Scapular Winging Lecture Notes

Types of Scapular Winging

• Medial Scapular Winging
  • Occurs due to injury of the long thoracic nerve.
  • Caused by paralysis of the serratus anterior muscle.
  • Medial border of scapula displaces from the thoracic cage.
  • Becomes prominent during shoulder flexion.
  • More common than lateral winging.
• Lateral Scapular Winging
  • Occurs due to spinal accessory nerve injury.
  • Leads to dysfunction of the trapezius muscle.
  • Superior trapezius atrophies and flattens.
  • Lateral border of the scapula becomes more prominent during shoulder abduction.

Causes and Symptoms

• Medial Winging
  • Long thoracic nerve comes from C5, C6, C7.
  • Inferior angle of the scapula migrates medially when muscle is paralyzed.
  • Worsens with arm flexion.
  • Can indicate preganglionic or preclavicular brachial plexus injury.
  • Associated with Horner's syndrome due to sympathetic chain disruption (C8, T1).
• Lateral Winging
  • Medial scapula drops, protrudes laterally and posteriorly.
  • Accompanied by ipsilateral trapezius atrophy.
  • Scapula depresses in accessory nerve injury.
  • Often linked to history of neck surgery.

Diagnostic Tests

• Medial Winging Test: Wall push-up test to check for serratus anterior muscle weakness.
• EMG can show loss of innervation indicating root problem rather than brachial plexus.

Treatment Approaches

Medial Winging Treatment

• Non-surgical:
  • Observation, activity modification, and physiotherapy for up to 2 years.
  • Nerve decompression of the long thoracic nerve based on EMG.
• Surgical:
  • Muscle transfer: Split pectoralis major transfer for serratus anterior palsy.
  • Transfer of the sternal head of the pectoralis major to the inferior border of the scapula.

Lateral Winging Treatment

• Non-surgical:
  • Observation, activity modification, and physiotherapy.
• Surgical:
  • Exploration of the spinal accessory nerve with neurolysis or repair.
  • Muscle transfer, such as Eden-Lange procedure if diagnosed late.
  • Eden-Lange procedure involves transferring levator scapulae and rhomboid muscles to the lateral border of the scapula.
  • Proven reliable for restoring range of motion and function.

Note: Finding winging of the scapula can indicate poor prognosis in brachial plexus injury, similar to Horner's syndrome.