Scapular Winging Research Articles

The winged scapula; a muscle rupture or a nerve paralysis? A case series

Winging of the scapula has a variety of causes and a variable prognosis. It contributes to a disruption of the scapulohumeral rhythm with a decreased flexion and abduction of the upper extremity and a source of a considerable pain. This condition can affect the ability to perform activities of daily living. The most common cause of scapula winging is serratus anterior paralysis resulting from a lesion of the long thoracic nerve. The rupture of the muscle itself remains uncommon. Six patients presented to the department of Physical Medicine and Rehabilitation complaining of shoulder pain and great difficulties performing activities of daily living. Five women and a man, with a mean age of 44 years (14 to 58). Physical examination found drooping and a moderate decrease of range of motion of the shoulder. A winged scapula was seen in all cases. A soft mass was palpable at the level of the lower half of the vertebral border of the left scapula in a woman. In this case, US and CT were performed, they showed a rupture of the serratus anterior along the vertebral border of the left scapula with a fatty degeneration of the muscle. In the other cases, ENMG was performed, showing partial denervation of the long thoracic nerve. Although rare, a good number of cases of paralysis of the long thoracic nerve are reported in the literature, but only a few concerning the muscle injury. The early differentiation between a nerve injury and a muscle injury is important. In most cases, nerve paralysis was due to traction of the nerve. Isolated serratus anterior rupture is a rare condition that is secondary to direct trauma or overuse. In all cases, the most common symptoms reported by patients are inability to elevate the arm above the level of the shoulder, pain about the shoulder and varying degrees of stiffness of the shoulder. The most striking thing noted on physical examination was the winged scapula. Rehabilitative treatment with specific exercises allows reducing the scapula winging, decreasing pain, consistent with a good functional improvement.

Poster 82 Bilateral Upper Trunk Plexopathy with a Winged Scapula: A Case Report.

Poster 82 Bilateral Upper Trunk Plexopathy with a Winged Scapula: A Case Report.

Therapeutic Taping for Scapular Stabilization in Children With Brachial Plexus Birth Palsy.

In this study, we aimed to assess whether therapeutic taping for scapular stabilization affected scapulothoracic, glenohumeral, and humerothoracic joint function in children with brachial plexus birth palsy and scapular winging. Motion capture data were collected with and without therapeutic taping to assist the middle and lower trapezius in seven positions for 26 children. Data were compared with one-way multivariate analyses of variance. With therapeutic taping, scapular winging decreased considerably in all positions except abduction. Additionally, there were increased glenohumeral cross-body adduction and internal rotation angles in four positions. The only change in humerothoracic function was an increase of 3° of external rotation in the external rotation position. Therapeutic taping for scapular stabilization resulted in a small but statistically significant decrease in scapular winging. Overall performance of positions was largely unchanged. The increased glenohumeral joint angles with therapeutic taping may be beneficial for joint development; however, the long-term impact remains unknown.

Teaching Neuro Images : Coats disease revealing facioscapulohumeral muscular dystrophy

A 21-year-old Brazilian woman presented with mild facial muscle weakness, scapular winging and an asymmetric shoulder girdle, and peroneal weakness. Medical history disclosed mildly symptomatic Coats disease (CD) (figure). Muscle MRI studies were highly suggestive of facioscapulohumeral muscular dystrophy type 1 (FSHD1) (figure) and genetic testing confirmed this diagnosis.

Chronic Myopathy Associated With Anti-Signal Recognition Particle Antibodies Can Be Misdiagnosed As Facioscapulohumeral Muscular Dystrophy.

To report cases of chronic autoimmune necrotizing myopathy with anti-signal recognition particle antibodies (anti-SRP myopathy) initially misdiagnosed as muscular dystrophy, in particular, facioscapulohumeral muscular dystrophy (FSHD). Medical records of patients with anti-SRP myopathy in our institution were retrospectively reviewed. All 6 patients were initially diagnosed with muscular dystrophy because of the long-term clinical course and lack of inflammation on biopsy; 5 were diagnosed with FSHD based on a winged scapula. However, the following features suggested an alternative diagnosis, leading to anti-SRP antibody measurement: (1) lack of family history, (2) lack of facial involvement and asymmetry, (3) prominent dysphagia, and (4) profuse spontaneous activities on needle electromyography. All patients showed improvement with immunomodulating therapy. Anti-SRP antibody measurement should be considered in patients diagnosed with FSHD if they present with diagnostic hallmarks of anti-SRP myopathy listed above, to avoid oversight of this potentially treatable disorder.

Celiac Disease Associated with Facioscapulohumeral Muscular Dystrophy

Introduction. The association of celiac disease and facioscapulohumeral muscular dystrophy was not reported earlier in the literature. Case presentation. A 35-year-old woman diagnosed clinically with facioscapulohumeral muscular dystrophy 23 years ago. In the family history patients’ mother was diagnosed with facioscapulohumeral muscular dystrophy, too. Physical examination revealed bilateral facial weakness, she had narrow smile and murmuring speech. She had low-degree atrophy of shoulder girdle muscles with left-dominated scapular winging. facioscapulohumeral muscular dystrophy DNA testing showed allele 1 deletion. From 2001 on, patient presented epigastrial pain, diarrhoea, weight loss. She had permanent fatigue and she was unable to do regular physical exercises, which led to the progression of muscular dystrophy. Since serological examination detected elevated tissue transglutaminase and deaminated gliadin peptide antibodies levels, and duodenal biopsy revealed subtotal villous atrophy. Celiac disease was diagnosed. She started strict gluten free diet. After 3 months of gluten free diet, patient reported the elimination of gastrointestinal symptoms, better general condition, weight gain and increased muscle strength. Conclusion. Appropriate nutrition is essential for facioscapulohumeral muscular dystrophy patients, therefore detection and treatment of any disorders leading to malabsorption, most commonly celiac disease, are of utmost importance.

Posterior Shoulder Pain in a High School Football Lineman

HISTORY: 16yo high school football lineman presented with right shoulder pain. He initially noticed moderate pain after squatting 350lbs and placing the weight back down. The pain was sharp and painful when turning his head to the left. He was evaluated at an urgent care facility and felt to have a muscular injury and placed on muscle relaxants and anti-inflammatories. His pain improved transiently. He then re-injured this area when he was in gym class running hurtles and brought his arms across his chest in the front of him. He states that he heard a pop in his shoulder and had excruciating pain, and presented to the sports medicine clinic for further evaluation. The pain was pleuritic and still localized to the posterior shoulder. PHYSICAL EXAMINATION: BMI 33.5RR 17O2 Sat 99% He appeared moderately uncomfortable. He had full motion at the neck with no tenderness of the cervical spine. Bending to the left was mildly painful. He had a negative Spurling’s maneuver. He had tenderness over the medial rhomboids, trapezius, and overlying the scapular body. He had no scapular winging. He had full range of motion at the shoulder and 5/5 rotator cuff strength. He had no AC tenderness or pain with cross arm adduction. His lung fields were clear to auscultation with good air movement throughout. DIFFERENTIAL DIAGNOSIS: 1. Strain or partial tear of scapular stabilizer 2. Snapping Scapula (scapulothoracic bursitis) 3. First Rib Fracture TEST AND RESULTS: Three views of the right shoulder (AP, scapular Y, and lateral axillary) -Nondisplaced, oblique fracture through mid-portion of the first right rib Two views of clavicles (AP and 15 degree cephalic) -Fracture confirmed; no pneumothorax is visualized FINAL WORKING DIAGNOSIS: 1st Rib Stress Fracture secondary to scalene and serratus anterior contraction TREATMENT AND OUTCOMES: 1. Patient was placed in sling and provided with narcotic analgesia; pendulum exercises were emphasized. 2. At three weeks, repeat XR showed minimal displacement of the fracture. His sling was discontinued and he was allowed to start back light weight training (30lbs max). Physical therapy was ordered. 3. At 7 weeks, he was pain free with normal strength and allowed to resume normal weight lifting. 4. At 3 month follow up, repeat XR showed some callus formation. He was allowed to resume contact sports, such as football.

Shoulder Pain in a Swimmer

HISTORY: A 17 year old male, right hand dominant, competitive swimmer presented to clinic with a 2 week history of right shoulder pain. Initial pain was associated with coughing secondary to an upper respiratory infection and localized to the right upper trapezius and scapula. Several days later, he playfully lifted a heavy friend, felt more pain in the same area, and dropped his friend due to severe pain. Pain occasionally radiated down posterior arm. Exacerbating factors included overhead activities including swimming, shoulder abduction, cross body reaching, deep breathing and coughing. Past history included possible right shoulder dislocation in fifth or sixth grade, when shoulder “popped in and out”. PHYSICAL EXAM: Peripheral pulses intact, normal capillary refill. Breathing unlabored; pain with deep breathing. Strength, reflexes, and sensation normal. No evidence of atrophy, scapular winging, or swelling. No obvious tenderness to palpation. Full active shoulder range of motion with pain at terminal arc of forward flexion and abduction. No glenohumeral internal rotation deficit. Pain with horizontal cross-body adduction, Neer’s maneuver and resisted shoulder external rotation. DIFFERENTIAL DIAGNOSIS: 1. Rotator cuff injury 2. Shoulder impingement 3. Labral tear 4. Myofascial pain 5. Cervical strain or radiculopathy 6. Brachial plexitis/Parsonage turner 7. Spontaneous pneumothorax 8. Rib injury TEST AND RESULTS: Shoulder radiograph - Complete transverse fracture right 1st rib with associated soft tissue swelling. - Flattening of greater tuberosity of right humerus posterolaterally suspicious for a Hill-Sachs fracture. Slight deformity of tuberosity on external rotation view raises possibility of fracture. FINAL/WORKING DIAGNOSIS: Right first rib fracture TREATMENT AND OUTCOMES: 1. Initial treatment: No swimming. Encouraged rest, analgesia with Tylenol and avoidance of overhead activities and activities that caused pain including lifting. 2. Return visit 5 weeks after initial pain onset: Right rib radiograph showed a slightly comminuted and displaced fracture of the lateral aspect of the right 1st rib. On physical exam, full non-painful range of motion and strength of shoulder. 3. At 6 weeks, he gradually re-introduced upper body activity. 4. Returned successfully to competitive swimming.

Don’t Overlook Winging Scapula in a Patient Presenting with Shoulder Pain

Yaz›flma Adresi/Address for Correspondence: Dr. Alparslan Yetisgin, Harran Universitesi Tip Fakultesi, Fiziksel Tip ve Rehabilitasyon Anabilim Dali, Sanliurfa, Turkiye Tel.: +90 414 318 31 23 E-posta: dra_yetisgin@yahoo.comm Gelis Tarihi/Received: 03.09.2015 Kabul Tarihi/Accepted: 16.09.2015 Sayin Editor; Otuz bir yasinda erkek hasta 3 haftadir devam eden ve steroid olmayan antiinflamatuvar ilaclara cok az yanit veren sag omuz agrisi sikayeti ile fizik tedavi amaciyla poliklinigimize basvurdu. Hastanin dis merkezde yapilan tetkiklerinde; tam kan sayimi, bobrek ve karaciger fonksiyon testleri, brusella testleri, romatoid faktor duzeyi, kan urik asit duzeyi, eritrosit sedimentasyon hizi ve C-reaktif protein dahil tum kan tetkikleri normal sinirlardaydi. Omuz radyografisi normal iken servikal radyografisinde servikal lordozda duzlesme disinda ozellik yoktu. Sag omuz manyetik rezonans goruntuleme; akromioklavikuler eklemde dejeneratif hipertrofi, supraspinatus tendon yapisma duzeyinde hafif sinyal artimi (tendinozis ile uyumlu olabilir) ve biseps kasi uzun basi tendonu etrafinda hafif sivi olarak raporlanmisti. Ozgecmisinde herhangi bir sistemik hastalik, cerrahi veya travma oykusu yoktu. Hastanin fizik muayenesinde boyun eklem hareket acikligi (EHA) acik ve agrisiz, sag omuzda istirahatte de olan ve omuz hareketleri ile artan (ozellikle abduksiyon sonunda) agrisi vardi. Hastanin omuz EHA’si aktif ve pasif olarak tamdi. Zorlu omuz hareketlerinde sag ust kostalarda da hafif agri tarifledi. Anatomik pozisyonda hastanin omuz ve dorsal kisminin inspeksiyonunda sag skapula inferior bolgesinin sola oranla daha belirgin olmasi disinda ozellik yoktu (Resim 1). Kollar duvara dayanarak ve hastanin dirseklerinden tutarak omuzlarini 90 derece fleksiyonda kaldirmasi istendiginde sagda kanat skapula tespit edildi (Resim 2a ve 2b). Hastanin travma oykusu detayli sorgulaninca, omuz agrilari baslamadan 1 hafta once ev tasirken sag omuzunu biraz zorladigini ifade etti. Elektromiyografisinde; sag serratus anterior kasinda spontan denervasyon bulgulari ve tek ossilasyon paterni ile sag uzun torasik sinirde cok dusuk amplitudlu bilesik kas aksiyon potansiyelleri izlendi. Minor travmaya bagli oldugu dusunulse de sekonder nedenlerin dislanmasi icin danisilan gogus cerrahisi poliklinigi tarafindan istenen PA-AC grafisi ve toraks bilgisayarli tomografisinde ozellik yoktu. Hastaya uzun torasik sinir lezyonuna sekonder kanat skapula tanisi konularak fizik tedavi programi olarak 15 gun sureyle; glenohumeral eklemin pasif ve aktif EHA egzersizleri, omuz kaslari ve skapula stabilizatorlerine guclendirme egzersizleri, omuza transkutanoz elektriksel sinir stimulasyonu, sicak paket ve ultrason onerildi. Hasta fizik tedavi programini dis merkezde almak istedigi icin takip edilemedi. Kanat skapula, skapulanin medial kenari veya inferior acisinin gogus duvarindan uzaklasmasi ile karakterize, nadir gorulen, estetik ve fonksiyonel problemlere de yol acabilen klinik bir bulgudur. Uzun torasik sinir ve aksesuar sinir lezyonlari, kanat skapulanin en sik nedenlerindendir. Uzun torasik sinir 5. 6. ve 7. servikal sinirlerin on koklerinden ayrilan birer dalin birlesmesinden Harran Universitesi Tip Fakultesi, Fiziksel Tip ve Rehabilitasyon Anabilim Dali, Sanliurfa, Turkiye *Harran Universitesi Tip Fakultesi, Noroloji Anabilim Dali, Sanliurfa, Turkiye Alparslan Yetisgin, Mehtap Kocaturk*, Ali Sakalar Don’t Overlook Winging Scapula in a Patient Presenting with Shoulder Pain Omuz Agrisi ile Gelen Hastada Kanat Skapulanin Atlanmamasi DOI: 10.4274/tod.19970 Turk J Osteoporos 2016;22:69-70 Editore Mektup / Letter to Editor

Inferior angle of scapula fractures: a review of literature and evidence-based treatment guidelines

Inferior angle of scapula (IAS) fractures are rare, with very few cases reported. They typically present with pain, loss of shoulder motion, and scapula winging. Operative and nonoperative treatments have been trialed with varying success. The aim of this study was to gather data relating to IAS fractures to develop evidence-based treatment guidelines as none are currently available. A search was conducted of the PubMed and Google Scholar databases to identify cases of IAS fractures. Data collected about each case included age and gender of the patient, mechanism of injury, fracture displacement, treatment, and outcome. The authors report 2 additional IAS fracture cases. Ten cases were identified for inclusion in this study, 8 from the literature and 2 described by the authors. Of the 10 cases, 7 described displaced IAS fractures and 3 described undisplaced fractures. All displaced fractures treated nonoperatively resulted in a painful nonunion. All that underwent operative fixation, whether acutely or after failed nonoperative treatment, had resolution of pain and a good functional outcome. All undisplaced fractures were treated nonoperatively; 1 had persisting pain. Surgical exploration identified the fracture fragment attached to serratus anterior in 2 cases and attached to both serratus anterior and latissimus dorsi in 2 cases. There are limited data available about IAS factures. From the cases reviewed, treatment recommendations include the following: (1) displaced IAS fractures should undergo operative fixation to prevent the development of a painful nonunion; (2) suture repair provides adequate fixation; and (3) undisplaced fractures have a variable outcome when treated nonoperatively.

Prominent scapulae mimicking an inherited myopathy expands the phenotype of CHD7-related disease.

CHD7 variants are a well-established cause of CHARGE syndrome, a disabling multi-system malformation disorder that is often associated with deafness, visual impairment and intellectual disability. Less severe forms of CHD7-related disease are known to exist, but the full spectrum of phenotypes remains uncertain. We identified a de novo missense variant in CHD7 in a family presenting with musculoskeletal abnormalities as the main manifestation of CHD7-related disease, representing a new phenotype. The proband presented with prominent scapulae, mild shoulder girdle weakness and only subtle dysmorphic features. Investigation revealed hypoplasia of the trapezius and sternocleidomastoid muscles and semicircular canal defects, but he did not fulfill diagnostic criteria for CHARGE syndrome. Although the shoulders are often sloping and anteverted in CHARGE syndrome, the underlying neuromuscular cause has never been investigated. This report expands the phenotypes associated with CHD7 mutations to include a musculoskeletal presentation, with hypoplasia of the shoulder and neck muscles. CHD7 should be considered in patients presenting in childhood with stable scapular winging, particularly if accompanied by dysmorphic features and balance difficulties.

Winged scapula incidence and upper limb morbidity after surgery for breast cancer with axillary dissection.

The aim of this study was to determine the incidence of winged scapula after breast cancer surgery, its impact on shoulder morbidity and difference in incidence according to surgery type. Patients with breast cancer and surgical indication for axillary dissection were included. A total of 112 patients were surveyed with one physical evaluation before the surgery and others 15, 30, 90, and 180days after. Winged scapula was assessed with test proposed by Hoppenfeld. Shoulder range of motion (ROM) was assessed with goniometer for flexion, extension, adduction, abduction, internal rotation, and external rotation. A verbal scale from 0 to 10 was used to assess pain. Winged scapula incidence was 8.0% 15days after surgery. Two patients recovered from winged scapula 90days after surgery and four more 180days after surgery, while three patients still had winged scapula at this time. The incidence after 15days from surgery was 20.9 and 22.6% among patients submitted to sentinel node biopsy or axillary lymphadenectomy (AL), respectively (p < 0.01). There was no statistical difference of incidence according to breast surgery type. Operated side shoulder flexion, adduction, and abduction ROM changes were statistically different in patients with or without winged scapula. The mean reduction was higher in patients with winged scapula. Both groups showed the same pattern over time in pain. Winged scapula incidence was 8.0% and was higher in AL, and prevalence decreased during 6months after surgery. Patients who developed winged scapula had more shoulder flexion, adduction, and abduction limitation.

Non-tuberculous mycobacterial head and neck infections in children: Analysis of results and complications for various treatment modalities

ObjectivesAnalyze the results and complications of various surgical interventions in a large cohort of children with non-tuberculous mycobacterial (NTM) head and neck infections and suggest a heuristic treatment protocol for managing this condition while aiming to maximize cure and minimize complications. MethodsRetrospective chart review of 104 consecutive patients diagnosed with head and neck NTM at a tertiary paediatric hospital between January 1994 and December 2013 inclusive. Results104 patients ranged in age between 8 months to 15 years (mean age 27 months) were reviewed and 97 patients were included in the final analysis. 6 patients excluded due to lack of follow-up and one excluded due to systemic immunocompromised condition. Sub-sites of NTM infections were submandibular (n=48, 46%), cervical (n=40, 38%), parotid (n=18, 17%) and submental (n=4, 4%). Some patients had more than one lesion so counted twice. Higher cure rates were demonstrated for primary excision (81%, p<0.01) versus incisional interventions (44%, p<0.01). Marginal mandibular nerve palsy following surgery was seen in 7 patients (7.2%). This was permanent in 4 patients (4%) and temporary in 3 patients (3%). All children who were complicated with marginal mandibular palsies had lesions in the submandibular region. The rate of palsy for submandibular disease alone was 15%, while 8% presented permanent palsy and 6% temporary. Marginal mandibular nerve palsy was more likely following excisional compared to incisional procedures (6 versus 1 patient, p<0.01). Hypertrophic scarring occurred in 7 patients: 3 patients following excision and 4 patients after an incisional procedure. One patient suffered long term spinal accessory nerve damage presented as winged scapula. ConclusionsExcision of NTM provides better cure rates compared to incision although at the expense of long term post-surgical morbidity. Excision should probably be the first line of treatment when the risk for neural damage is low. Incision and drainage with or without antimycobacterial treatment may be the preferred option for at-risk sub-sites (submandibular or parotid) in order to reduce long term morbidity.

Kanat Skapula ile Prezente Olan Pancoast Tümörü

Kanat Skapula ile Prezente Olan Pancoast Tümörü

Entire pectoralis major tendon transfer with the hamstring tendon autograft for the treatment of scapular winging due to long thoracic nerve injury

Aim The aim of this study was to evaluate the results of treatment of patients with scapular winging due to long thoracic nerve (LTN) injury through the indirect transfer of the entire pectoralis major tendon (PMT) using the hamstring autograft. Patients and methods Between November 2011 and October 2012, six patients with painful scapular winging due to LTN injury underwent PMT transfer at Mansoura University Hospital and a private hospital. All patients were male with a mean age of 35.2 years at the time of surgery. All patients underwent clinical examination. All patients underwent plain radiography of the shoulder and electromyography and nerve conduction for the LTN. All patients were treated with the indirect transfer of the entire PMT to the inferior angle of the scapula using the hamstring autograft. Results The mean preoperative to postoperative results included increases in active forward flexion from 142.5° to 167.5° and active external rotation from 50° to 65°, and improvement in the American Shoulder and Elbow Surgeons score from 30 to 71.6 and Visual Analog Scale pain score from 6.3 to 1.8. Conclusion Entire PMT transfer with the hamstring tendon autograft is effective for restoring shoulder function, relieving shoulder pain, and treating scapular winging caused by serratus anterior paralysis due to electromyography-confirmed LTN injury.

Delayed Presentation of Osteochondroma at Superior Angle of Scapula-A Case Report.

Introduction:Osteochondroma or exostosis is most common primary benign bony tumor comprising of more than one third of the total occurrences. Osteochondromas are considered as an aberration in the normal physial growth plate and originate from the metaphysis of long bone with more than third (35-46%) of cases affecting the bone around the knee (lower end femur> upper end tibia), 10% cases involve the small bones of the hand and 5% involve the pelvis and flat bones like scapula (4-6%) are least involved. These tumors usually affect the growing skeleton and cease to increase in size after skeletal maturity. These are usually painless but may become painful due to neurovascular entrapment/compression, fracture at the stalk, bursal inflammation or malignant transformation.Case Presentation :This article presents a case of osteochondroma on superior angle of scapula in a 23-year-old male presented with pseudo winging and snapping of scapula, crepitus on scapulothoracic motion and occasional pain since 5 years. However, there was no increase in size of the swelling or local and systemic signs of malignant transformation. X-ray demonstrated a pedunculated exophytic mass on supero medial aspect of the right scapula. The findings were confirmed on CT and excision of the lesion was done. The patient demonstrated full painless range of motion after 1 month and no recurrence was demonstrated during 1 year follow up.Conclusion:Scapular osteochondroma is a relatively rare condition. Usually a patient presents in early to late childhood, however, in some cases it may be presented in adults. Growth after maturity is indicative of a metastatic transformation. So an excision of the same should be accompanied with histopathological examinations.

Posture and isokinetic shoulder strength in female water polo players

Background: Being overhead athletes, water polo players can present with muscular imbalances of the shoulder, between the internal rotators (IR) and external rotators (ER), leading to changes in posture and an increased risk of injury. Objectives: To assess posture and isokinetic shoulder strength of female club-level water polo players. Methods: A descriptive study assessing posture and isokinetic strength of the IR and ER shoulder muscles in 15 female club-level South African water polo players (age: 21.3 ± 1.5 years) was conducted. Posture was assessed using a posture grid. Isokinetic shoulder rotator muscle strength was tested over five repetitions concentrically and eccentrically at 60°/sec using a Biodex system 3 isokinetic dynamometer. The bilateral, reciprocal and functional dynamic control ratios (DCR) were calculated. Results: Typical postures noted were a forward head, rounded shoulders, increased thoracic spine kyphosis, elevated non-dominant shoulder and mild scapula winging. The mean concentric reciprocal ratios for the dominant (52.2 ± 7%) and non-dominant (51.9 ± 6.4%) sides indicated ER muscle weakness. DCR values were within normal limits for the group. (D: 0.75 ± 0.2 and ND: 0.75 ± 0.1). Conclusion: There is a trend for these female water polo players to have rounded shoulders and forward head postures, as well as ER muscle strength weakness, the combination of which could predispose the athletes to shoulder injury.

Dynamic Stabilization of the Scapula for Serratus Anterior Dysfunction: A Retrospective Study of Functional Outcome and Results

Background: Twenty-six patients (12 male and 14 female) with symptomatic scapular winging caused by serratus anterior dysfunction were managed by split pectoralis major tendon transfer (sternal head) with autogenous hamstring tendon augmentation from 1998 to 2006. Methods: Twenty-five patients showed positive results upon long thoracic nerve palsy on electromyography. The mean duration of symptoms until surgery was 48 months (range, 12–120 months). Four patients had non-traumatic etiologies and 22 patients had traumatic etiologies. On follow-up assessment for functional improvement, a Constant-Murley score was used. Twenty-one patients were completely evaluated, while five patients who had less than 12 months of follow-up were excluded. Results: Pain relief was achieved in 19 of the 21 patients, with 20 patients showing functional improvement. The pain scores improved from 6.0 preoperatively to 1.8 postoperatively. The mean active forward elevation improved from 108o (range, 20°–165°) preoperatively to 151° (range, 125°–170°) postoperatively. The mean Constant-Murley score improved from 57.7 (range, 21–86) preoperatively to 86.9 (range, 42–98) postoperatively. A recurrence developed in one patient. Of the 21 patients, ten had excellent results, six had good results, four had fair results, and one had poor results. Conclusions: Most patients with severe symptomatic scapular winging showed functional improvement and pain relief with resolution of scapular winging.

Scapula alata dynamique d’origine neuromusculaire : diagnostic clinique, électromyographique et à l’imagerie par résonance magnétique

Dyskinesia of the scapula is a clinical diagnosis and includes all disorders affecting scapula positioning and movement whatever its etiology. Scapular winging is a subtype of scapular dyskinesia due to a dynamic prominence of the medial border of the scapula (DSW) secondary to neuromuscular imbalance in the scapulothoracic stabilizer muscles. The two most common causes of DSW are microtraumatic or idiopathic lesions of the long thoracic nerve (that innerves the serratus anterior) or the accessory nerve (that innerves the trapezius). Diagnosis of DSW is clinical and electromyographic. Use of magnetic resonance imaging (MRI) could be of interest to distinguish lesion secondary to a long thoracic nerve from accessory nerve and to rule out scapular dyskinesia related to other shoulder disorders. Causal neuromuscular lesion diagnosis in DSW is challenging. Clinical examinations, combined with scapular MRI, could help to their specific diagnosis, determining their stage, ruling out differential diagnosis and thus give raise to more targeted treatment.

Limb-girdle muscular dystrophy type 2A in Brazilian children.

Calpainopathy is an autosomal recessive limb girdle muscular dystrophy (LGMD2A) caused by mutations in CAPN3 gene. To present clinical and histological findings in six children with a molecular diagnosis of LGMD2A and additionally the MRI findings in two of them. We retrospectively assessed medical records of 6 patients with mutation on CAPN3 gene. All patients were female (three to 12 years). The mean of age of disease onset was 9 years. All of them showed progressive weakness with predominance in lower limbs. Other findings were scapular winging, joint contractures and calf hypertrophy. One female had a more severe phenotype than her dizygotic twin sister that was confirmed by muscle MRI. Muscle biopsies showed a dystrophic pattern in all patients. In this cohort of children with LGMD2A, the clinical aspects were similar to adults with the same disorder.