The integrated postoperative care given to the patient tin can make up one's mind whether the patient will brand a full recovery or to what extent. When the patient is nether mail-operative management, all interprofessional squad members, including the nurse and physical therapist involved in patient care, should be fabricated aware of scapular winging as a potential complication. Thus, nurses who piece of work closely with the patients tin monitor and know what to wait for to warning the medical team. The pharmacist should educate the patient on pain direction, and the physical therapist should recommend the relevant exercises. That manner, early on and effective intervention tin can commence before the patient presents with symptoms. Prevention of this condition will conspicuously pb to the best outcomes for patient care. Interprofessional intendance tin lead to the best success in the planning and evaluation of patient progress in recovery. Interprofessional collaboration is guaranteed to consequence in a amend prognosis and outcome for the patient as an integrated approach to care.[8] [Level v]

Review Questions

Figure

Winging of scapula. Image courtesy S Bhimji MD

References

1.: Saied GM, Kamel RM, Dessouki NR. The event of mastectomy and radiotherapy for breast carcinoma on soft tissues of the shoulder and its joint mobility amidst Egyptian patients. Tanzan Health Res Bull. 2007 May;9(ii):121-5. [PubMed: 17722415]
two.: Lung K, Lui F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 31, 2021. Beefcake, Thorax, Long Thoracic Nervus. [PubMed: 30571017]
3.: Didesch JT, Tang P. Beefcake, Etiology, and Management of Scapular Winging. J Hand Surg Am. 2019 Apr;44(4):321-330. [PubMed: 30292717]
four.: Krzesniak-Swinarska M, Caress JB, Cartwright MS. Neuromuscular ultrasound for evaluation of scapular winging. Musculus Nerve. 2017 Jul;56(1):7-fourteen. [PubMed: 28006862]
5.: Srikumaran U, Wells JH, Freehill MT, Tan EW, Higgins LD, Warner JJ. Scapular Winging: A Dandy Masquerader of Shoulder Disorders: AAOS Exhibit Selection. J Bone Articulation Surg Am. 2014 Jul sixteen;96(14):e122. [PubMed: 25031384]
vi.: LURJE A. Concerning surgical handling of traumatic injury of the upper division of the brachial plexus (Erb's-type). Ann Surg. 1948 Feb;127(2):317-26. [PubMed: 18905933]
7.: Kauppila LI, Vastamäki K. Iatrogenic serratus inductive paralysis. Long-term outcome in 26 patients. Chest. 1996 January;109(1):31-4. [PubMed: 8549212]
8.: Pallara T, Del Buono R, Marangi GF, Langella M, Toto V, Persichetti P. Outcomes of traditional cosmetic abdominoplasty in a community setting: a retrospective assay of 1008 patients. Plast Reconstr Surg. 2013 Nov;132(5):863e-864e. [PubMed: 24165640]

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Source: https://www.ncbi.nlm.nih.gov/books/NBK541005/#:~:text=The%20most%20common%20etiology%20of,of%20the%20serratus%20anterior%20muscle.