scapular winging scapular winging are mainly two types medial scapular winging and lateral scapular winging the direction of the winging middle or lateral is determined by the medial border of the scapula is it going medially so it will be medial wing of the scapula or if it is going laterally will be lateral winging of the scapula which occurs due to spinal accessory nerve injury and that will lead to dysfunction of the trapezius muscle the medial winging of the scapula occurs due to injury of the long thoracic nerve the long thoracic nerve comes from c5 c6 c7 it is a long nerve and it supplies the serratus anterior muscle the medial winding of the scapula is caused by paralysis of the serratus anterior muscle which supplied by the long thoracic nerve in the medial winging of the scapula the medial scapular border displaces itself from the thoracic cage and it becomes more prominent during shoulder flexion there is a medial and superior translation of the scapula compared to the other side function of the serratus anterior muscle the serratus anterior pulls the scapula away from the midline and forward called scapular abduction that also rotates the scapula upwards the most important function of the serratus anterior is that it helps to stabilize the scapula so that the other muscles attached to the scapula can work properly the muscle holds the scapula to the chest wall and it prevent the inferior angle of the scapula from migrating medially so when the muscle is paralyzed the inferior angle of the scapula will migrate medially in the lateral winging of the scapula the superior trapezius becomes atrophied and flattened and the lateral border of the scapula becomes more prominent during shoulder abduction in examination the medial scapula will drop downwards and protrude laterally and posteriorly with atrophy of the epsilateral trapezius in lung thoracic nerve injury the scapula elevates in the accessory nerve injury the scapula depresses the medial winging is more common than the lateral winging the medial winging of the scapula will be worsened by arm reflection the lateral winging of the scapula will be worsened by arm abduction in the lateral winging there is usually history of neck surgery especially in the posterior triangle of the neck medial winging of the scapula can also be a part of the findings in a preganglionic or preclavicular brachial plexus injury you will also find this horner's syndrome the horner's syndrome occur due to disruption of the sympathetic chain c8 c8t1 that medial winging of the scapula will suggest preganglionic injury also chromboyd muscle paralysis occurs due to involvement of the dorsal scapular nerve supraspinatus and infraspinatus weakness occurs due to suprascapular nerve involvement the emg will show loss of innervation to the paraspinal cervical muscles which means a root problem not a brachial plexus problem so finding winging of the scapula is not a good thing when the patient has brachial plexus injury it may indicate a poor prognosis the same like horner's syndrome medial winging of the scapula is checked by having the patient perform the wall push-up test for serratus anterior muscle weakness of medial winging of the scapula most scapular winging resolve with non-surgical treatment medial winging of the scapula can be treated with observation activity modification and physiotherapy observe for a minimum of six months observe for a long period of time it may take up to two years to wait for the recovery of the nerve the nerve is a long nerve that needs time to recover with emphasis on the serratus anterior muscle surgery may be in the form of nerve decompression of the long thoracic nerve and this is based on an emg that will show there is a compression of the nerve then muscle transfer the split pectoralis measure transfer for serratus anterior palsy the sternal head of the pectoralis major muscle may be transferred to the inferior border of the scapula treatment of lateral winging of the scapula observation activity modification and physiotherapy operative treatment will include exploration of the spinal accessory nerve with neurolysis or repair then muscle transfer eating leg procedure if the injury is diagnosed late will do eating leg transfer which is transfer of the elevator scapulae and rhomboid from the medial border of the scapula to the lateral border in order to reconstruct a trapezius function eating length procedure is shown to be a reliable procedure in restoring the range of motion and function thank you very much i hope that was helpful you