Medial Winging Research Articles

Comparison of ultrasound with electrodiagnosis of scapular winging: A prospective case control study

ObjectiveCompare high-resolution ultrasound (HRUS) and electrodiagnostic examination (EDX) in the diagnostic workup of patients with scapulae alatae. Methods27 patients with scapulae alatae and 41 healthy subjects (HS) and underwent a standardized clinical examination (CEX), EDX and HRUS. We measured the thickness of the serratus anterior (SER), rhomboid major and trapezius muscles and the diameter of the long thoracic (LTN), dorsal scapular and spinal accessory nerves (SAN). ResultsTwenty patients showed medial winging and six patients showed lateral winging on CEX. One patient had both lateral and medial winging. In patients with medial winging, the SER muscle was thinner and the LTN diameter was larger on the symptomatic side compared with the asymptomatic side and with the dominant side in HS. In this group, both EDX and HRUS detected abnormalities of SER muscle/ LTN with sensitivity of 65%, and with specificity of 100% and 57%, respectively.EDX and HRUS detected abnormalities of the trapezius muscle/ SAN with sensitivity of 60% and 40%, and specificity of 91%, and 86 % a, respectively. There was no significant difference between the two methods. ConclusionHRUS can contribute to the diagnostic workup of scapulae alatae by demonstrating atrophy of muscles and enlargement in nerve diameter. SignificanceHRUS supplements EDX in the diagnostic workup of scapulae alatae.

Scapular Winging – A Schematic Review

Scapular winging is a rare, painful and debilitating condition that leads to limited functional activity of the upper extremity. The composite scapular movement of rotation, abduction, and tilting is necessary for proper shoulder function. Weakness or loss of scapular mechanics can lead to difficulties with elevation of the arm and lifting objects. It can result from numerous causes, including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made by inspection of the scapula from back, with serratus anterior paralysis resulting in medial winging of the scapula while lateral winging is caused by trapezius and rhomboid paralysis. Most cases of serratus anterior and rhomboid paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. Patients become candidates for corrective surgery if they fail a 6–24 month course of conservative treatment. This review explores the causes of scapula winging, with overview of the relevant anatomy, proposed aetiology and treatment.

O-39 High resolution ultrasound of scapula alata – A prospective case control study

Scapulae alatae (SA) is a rare but also underreported disorder caused by neuromuscular disturbance in the scapulothoracic stabilizer muscles. The study is a single-blinded, prospective, controlled multi-center-study. We recruited 27 patients and 41 healthy-subjects. A standardized clinical examination was performed, electrodiagnostic-tests(EDx) were performed according to the department’s guidelines, and a Siemens ACUSON S1000 device with a high-frequency linear array transducer (18L6HD) used. The serratus anterior (SAM), trapezius and rhomboid muscles and the long thoracic (LTN), dorsal scapular, and accessory nerves were scanned bilaterally at predefined standardized sites. Muscle-thickness and nerve-diameter were measured. A reliability study in ten subjects was performed. Twenty patients showed a medial winging, seven patients showed a lateral winging and one patient had a lateral winging on the static examination but a medial winging on the dynamic examination. EDx were normal in 11 (40%) out of 27 patients. In patients with medial winging, the ratio of muscle thickness of SAM between the symptomatic side and the asymptomatic side differed significantly from the ratio in healthy-subjects: upper SAM (p-value: 0.007), lower SAM (p-value: 0.003), but no difference found for middle SAM (p-value: 0.051). Comparing difference in LTN diameter between the symptomatic and asymptomatic side in the patients with the difference between sides in the healthy-subjects, we found significant difference in two of three scanning-sites in the neck. The diagnosis of SA patients can be difficult and EDx are often normal. Our study shows that ultrasound of the neck/ shoulder may be used as a supplement in the diagnostic work-up.

F39. Parsonage from a power tool: An unusual presentation of neuralgic amyotrophy in a 78 year old woman after using a chainsaw

Introduction A 78 year old Caucasian female presented for an electrodiagnostic (EDX) evaluation for right hand weakness and atrophy. Symptoms began 3 months prior one day after she was working with a chainsaw in the backyard and experienced severe right scapular pain followed by a monophasic course of progressively worsening weakness, inability to grip things such as a pen or coffee cup, and numbness and tingling into digits 1–3. Exam showed right sided prominent atrophy of the first dorsal interosseous (FDI) and thenar eminence, 4/5 strength in shoulder abduction and elbow flexion/extension, 3/5 strength in finger flexion and abduction, a positive okay sign, diminished sensation throughout the right upper limb. She also has weakness of the serratus anterior with mild medial winging of the right scapula during anteflexion. Myelogram and computed tomography showed no significant neural compression to explain patient’s symptoms, specifically no C8 compression. Methods The patient underwent EDX testing and a neuromuscular ultrasound. Results Nerve conduction studies showed prolonged distal onset latency and reduced amplitude of the right median motor nerve and no response in the right ulnar motor nerve, but were otherwise normal. Needle evaluation of the right FDI muscle showed reduced insertional activity with no recruitment of motor units, and the right pronator quadratus muscle showed reduced recruitment. Neuromuscular ultrasound of the right brachial plexus showed some increased hypoechogenicity and possible increased caliber compared to the left. The right forearm musculature including the pronator quadratus and FDI demonstrated increased hyperechogenicity and atrophy consistent with chronic denervation. Patient was diagnosed with a distal predominant neuralgic amyotrophy (NA) variant. Conclusion Neuralgic amyotrophy (NA), also known as Parsonage-Turner Syndrome, exhibits a high degree of phenotypic variability with only two-thirds of patients presenting with the classic phenotype with its predilection for the superior trunk of the brachial plexus. In this case, the patient met 5/5 of the clinical criteria for NA as defined by Van Alfen and neuromuscular ultrasound was helpful in further confirming the diagnosis. NA should be considered in patients even if they do not fit the classic phenotype of predominately proximal arm weakness and ultrasound of the plexus and affected muscles can be a helpful adjunctive diagnostic tool is such cases which do not “fit the textbook.”

Split Pectoralis Major Transfer for Chronic Medial Scapular Winging

Scapular winging can be a significant source of chronic pain, weakness, and disability of the shoulder. Isolated serratus anterior palsy from long thoracic nerve injury, which is the most common cause of this condition, produces prominent winging and medial malpositioning of the inferior angle of the scapula. In the case of persistent symptoms despite conservative care, treatment options primarily include scapulothoracic fusion and pectoralis major transfer. Outcomes of scapulothoracic fusion are notable for a high complication rate and limited functional improvements. We describe our technique of indirect, split pectoralis major transfer to the inferolateral scapula with allograft tissue augmentation for the surgical treatment of chronic medial winging. This procedure provides dynamic stabilization of the scapula with secure and tension-free tendon transfer. Advantages over alternative treatments include a relatively low complication rate, acceptable cosmesis, and better range of motion. The rationale and technical aspects of this procedure are discussed. Additional clinical studies are warranted to compare outcomes for the direct and indirect split transfer methods.

Treatment for Medial and Lateral Scapular Winging: Tendon Transfers

Although rare, scapular winging can be a painful and disabling condition. Scapular winging has been categorized as medial or lateral winging, with medial being the more common type. Medial winging is the result of serratus anterior paralysis from injury to the long thoracic nerve. The most common etiology is neuropraxia after blunt or stretch injury. Lateral winging, from trapezius paralysis with injury to the spinal accessory nerve, is most likely iatrogenic from procedures involving the posterior cervical triangle. Recovery of nerve function can take up to 2 years. For those cases that do not have return of nerve function, operative treatment is an option. Tendon transfers were introduced in the early 1900s and have been met with satisfactory results in small case series. The purpose of this article is to describe the indications, operative technique, postoperative rehabilitation, and results of tendon transfer for medial and lateral scapular winging.

An unusual case of scapula winging

Acute or subacute unilateral winging of the scapula is a relatively uncommon cause of referral to a paediatric neurologist. Lesions such as neuralgic amyotrophy, long thoracic nerve injury, injury to the spinal accessory nerve causing loss of trapezius function, or weakness of all the scapula stabilisers caused by a primary muscle disorder are likely to be at the top of the list of differential diagnoses. Differentiation between these causes is usually relatively straightforward clinically. Damage to the long thoracic nerve can be differentiated from damage to the spinal accessory nerve as serratus anterior paralysis results in medial winging of the scapula with prominence of the vertebral border while trapezius paralysis causes lateral winging with downward rotation.

A 33-year-old male with a strenuous occupation and gradual inability to lift, pull, and push heavy weights during working: diagnosis and discussion

Scapulothoracic stabilization and motion is mainly carried out by the synergic and antagonistic action of three muscles: the serratus anterior, the trapezius, and the rhomboid [1, 2]. The serratus anterior is innervated by the long thoracic nerve (LTN), the trapezius by the spinal accessory nerve, and the rhomboid muscles by the dorsal scapular nerve [1–3]. Direct or indirect trauma, iatrogenic injuries, or idiopathic processes such as the Parsonage– Turner syndrome may result in nerve injury and eventually paresis of the affected muscle [1–3]. The LTN is formed from the anterior rami of the 5th, 6th, and 7th cervical nerves. It passes between the clavicle and the first rib and then enters a fascial sheath and descends along the lateral aspect of the thoracic wall innervating the muscle fibers of serratus anterior [4]. Due to its lengthy course (24 cm in average), its delicate and thin nature (2–3 mm) and the fact that it traverses the middle scalene muscle and descends between the clavicle and the first rib, the nerve is easily susceptible to injuries [4]. In the vast majority of cases, the mechanism of traumatic nerve injury is either overstretchingtraction or compression and constriction of nerve fascicles and the clinical result is serratus anterior muscle denervation, which is demonstrated as medial scapular winging [1–4]. Clinical examination provides valuable information for a correct diagnosis. Serratus anterior paresis results in medial scapular winging whereas lateral winging is the consequence of trapezius and rhomboid paresis [1–5]. In our case, the physical examination revealed medial winging of the right scapula, which became more pronounced when the patient was asked to perform active forward or upward elevation and abduction of his arms (Fig. 1). Since the diagnosis is easily made during clinical examination and visual inspection of the scapula, the need for MR imaging evaluation is limited [6–9]. MR imaging was requested in order to exclude a disk disease-radiculopathy and rule out a possible mass lesion either in the spinal canal or more peripherally. The anatomical distribution of the signal changes on MR aided in the correct diagnosis. The MR imaging findings of uniform muscle edema and the absence of fatty infiltration correlated well with the onset of symptoms and suggested a subacute phase of aponeurositis. This finding is considered essential in treatment planning. Due to imaging findings, electromyographic testing and nerve conduction studies were not performed. The electromyographic testing could have provided the degree of denervation, but according to the literature, the initial degree of denervation cannot be used to predict the extent of nerve recovery [10]. The isolated serratus anterior paresis and the associated medial scapular winging has been shown to respond well to The case presentation can be found at doi:10.1007/s00256-011-1231-2. E. Perdikakis : L. Palladas :A. Karantanas Department of Radiology, University of Crete, Stavrakia, Heraklion, Crete, Greece

Poster 69: A Unique Presentation of Medial Winging of the Scapula with Dorsal Scapular and Spinal Accessory Neuropathy: A Case Report

Poster 69: A Unique Presentation of Medial Winging of the Scapula with Dorsal Scapular and Spinal Accessory Neuropathy: A Case Report

Scapular winging: anatomical review, diagnosis, and treatments

Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. It is the result of numerous causes, including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made upon visible inspection of the scapula, with serratus anterior paralysis resulting in medial winging of the scapula. This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. A conservative course of treatment is usually followed for rhomboid paralysis. To allow time for spontaneous recovery, a 6–24 month course of conservative treatment is often recommended, after which if there is no recovery, patients become candidates for corrective surgery.

Cervical radiculopathy vs Parsonage-Turner syndrome: a case report.

Case reportA 42-year-old recreational cyclist presented with a 3-month history of right-sided neck pain. The patientexperienced pain radiating to the right periscapular regionand paresthesias in digits 1–3. The onset of the pain wassudden. She described the pain as intermittent and sharp,ranging from 8–10/10 on numeric pain rating scale. Thepain was worse at nighttime, often so severe that it wouldwake her from sleep. She also noted severe headaches andright upper extremity numbness and weakness. She hadvisited the emergency room twice, both times beingadmitted to a neurology service because of the severenature of the pain and what was described as atypicalhemiplegia and migraines. A CT scan of the head andcervical spine and an MRI of the cervical spine werenormal. The patient was discharged on pain medication,which included prednisone, depakote, zoloft, motrin, andtopamax. There was no history of trauma, falls, or anyinciting events. She had no history of bowel or bladderincontinence, recent travel, or fever and chills. Her medicalhistory was significant for migraines, right carpal tunnelsyndrome, and depression. She was taking lexapro andclonazepam for depression.Physical examination revealed mild limited cervicalrange of motion with end range axial pain with flexion,extension, and lateral rotation. Spurling maneuver waspositive on the right side eliciting pain in digits 1 and 2.Active and passive range of motion of the right shoulderwas minimally limited compared to the left (asymptomatic)side. Additional findings included medial winging of theright scapula and mild weakness (4+/5) of the right triceps.Muscle strength throughout the rest of the upper extrem-ities was 5/5. The rest of the physical examination revealednormal muscle bulk and tone, normal sensation, symmetricupper extremity reflexes, and negative Hawkins_, Neer_s,Roos_, Wright_s, and Adson_s provocative tests.Clinical evaluation at this point was suggestive ofParsonage–Turner syndrome vs a cervical radiculopathy,although a broader differential diagnosis was considered(Fig. 1). Electrodiagnostic studies were performed andshowed evidence of severe denervation (2+ positive sharpwaves and fibs) corresponding to muscles of the right C7myotome and including the paraspinal muscles, consistentwith a right C7 radiculopathy (Fig. 2). Motor unitrecruitment was reduced in the involved muscles and therewere no polyphasic potentials. An MRI of the cervicalspine was repeated and revealed mid to lower cervicalspondylosis, moderate left-sided C5/6 foraminal stenosis,and mild right-sided C6/7 foraminal stenosis (Fig. 3).Because the MRI findings did not demonstrate significantnerve root compression, the patient was diagnosed withParsonage–Turner syndrome and Lyrica was prescribed.Over the next 6 weeks the patient_s symptoms improvedbut then suddenly worsened.The patient returned for follow-up with complaints ofrecurrent right neck pain and right upper extremityweakness. Neck range of motion was now normal andSpurling_s maneuver was now negative. There was greaterupper right extremity weakness, with motor strength ofright triceps 4+/5, right wrist extension 4j/5, and rightwrist flexion 4/5. Reflexes were normal and sensation wasintact. Parsonage–Turner syndrome was still the workingdiagnosis and the patient was referred to physical therapyto treat a superimposed cervical radicular component.Over the next 2 months, the patient continued to havesymptoms and developed a shingles-like rash on herbuttock. She was treated by her primary care physicianwith Valtrex and within a few days the patient_s neck andright arm pain completely resolved. One month later, shehad recurrence of the buttock rash along with return of theneck and arm pain. She again received a course of Valtrexand her symptoms completely resolved. To date, 1 yearlater, she has been pain-free with almost full strength andable to return to all previous activities, including recrea-tional cycling.DiscussionEvaluation of the patient with neck and unilateral arm paincan present a diagnostic and treatment challenge. Anatomic

Poster 89: Suprascapular neuropathy presenting as myofascial pain: a report of 4 cases

Setting: Outpatient clinic. Patients: 4 women presenting with myofascial pain in the upper trapezius, diffuse shoulder pain, and pain with shoulder abduction above 90°. Case Descriptions: All patients were symptomatic for 6 months to >3 years and had been previously diagnosed and treated for cervicobrachial myofascial pain. Assessment/Results: On clinical exam, asymmetric scapular movements were noted with reversal of abduction including mild lateral displacement and medial winging. No atrophy was noted. Electromyography was notable for chronic denervation in the infraspinatus. In 3 of the cases, symptoms improved significantly with a physical therapy program aimed at strengthening the infraspinatus and thereby restoring the scapulohumeral rhythm. In the fourth case, the patient declined further therapy and/or imaging studies. Discussion: Classically, suprascapular neuropathy presents with posterior shoulder pain and weakness and atrophy of the infraspinatus and/or supraspinatus muscles. This is the first report, to our knowledge, of a suprascapular neuropathy presenting with myofascial pain as the primary complaint. Conclusion: These cases emphasize the need for clinicians who treat cervicobrachial myofascial pain to assess scapular movements for potential suprascapular neuropathy.