Thoracic Nerve Palsy Research Articles

Long-term outcomes of pectoralis major transfer for scapular winging due to long thoracic nerve palsy: results after a median follow-up of 17 years

A pectoralis major (PM) transfer is a viable treatment option for patients with scapular winging due to long thoracic nerve (LTN) palsy not responding to nonsurgical management. However, the long-term outcomes remain unknown. Therefore, the purpose of this study was to evaluate the long-term outcome of shoulder function (ie, minimum follow-up of 10 years) and quality-of-life (QoL) of patients treated for scapular winging due to LTN palsy with a PM transfer. This observational cohort study included 15 patients (16 shoulders) who underwent PM transfer, using a tendoachilles allograft, between 1995 and 2012. Shoulder forward flexion and abduction were analyzed preoperatively, 1 year after surgery and at the final follow-up. SF-36 component scores (physical component summary (PCS) and mental component summary (MCS)) were used to evaluate the QoL. Shoulder forward flexion and abduction measured in degrees improved from 86 (SD 14.5) and 82 (SD 33.8) preoperatively to 140 (SD 27.3) and 138 (31.3) at 1 year postoperatively. After a median follow-up of 17 years, mean shoulder functions were slightly lower than at 1 year postoperatively, but still better than preoperative function, ie, forward flexion 121 (SD 41.9) and abduction 122 (SD 44.5). The mean PCS score at the final follow-up was 41.9 (SD 9.7), and the mean MCS score was 49.9 (SD 12.5). Better shoulder function at the final follow-up was significantly associated with higher QoL in terms of PCS scores (P=.023), but not MCS scores (P=.287). The results of the present study indicate that PM transfer augmented with an achilles tendon allograft for scapular winging due to LTN palsy leads to functional improvements that persist in long term. These functional improvements likely translate to better QoL based on their association.

A Case Study on a Collegiate Baseball Player with Long Thoracic Nerve Palsy

A Case Study on a Collegiate Baseball Player with Long Thoracic Nerve Palsy

Scapular Winging in a Young Tennis Player: A Case Report

BACKGROUND: Facioscapulohumeral muscular dystrophy (FSHD) is often characterized by weakness of the scapular stabilizing muscles. FSHD is a genetic disorder in which skeletal muscles of the face (facio), the shoulder blades (scapulo), arms (humeral), and other muscles progressively weaken over time. 5 CASE PRESENTATION: A 13-year-old tennis player developed progressive right shoulder pain and limited range of motion. He did not have a precedent injury and his symptoms were exacerbated by tennis. His exam was notable for medial scapular winging. An electromyogram was read as a long thoracic nerve palsy, presumed to be a tennis-related traction injury. He was treated with aggressive therapy, taping, and bracing to improve scapulothoracic and glenohumeral biomechanics for optimal upper extremity strength and range of motion. OUTCOME AND FOLLOW-UP: His pain and motion improved, but he was unable to return to his prior level of tennis competition. Eighteen months after the initial diagnosis, the patient presented with similar symptoms and findings on the contralateral side, raising concern for a neuromuscular etiology. DISCUSSION: A repeat electromyogram and genetic tests were consistent with FSHD, rather than a sport-related peripheral nerve injury. JOSPT Cases 2023;3(2):96–99. Epub: 13 March 2023. doi:10.2519/josptcases.2023.10887

Clinical Examination and Electrodiagnostic Testing in a Rare Case of Long Thoracic Nerve Palsy Following Surgeries Related to an Emergency Appendectomy: A Case Report

BACKGROUND: Postoperative neuropathy is an infrequent but potentially serious complication of surgery and may result in significant morbidity. While mechanical injury and perioperative factors are commonly implicated, etiology of postoperative neuropathy can be unclear, particularly when the lesion is spatially remote from the surgical site. CASE PRESENTATION: A 27-year-old male Doctor of Physical Therapy student presented to his orthopaedic professor during class describing a 10-week history of significant right shoulder weakness following surgeries related to an emergency appendectomy. Examination revealed unilateral scapular winging and findings consistent with long thoracic nerve (LTN) palsy. Given the unknown etiology, electrodiagnostic (EDX) testing was subsequently performed for diagnostic clarity. OUTCOME AND FOLLOW-UP: Clinical and EDX examinations confirmed an isolated LTN palsy, while ruling out competing neurogenic and orthopaedic etiologies. Seven-month follow-up revealed minimal subjective and objective improvement in shoulder function and continued scapular winging. DISCUSSION: Orthopaedic physical therapy examination, including EDX testing, correctly identified a rare case of LTN palsy following surgeries related to an emergency appendectomy. Findings informed prognosis and guided exercise prescription. JOSPT Cases 2023;3(1):53–58. Epub: 14 December 2022. doi:10.2519/josptcases.2022.11457

Pectoralis Major Transfer for Medial Scapular Winging

Background: Scapular winging is a rare and often misdiagnosed disorder, which can be painful and functionally limited. Medial scapular winging is often due to serratus anterior dysfunction in the setting of a long thoracic nerve palsy. While nonoperative management can be successful, transfer of the pectoralis major with autograft hamstring augmentation to the inferior scapula is an effective operative means of relieving pain and restoring shoulder function in those who fail conservative management. Indications: The patient is a 16-year-old woman with symptomatic medial scapular winging who had a complete workup and 6-month course of conservative treatment, including physical therapy. Thus, we elected to proceed with a 2-incision transfer of the sternal head of pectoralis major transfer with autograft hamstring augmentation to the inferior scapular angle. Technique Description: A 2-incision transfer of the sternal head of pectoralis major with autograft hamstring to the inferior scapular angle is a strong and reliable method of operatively treating medial scapular winging. In addition, performing this operation in the lateral position allows for ease of access to both the anterior and posterior incisions. Results: At 1-year follow-up, the patient had full, painless range of motion of the shoulder with 5/5 strength in all tested planes. She also had returned to all activities, including softball, without restrictions. Discussion/Conclusions: A 2-incision transfer of the sternal head of the pectoralis major with autograft hamstring augmentation to the inferior scapular angle is an effective means of operatively treating medial scapular winging. Multiple studies have shown that this operation improves motion, pain, and function for those who have failed an appropriate course of conservative treatment. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Subcutaneous lobular capillary hemangioma mimicking brachial plexus neurofibroma

To describe the case of subcutaneous lobular capillary hemangioma (LCH) mimicking brachial plexus neurofibroma. Pyogenic granuloma or LCHs is benign vascular lesions affecting the superficial dermis or mucous membranes. Subcutaneous forms have been very rarely reported. We present the rare case of a 22-year-old female presented with a 5-year history of firm gradually progressive left supraclavicular swelling. The patient had an iatrogenic long thoracic nerve palsy from an exploration and partial excision 3 years back in another hospital and had developed axillary and suprascapular nerve palsy for the last 2 years. Imaging was suggestive of a large contrast-enhancing supraclavicular lesion involving the brachial plexus. The lesion was explored and total excision was achieved under neuromonitoring without any new deficits. The histopathological examination revealed a diagnosis of a LCH. Subcutaneous LCH involving the brachial plexus is a rare entity. Surgical excision assisted by neuromonitoring provides good outcomes. Subcutaneous LCH is a rare diagnosis but can mimic a neurofibroma of the brachial plexus and should be kept as a differential diagnosis.

The Use of Spinal High-Velocity Thrust Manipulation and Changes in Serratus Anterior Strength in an Individual With Long Thoracic Nerve Palsy: A Case Report

BACKGROUND: Spinal manipulation may produce neurophysiologic effects by stimulating central control mechanisms that result in an increase in strength. The purpose of this case report was to observe changes in serratus anterior (SA) strength in an individual with long thoracic nerve palsy who received spinal manipulation and exercise. CASE PRESENTATION: A 28-year-old female with diagnosis of long thoracic nerve palsy with SA weakness was seen for 8 visits for spinal manipulation, followed by 15 weeks of scapulothoracic stabilization exercise. OUTCOME AND FOLLOW-UP: Immediate and short-term (20 weeks) improvement in SA strength was reported. Scapular posture and dyskinesis improved, but deficits persisted. DISCUSSION: Although cause and effect cannot be established, manipulation followed by resistance training may have an impact on strength deficits resulting from peripheral nerve injury but appears to be insufficient in the amelioration of scapular dyskinesis. JOSPT Cases 2022;2(4):248–254. Epub: 12 October 2022. doi:10.2519/josptcases.2022.11177

Winged Scapula: Clinical and Electrophysiological Features and Common Causes Based on 20 Years of Experience in a Referral Center in Turkey.

Winged scapula (WS) is a functionally disabling problem and it occurs because of neurogenic causes frequently. The authors aimed to assess WS patients by physical and electrodiagnostic examinations as well as some further investigations and define the common causes of WS. The authors reviewed clinical and neurophysiological findings of 52 patients who were referred for electrodiagnostic examination because of WS in the period of 20 years. The mean age was 39 (range, 11-73) years and 32 were male patients. Right side was involved in 60% of patients (n = 31). According to electrodiagnostic examinations, 44 patients (85%) had neurogenic causes; 29 spinal accessory nerve palsy (17 occurred after surgical procedure), nine long thoracic nerve palsy (four occurred after strenuous activity), two dorsal scapular nerve (both neuralgic amyotrophy), one long thoracic nerve and spinal accessory nerve (relevant with strenuous trauma), one spinal accessory nerve and dorsal scapular nerve palsies (after surgical procedure and radiotherapy), one C5-7 radiculopathy (avulsion), and one brachial plexopathy (obstetric trauma). Five patients (10%) had muscle-related findings (four facio-scapulo-humeral dystrophy and one Duchenne muscular dystrophia) and three patients (5%) had normal findings (bone-joint related). This study presents a relatively large series of patients with WS because of several causes from a referral tertiary EMG laboratory. The authors found that spinal accessory nerve palsy after neck surgery is the most common cause and long thoracic nerve palsy is the second common cause of unilateral WS. Electrodiagnostic examinations should be performed in WS patients to establish exact diagnosis and reveal some coexistence of WS causes.

Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury

Preoperative diagnosis of long thoracic nerve (LTN) palsy is important for shoulder reconstruction after a traumatic brachial plexus injury (BPI). In the present study, we developed an objective diagnostic method for LTN palsy for patients with traumatic BPI. This is a retrospective review of 56 patients with traumatic BPI who had been receiving treatment at a single institution for over 8 years. The patients were divided into 2 groups: an LTN palsy group (n = 30) and a no palsy control group (n = 26). The LTN palsy group had 21 different palsy types with 4 and 5 C5-7 and C5-8, whereas the no palsy group had 18 different palsy types with 5 and 3 C5-6 and C5-8, respectively. Preoperative plain anteroposterior radiographs were taken in shoulder adduction and shrug positions. Scapulothoracic (ST) upward rotation and clavicle lateral (CL) rotation angles were measured on X-rays. The differences between the adduction and shrug positions for the respective angles were calculated and defined as ΦST and ΦCL, respectively. The differences in the ΦSTand ΦCL values due to the presence or absence of LTN palsy were examined, the cutoff values of ΦSTand ΦCLfor the diagnosis of LTN palsy were determined, and further sensitivity and specificity were calculated. Both ΦSTand ΦCLwere significantly decreased in the LTN palsy group compared with the no palsy control group. The sensitivity and specificity for LTN palsy were 0.833 and 1.000 for ΦSTand 0.833 and 0.840 for ΦCL, respectively, when the cutoff value was set as ΦST= 15° and ΦCL≤ 24°. Dynamic shrug radiographs provide a useful objective diagnosis of LTN palsy after traumatic BPI.

P51 Is it injury or inflammation: teenage boy with back pain

Abstract Background A 14 year-old boy was referred by an orthopaedic colleague at the district hospital for evaluation of ankylosing spondylitis. The child was previously fit and well. His symptoms reported at the referral was back pain and also possibility of foot drop on the right ankle. His dad had ankylosing spondylitis and was on biologic treatment. Also, there was significant history of autoimmunity in other family members. Methods During the initial consultation, we revisited the history. The boy reported that main symptoms were recurrent popping sensation of his right side shoulder associated with pain and burning sensation on the shoulder which usually settles after an hour. He is sporty boy and plays regular rugby, football and used to throw discus. He denied any history of injury or illnesses preceding his symptoms. There was past history of fracture of right ankle on two occasions managed conservatively. There were no other systemic symptoms. On examination, the child was afebrile and systemically looked well. There was no lymphadenopathy, mouth ulcers or clubbing. His cardio respiratory examination was normal. Abdomen was soft with no organomegaly. He was noted to have winging of scapula on the right side and weakness of the abductor muscles on the right side shoulder. There was wasting of muscles around the right ankle. He was noticed to have bilateral cavovarus and high arched feet. There was scoliosis at the thoracic and lumbar level. His muscle tone, power and reflexes were all normal. Results With his clinical presentation of winging of scapula, long thoracic nerve palsy was considered and he was referred to local physiotherapy. MRI spine done at local hospital was reviewed in the MSK radiology meeting and this showed no evidence of ankylosing spondylitis and confirmed scoliosis. His blood tests showed normal full blood count, liver and kidney function, raised creatinine kinase of 358 and HLA B27 positive. The repeat creatinine kinase was normal (153).The nerve conduction study of both the upper and lower limbs were normal. He was also seen by the neurology team. Further discussion with sport medicine colleagues and advised to continue physiotherapy. On the review 3 months later, his symptoms were much improved. Conclusion The presentation of a teenage boy with back pain and family history of ankylosing spondylitis warrants further evaluation. Thorough history, examination and early referral to specialist centre is beneficial for appropriate management of complex situations like this. Conflicts of Interest The authors declare no conflicts of interest.

Unilateral winged scapula: Clinical and electrodiagnostic experience with 128 cases, with special attention to long thoracic nerve palsy.

In this study we report a large series of patients with unilateral winged scapula (WS), with special attention to long thoracic nerve (LTN) palsy. Clinical and electrodiagnostic data were collected from 128 patients over a 25-year period. Causes of unilateral WS were LTN palsy (n = 70), spinal accessory nerve (SAN) palsy (n = 39), both LTN and SAN palsy (n = 5), facioscapulohumeral dystrophy (FSH) (n = 5), orthopedic causes (n = 11), voluntary WS (n = 6), and no definite cause (n = 2). LTN palsy was related to neuralgic amyotrophy (NA) in 61 patients and involved the right side in 62 patients. Clinical data allow for identifying 2 main clinical patterns for LTN and SAN palsy. Electrodiagnostic examination should consider bilateral nerve conduction studies of the LTN and SAN, and needle electromyography of their target muscles. LTN palsy is the most frequent cause of unilateral WS and is usually related to NA. Voluntary WS and FSH must be considered in young patients. Muscle Nerve 57: 913-920, 2018.

Surgical and Clinical Decision Making in Isolated Long Thoracic Nerve Palsy.

Isolated long thoracic nerve palsy results in scapular winging and destabilization. In this study, we review the surgical management of isolated long thoracic nerve palsy and suggest a surgical technique and treatment algorithm to simplify management. In total, 19 patients who required surgery for an isolated long thoracic nerve palsy were reviewed retrospectively. Preoperative demographics, electromyography (EMG), and physical examinations were reviewed. Intraoperative nerve stimulation, surgical decision making, and postoperative outcomes were reviewed. In total, 19 patients with an average age of 32 were included in the study. All patients had an isolated long thoracic nerve palsy caused by either an injury (58%), Parsonage-Turner syndrome (32%), or shoulder surgery (10%); 18 patients (95%) underwent preoperative EMG; 10 with evidence of denervation (56%); and 13 patients had motor unit potentials in the serratus anterior (72%). The preoperative EMG did not correlate with intraoperative nerve stimulation in 13 patients (72%) and did correlate in 5 patients (28%); 3 patients had a nerve transfer (3 thoracodorsal to long thoracic at lateral chest, 1 pec to long thoracic at supraclavicular incision). In the 3 patients who had a nerve transfer, there was return of full forward flexion of the shoulder at an average of 2.5 months. A treatment algorithm based on intraoperative nerve stimulation will help guide surgeons in their clinical decision making in patients with isolated long thoracic nerve palsy. Intraoperative nerve stimulation is the gold standard in the management of isolated long thoracic nerve palsy.

Pectoralis Major Transfer for Treatment of Serratus Anterior Dysfunction in the Setting of Long Thoracic Nerve Palsy

Symptomatic scapular winging resulting in scapular dyskinesia leads to a wide spectrum of clinical complaints, most notably periscapular pain. The malpositioning of the scapula, termed through use of the acronym SICK (scapular malposition, inferior-medial border prominence, coracoid pain and malposition, and dyskinesia of scapular movement), is due to the irregular activity of one or more of the periscapular muscles. In particular, the serratus anterior, innervated by the long thoracic nerve, is a key muscle that stabilizes the scapula and provides coordinated scapulohumeral rhythm. If the long thoracic nerve is injured, this results in significant shoulder dysfunction and scapular winging that may require surgical intervention. The purpose of this Technical Note is to present our preferred technique to treat symptomatic scapular winging due to long thoracic nerve palsy through transfer of the pectoralis major with its bone insertion to the inferior edge of the scapula.

Indirect transfer of the sternal head of the pectoralis major with autogenous semitendinosus augmentation to treat scapular winging secondary to long thoracic nerve palsy

Scapular winging resulting from long thoracic nerve palsy is uncommon but debilitating, and the choice of surgical treatment is inconsistent. The autogenous semitendinosus tendon plays a key role as an interposed tendon graft, although its use in the indirect transfer of the sternal head of the pectoralis major during the treatment of scapular winging has rarely been reported. A retrospective review was performed during a 9-year period from the clinical data of 26 cases (28 shoulders) with indirect transfer of the sternal head of the pectoralis major with the interposition of an autogenous semitendinosus tendon graft for dynamic stabilization of the scapula. The range of active movement (forward elevation, abduction, and external rotation), American Shoulder and Elbow Surgeons score, visual analog scale score, and complications were evaluated with a mean of 47 months of clinical follow-up. Patients' active shoulder movements (forward elevation, abduction, and external rotation), American Shoulder and Elbow Surgeons score, and visual analog scale score showed significant improvements (P < .01). One seroma developed and resolved with extraction. Four shoulders had adhesive capsulitis and recovered after physiotherapy. There was no recurrence of scapular winging in any patient. Timely treatment, often surgical, is vital to the recovery of scapular winging secondary to long thoracic nerve palsy. Our results suggest that indirect transfer of the sternal head of the pectoralis major with interposition of the autogenous semitendinosus tendon can effectively treat scapular winging due to long thoracic nerve palsy with limited sequelae. Widespread use of this technique is recommended.

“Isolated long thoracic nerve palsy”: More than meets the eye

Two main hypotheses have been proposed for the pathophysiology of long thoracic nerve (LTN) palsy: nerve compression and nerve inflammation. We hypothesized that critical reinterpretation of electrodiagnostic (EDX) studies and MRIs of patients with a diagnosis of non-traumatic isolated LTN palsy could provide insight into the pathophysiology and, potentially, the treatment. A retrospective review was performed of all patients with a diagnosis of non-traumatic isolated LTN palsy and an EDX and brachial plexus or shoulder MRI studies performed at our institution. The original EDX studies and MR examinations were reinterpreted by a neuromuscular neurologist and musculoskeletal radiologist, respectively, both blinded to our hypothesis. Seven patients met the inclusion criteria as having a non-traumatic isolated LTN palsy. Upon reinterpretation, all of them were found to have findings not consistent with an isolated LTN. On physical examination, three of them (43%) presented with weakness in muscles not innervated by the LTN. Four of them (57%) had additional EDX abnormalities beyond the distribution of the LTN. Five of them (71%) had MRI evidence of enlargement of nerves or denervation atrophy of muscles outside the innervation of the LNT, without evidence of compression of the LTN in the middle scalene muscle. In our series, all 7 patients, originally diagnosed as having an isolated LTN, on reinterpretation, were found to have a more diffuse muscle/nerve involvement pattern, without MR findings to suggest nerve compression. These data strongly support an inflammatory pathophysiology.

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.

Right Arm Pain In A Collegiate Softball Shortstop

HISTORY: 18 year old right hand dominant female college softball shortstop complaining of right elbow pain x 5 months. She describes paresthesias from elbow to hand, along with notable weakness in the hand. Pain worsens with overhead activity, improves with resting arm at her side. Hx of subluxation of right shoulder several years earlier. PHYSICAL EXAMINATION: Right Shoulder: Inspection: prominence winging of scapulae b/l, + scapular dyskinesia b/l. ROM: Flexion:180, Extension:60, Adduction:nl, Abduction:180, Ext rot:90, Internal rot:T10. Palpation: AC/SC/Clavicle:non TTP. MSK Strength: Supraspinatus:5/5, Infraspinatus:5/5, Subscapularis:5/5. Special test:Jobe’s test:Neg, Hawkins-Kennedy test:Neg, Speeds test:+, Biceps tendon:+TTP, Cross chest Adduction:Neg, Obrien’s test:Neg, Neer’s test:Neg, Tinel’s test: Neg, Scapular Function: Severe dysfunction of right scapula, + profound winging b/l, Rt>Lt, + wall push up test. Roos:+, Adson’s:+ recurrence of symtpoms. DIFFERENTIAL DIAGNOSIS: Thoracic Outlet Syndrome, Long Thoracic nerve palsy, Cervical Radiculopathy, Myofascial pain syndrome, Shoulder impingement syndrome, Cubital tunnel syndrome, Scapular dyskinesia TEST AND RESULTS: A/P Xray C-spine: unremarkable, no abnormalities of alignment seen or cervical ribs noted. EMG: All nerve conduction velocities, terminal latencies, and amplitudes were wnl’s, with the exception of very mild slowing of all nerve conduction velocity across the ulnar groove with no loss of amplitude. The right serratus anterior revealed silence at rest with normal motor units and it is recruitment when samples at the rivet insertion. When sampled at the origin while the pt intentionally caused scapular winging, this also revealed silence at rest with no volitional activity. FINAL WORKING DIAGNOSIS: Thoracic outlet syndrome secondary to scapular dyskinesia, with congenital denervation vs. absence of serratus anterior muscle. TREATMENT AND OUTCOMES: 1.Referral to formal PT for rotator cuff/scapular strengthening and stabilization exercises. Office f/up in 4 wks, pt is struggling to return to collegiate softball play at a high level. Pt continues to have numbness and tingling in right hand. Pt continues physical therapy.

Analysis of complications of reverse total shoulder arthroplasty.

the aim of this study was to analyze complications of reverse total shoulder arthroplasty (RTSA) used to treat different shoulder diseases. from March 2000 to March 2013, 195 RTSA were implanted by the senior Author. The indications for reverse prosthesis surgery were secondary osteoarthritis (OA) in 49 cases, irreparable rotator cuff tear (RCT) in 48 cases, and complex humeral fractures in 75 cases, while 19 were patients requiring surgical revision for first prosthesis implant. We used different prostheses with different designs. the clinical and radiological results of all the patients were analyzed retrospectively at an average follow-up of 7 years. The cases were divided into four groups on the basis of the diagnosis and complications were classified as perioperative, postoperative, or late. The mean total Constant score improved from 28 to 69 points in the OA group; from 21 to 70.8 points in the irreparable RCT group, to 76.4 in the fracture group, and from 16.6 to 59.8 points in the revision group. Scapular notching was observed in 59 cases (30.2%). Thirty-three other complications (16.9%) were observed, namely: hematomas (n=3), instability of the humeral component (n=1), scapular spine fractures (n=2), ulnar nerve deficit (n=2), long thoracic nerve palsy (n=2), deep infections (n=2), periprosthetic fractures (n=6), glenoid fractures (n=2), implant loosening (n=2), anterior deltoid muscle deficiency (n=2) and periarticular heterotopic calcifications (n=9). the rates of complications, especially fractures, reported in the present study were lower than those reported in the current literature. Level IV, therapeutic case series.

A comprehensive analysis of pectoralis major transfer for long thoracic nerve palsy

In the treatment of long thoracic nerve palsy with pectoralis major transfer, it remains unknown whether direct transfer of the pectoralis to the scapula or indirect transfer with an interpositional graft provides superior outcomes. A 3-tiered study was performed to gain a comprehensive understanding. (1) A survey of the membership of the American Shoulder and Elbow Surgeons (ASES) was conducted to reach a Level V consensus. (2) A systematic review was conducted to identify all series evaluating direct and indirect transfer of the pectoralis major tendon to create a Level IV consensus. (3) A retrospective review was performed to provide Level III evidence. (1) Surgeons were evenly split between whole and split tendon transfers, direct and indirect transfers, and graft types. More experienced surgeons were more likely to prefer an indirect transfer. (2) Analysis of 10 Level IV studies (131 shoulders) revealed that patients who underwent indirect transfer were significantly more likely to develop recurrent winging (P=.009) and had lower active forward elevation (P<.001) and ASES scores (P=.0016). (3) Twenty-four patients were included in our retrospective review with a mean follow-up of 4.3years (77% follow-up), of whom 14 underwent indirect transfer and 10 underwent direct transfer. There were no significant differences in recurrence of winging, range of motion, or ASES scores. Level V and III evidence suggests that there is no functional difference between direct and indirect transfer. Level IV evidence must be interpreted with caution.

Osteochondroma as a Cause of Scapular Winging In an Adolescent Girl- Case Report

Introduction: Although long thoracic nerve palsy is the classical pathogenesis of winging scapula, it may also be caused by osteochondroma. We report a rare case of a scapular osteochondroma arising from the medial border and causing a pseudowinging of the scapula. Case presentation: 15 year old girl presented with progressive deformity and painless swelling in the medial aspect of scapula. Clinical examination showed bony hard swelling in the medial aspect of scapula and had full painless range of movement with grating sensation on extreme range of movement. Patient was investigated and underwent open surgical excision. A histopathology examination confirmed the clinical diagnosis of osteochondroma. A clinical examination three months later showed a painless full range of motion and absence of grating sensation and disappearance of deformity. Conclusion: osteochondroma should be considered in the differential diagnosis for any adolescent presents with a winging of the scapula.