Scapular Winging Research Articles

Modified Eden-Lange Triple-Tendon Transfer for Chronic Trapezius Palsy

Background: Trapezius palsy can occur due to traumatic or idiopathic spinal accessory nerve injury. As a result of trapezius palsy, shoulder girdle imbalance can develop and present as lateral scapular winging and diminished shoulder range of motion and function. The modified Eden-Lange triple-tendon transfer procedure is a notable salvage operation which can treat chronic trapezius palsy after failure of conservative and nonsalvage interventions. Indications: A 42-year-old right-hand dominant woman who underwent a cervical lymph node biopsy 3 years before presents with chronic left shoulder weakness, severe shoulder pain, and scapular winging. On presentation, she has failed conservative treatments and operative interventions including attempted spinal accessory nerve exploration and repair with ansa cervicalis autograft. Technique Description: A modified Eden-Lange triple-tendon transfer, using the Elhassan modification, was performed to treat the patient’s chronic trapezius palsy. The levator scapulae, rhomboid minor, and rhomboid major were sequentially transferred to the lateral scapular spine, central scapular spine, and medial scapular spine, respectively. Results: At interval follow-up, the patient was recovering well from her operation and with progressively improving range of motion and strength. Discussion/Conclusion: The modified Eden-Lange triple-tendon transfer technique is a salvage procedure for treating chronic trapezius palsy by anatomically reconstructing the force vectors of the native trapezius muscle. Effective restoration of proper scapular and shoulder kinematics via the triple-tendon transfer technique can result in improved pain and shoulder girdle function. 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.

Синдром крыловидной лопатки

Since A. Velpeau [1] first described a case of isolated paralysis of the anterior serratus muscle leading to the development of winged scapula syndrome, it has been shown that this lesion leads to shoulder joint dysfunction and the development of pain syndrome. Correct movement and positioning of the scapula relative to the rib cage is essential for proper shoulder joint function and positioning of the upper extremity in space. Weakness and loss of biomechanics of scapula motion leads to difficulty in lifting the upper extremity as well as lifting weights. According to the literature, the most common causes of winged scapula syndrome are injuries of the long thoracic nerve (paralysis of the anterior serratus muscle) and the spinal accessory nerve (paralysis of the trapezius muscle). The number of cases of anterior serratus muscle paralysis ranges from 0.0026 to 0.21% [2]. Most authors focus on nerve damage leading to paralysis of the anterior dentate and trapezius muscles. However, in 1930, S. Fichet described the development of winged scapula syndrome as a result of traumatic detachment of the muscles surrounding the scapula [3]. Traumatic detachment of the anterior serratus, trapezius, and rhomboid muscles is an important and understudied problem leading to shoulder joint dysfunction and development of winged scapula. The aim of the review is to study the main injuries leading to the development of wing-shaped scapula syndrome, as well as the main methods of diagnosis and treatment of this pathology.

Comparison of Strength and EMG Activity of Shoulder Flexor Muscles and Scapular Winging in Subjects with and without a Winged Scapula during Shoulder Flexion

Background Subjects with a winged scapula (WS) can cause musculoskeletal disorders of the shoulder due to uncontrolled movement of the scapula during shoulder flexion. A WS results in abnormal positioning of the scapula, leading to shoulder dysfunction. Objectives This study is to compare shoulder flexion strength, electromyography (EMG) activity of the periscapular muscles, and scapular winging during shoulder flexion in subjects with and without a WS. Methods Twelve with and thirteen without a WS participated in this study. To compare shoulder flexion strength, muscle activity, and scapular winging between the two groups, maximal flexion was measured using a tensiometer during shoulder flexion. Concurrently, surface EMG was used to measure the activities of the upper trapezius (UT), anterior deltoid (AD), serratus anterior (SA), and lower trapezius (LT) muscles, and a scapulometer was used to measure scapular winging during shoulder flexion. The independent t-test was used to compare shoulder flexion strength, muscle activity, and scapular winging between the two groups. Results There was no significant difference in shoulder flexion strength between the two groups (p = 0.172). The activities of the SA and UT muscles decreased significantly in subjects with a WS compared to subjects without a WS (p = 0.001 vs p = 0.023). In addition, scapular winging was significantly greater in subjects with a WS compared to those without a WS (p = 0.001). Conclusions These findings muscle activities of the SA and UT in subjects with WS is associated with upward rotation of the scapula and scapular winging rather than shoulder flexion strength. This may be supporting evidence for exercises reflecting the degree of activity of the muscles around the shoulders rather than focusing on the shoulder flexor during physical therapy related to shoulder flexion in a clinical setting.

Scapular winging due to rhomboid muscle paralysis: clinical assessment of 4 cases and anatomic study of the dorsal scapular nerve.

A rare cause of scapular winging is rhomboid muscle paralysis secondary to dorsal scapular nerve (DSN) neuropathy. This paralysis causes winging of the medial border of the scapula with lateral rotation of its inferior angle. We report a series of 4 clinical cases of isolated DSN compression and the results of a specific rehabilitation protocol. A continuous clinical series of 4 patients with isolated rhomboid muscle deficiency was analyzed. Two patients were men and 2 were women, with a mean age of 40years (range, 33-51years). Three patients were right-handed and 1 was left-handed. Scapular winging always affected the dominant side. Two patients had occupations involving heavy physical work. The sports practiced involved exertion of the arms (dancing, boxing, gymnastics, muscle strengthening). A specific rehabilitation protocol was offered to the patients. In addition, 6 fresh cadaver dissections were performed to reveal possible DSN compression. Potential areas of compression were identified, in particular when the arm was raised. The 4 patients presented with isolated DSN neuropathy were confirmed by electroneuromyographic testing. Total correction of scapular winging was not obtained in any patient. Three patients experienced residual pain with a neuropathic pain by the questionnaire for a Diagnosis of Neuropathic Pain (DN4) score of 2. The mean Quick-Disabilities of the Arm, Shoulder and Hand (DASH) score after treatment was 31.8 of 100. The mean ASES score was 56.2. Only 1 patient agreed to rehabilitation in a specialized center and underwent follow-up electroneuromyography. Signs of rhomboid muscle denervation were no longer present and distal motor latencies had become normal. In all cadaver dissections, the DSN originated from the C5 nerve root and did not pass through the middle scalene muscle. We identified a site of dynamic compression of the DSN by the upper part of the medial border of the scapula when the arm was raised. DSN compression is conventionally attributed to the middle scalene muscle, but it is noteworthy that our study reveals the possibility of dynamic compression of the nerve by the proximal part of the medial border of the scapula, which occurs when the arm elevation is above 90°. Our study reveals the possibility of dynamic compression of the DSN by the proximal part of the medial border of the scapula, which occurs when the arm is raised above 90°. In the absence of a surgical solution, conservative treatment is fundamental and requires management in a rehabilitation center with intervention by a multidisciplinary team.

Serratus anterior plane block with ultrasound-guided hydrodissection for lateral thoracic pain caused by long thoracic nerve neuropathy – A case report -

Long thoracic nerve (LTN) neuropathy occasionally occurs in young people who engage in various sports. It may have a traumatic or non-traumatic etiology. The landmark manifestation of LTN neuropathy is scapular winging; however, it can also occur without scapular winging and specific magnetic resonance imaging findings. An 18-year-old male complained of right-sided lateral chest pain for 7 months. He was treated with medication, trigger point injection, and physical therapy but showed no improvement. Electromyelogram findings suggested LTN neuropathy in the right lateral chest. We performed a serratus anterior (SA) plane block with ultrasound (US)-guided hydrodissection and achieved pain relief. We report the successful treatment of LTN neuropathy with an SA plane block and US-guided hydrodissection.

Neurolysis of the distal segment of the long thoracic nerve for the treatment of scapular winging due to serratus anterior palsy: a continuous series of 73 cases

Serratus anterior (SA) palsy following mechanical injury to the long thoracic nerve (LTN) is the most common cause of scapular winging. This study aimed to identify the factors influencing the outcome of neurolysis of the distal segment of the LTN. We hypothesized that poor results are due to duration before surgery and to persistent scapulothoracic dysfunction. A retrospective study was conducted. The inclusion criteria were partial or complete isolated noniatrogenic SA paralysis of at least 4-month duration with preoperative electrophysiologic assessment confirming the neurogenic origin without signs of reinnervation. Seventy-three patients were assessed at 45days, 6months, and 24months after neurolysis of the distal segment of the LTN. At the last follow-up, improvement was excellent in 38 (52%), good in 22 cases (30%), moderate in 6 (8%), and poor in 7 (10%). No patient showed deterioration in outcomes since the beginning of follow-up. Scapular winging was no longer present in 46 cases (63%), while it was minimal in 23 (31.5%). In 4 cases (5.5%), winging was similar to the preoperative condition. The best outcomes occurred in patients who presented without compensatory muscle pain and who were treated within 12months of paralysis. Beyond this time frame, neurolysis can still provide useful functional improvement and avoid palliative surgery. Neurolysis of the distal segment of the LTN is a safe and reliable procedure. This technique allows treatment of SA muscle palsy and corrects scapular winging with excellent or good outcomes in 82% of cases.

Lower Trapezius Myocutaneous Propeller Flap Based on Dorsal Scapular Artery.

The pedicled lower trapezius myocutaneous flap is generally transferred to the recipient site through a subcutaneous tunnel, and a portion of the flap buried in the tunnel needs to be de-epithelialized. Thus, considerable amount of normal skin is sacrificed, and the redundant tissue buried in the tunnel can cause bulging deformity. We believe that transferring the lower trapezius myocutaneous flap in a propeller fashion can avoid the aforementioned issues. A retrospective review was performed on all lower trapezius myocutaneous propeller flap reconstructions by a single surgeon from July 2013 to March 2021. Data on patient demographics, diagnosis, features of the defect, characteristics of the flap, and the outcome were collected and analyzed. Thirty-three lower trapezius myocutaneous propeller flaps were used to reconstruct soft tissue defects in the head, neck, and back. The etiologies were malignancy, trauma, postburn scar contracture, and congenital melanocytic nevus. The mean skin paddle dimensions were 29.0 cm in length (range, 13-45 cm) and 10.9 cm in width (range, 6-15 cm). The donor sites were closed primarily in 30 patients, closed using a skin graft in 1 patient, and covered with the second flap in 2 patients. Venous congestion occurred in the distal portion of 4 flaps and partial necrosis in the distal 6 cm of 1 flap. The average follow-up time was 17.5 months (range, 1-56 months). The normal contour of the back was preserved without bulging deformity. No patient developed a winged scapula or a decrease in shoulder elevation. The lower trapezius myocutaneous propeller flap may be an option for reconstruction of soft tissue defects of the head, neck, and back with less waste of normal tissue and bulging deformity.

On the Role of Delays to Diagnosis of Facioscapulohumeral Muscular Dystrophy

Facioscapulohumeral muscular dystrophy (FSHD) is a rare genetic muscle disease that predominantly affects the facial, scapular, and humeral musculature. Scapular winging is the most common initial finding in patients with FSHD. FSHD can substantially impact a patient’s daily life, ranging from discomfort during work to athletic disadvantages. Another aspect of FSHD that is essential for obtaining successful patient outcomes is timely diagnosis, which can be challenging, possibly due to the heterogeneity of presenting features as well as the rarity of the condition. Some of the methods for increasing the ability to diagnose FSHD should include increased education regarding the disease, as well as other muscular dystrophies, specifically in underserved communities that may have less access to healthcare. Although there is currently no effective pharmacologic intervention for FSHD, recommendations of the American Academy of Neurology and the Practice Issues Review Panel of the American Association of Neuromuscular & Electrodiagnostic Medicine (2015) provide helpful guidance.

Genotype–phenotype correlations in valosin-containing protein disease: a retrospective muticentre study

BackgroundValosin-containing protein (VCP) disease, caused by mutations in the VCP gene, results in myopathy, Paget’s disease of bone (PBD) and frontotemporal dementia (FTD). Natural history and genotype–phenotype correlation data are...

Clavicular and scapular, but not spinal kinematics vary with scapular dyskinesis type during arm elevation and lowering in persons with neck pain

BackgroundScapular dyskinesis is often observed in patients with neck pain. However, it is unknown whether clavicular, scapular and spinal kinematics vary with different types of scapular dyskinesis during arm movement. Research questionAre there differences in clavicular, scapular and spinal kinematics during unilateral arm elevation and lowering among neck pain patients presenting with (i) scapular winging, (ii) with dysrhythmia, (iii) with no scapular abnormality and (iv) healthy controls? MethodsSixty participants with neck pain (20 in each group) and 20 asymptomatic controls were recruited. The 3D kinematic data were measured during unilateral arm elevation and lowering at 30°, 60°, 90°, and 120° in the scapular plane. A three-way mixed-effects ANOVA was used to determine the main effects (group, phase and angle) and the interactions between three independent variables on the kinematic data. ResultsThe neck pain group with scapular winging had decreased clavicular retraction and increased scapular internal rotation and anterior tilt compared to the other neck pain and control groups at all angles during both phases of arm movement (p < 0.01). The neck pain group with scapular dysrhythmia had decreased scapular upward rotation compared to all other groups (p < 0.01). Some alterations in the kinematics existed during the lowering phase compared to the raising phase for all groups (p < 0.05). Spinal kinematics were similar across all groups (p > 0.05). SignificanceSpecific patterns of clavicular and scapular kinematics were identified during arm movement relevant to the type of observed scapular dyskinesis in patients with neck pain. Such findings stand to inform more precise and relevant motor training in rehabilitation and improve understanding of the association between altered scapular kinematics and neck pain.

A COMPREHENSIVE STUDY OF KAKSHADHARA MARMA WITH SPECIAL REFERENCE TO WINGED SCAPULA

The Marma sharira has a special importance in Sharira Sthana. There are 107 Marma present in the human body, surrounded by Mamsa, Sira, Snayu, and Asthiand Sandhi. The KakshadharaMarma is a SnayuMarma, located in between the axilla and thorax on both sides. Injury to Kakshadhara Marma leads to Pakshaghata. The area surrounding Kakshadhara Marma consists of the brachial plexus and its branches and the presence of the Axillary artery. Winging of scapula caused by injury of long thoracic nerve mainly, sometimes dorsal scapular nerve and spinal accessory nerve. The Most common muscles involved are Serratus anterior and Rhomboidus, but occasionally trapezius muscle is involved. The winged scapula presents with drooping of the shoulder, weakness in the neck, shoulders, and arm muscles, associated with painand discomfort in the neck region, shoulders, and back.

The impact of external beam radiation therapy on shoulder surgical outcomes: a case series study

External beam radiation therapy (XRT) is a commonly used treatment adjunct in patients with breast cancer and is known to cause soft tissue dysfunction. However, data on XRT as a preoperative risk factor for shoulder surgery is limited. The purpose of this study was to assess whether prior history of breast cancer treated with XRT has an impact on surgical complications or outcomes. We hypothesize that patients treated with XRT will have a higher rate of surgical complications and lower outcomes. A 20-year retrospective chart review across a large, academic health care system was performed. Inclusion criterion comprised any patient with history of breast cancer of the upper-outer or axillary region treated with XRT. Patients also must have undergone a surgical procedure to the ipsilateral shoulder with at least 1-year postoperative follow-up. Patients were stratified by demographics, hand dominance, and surgery type. Postoperative outcomes including range of motion (ROM) and visual analog scale (VAS) scores for pain were also collected. Eighteen patients were identified (100% female) with an average age of 66.3 years (standard deviation 10.5 years). Ten shoulders underwent rotator cuff repair (RCR), 4 total shoulder arthroplasty (TSA), 3 reverse shoulder arthroplasty (RSA), and 1 arthroscopic superior labrum anterior to posterior (SLAP) repair. Four patients treated with RCR (40%) experienced postoperative complications related to their procedure. These included scapular winging, adhesive capsulitis, stiffness, and one retear. Two patients treated with shoulder arthroplasty (28.6%) experienced postoperative complications that included lymphedema and periprosthetic fracture following a mechanical fall in one RSA patient and periprosthetic infection in a TSA patient. ROM across all groups improved, most significantly in forward flexion and internal rotation among RCR patients (P<.001). Furthermore, a statistically significant improvement in VAS scores was achieved in each group (6.2±2.14 preoperation, 1.06±1.75 postoperation; P<.001). When compared to national averages, complication rates in our cohort were higher (40% vs. 10%-17% in RCR patients and 28.6% vs. 4%-14% in arthroplasty patients). On further scrutiny, many of these complications were independent of a history of XRT and many resolved with appropriate therapy. Most importantly, functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. Thus, our results suggest that performing shoulder surgery after ipsilateral XRT for breast cancer is likely safe and may offer improved pain and ROM compared to forgoing surgery without necessarily increasing the risk for postoperative complication.

Clinical and Genetic Studies of Limb Girdle Muscular Dystrophy: Reports of Two Cases

Limb girdle muscular dystrophy (LGMD) presents with weakness and wasting of muscles, initially appear at proximal group of pelvic and shoulder girdles and inherited by an autosomal recessive disorder mainly and rarely autosomal dominant trait. We report two young girls of limb girdle muscular dystrophy (LGMD), who presented with gradual onset of weakness in proximal muscle of all four limbs. There was positive family history in one girl. Neurological examination revealed pseudo hypertrophy of both calves, hypotonia in all four limbs, muscle power diminished, more on proximally. All deep tendon reflexes were diminished with planters bilateral flexors. Gower sign was positive and winging of scapula was also present. Electromyography (EMG) showed myopathic pattern. Both had elevated creatinine phosphokinase levels and finally genetic study confirmed the diagnosis. J Enam Med Col 2020; 10(3): 190-194

AĞIRLIK EGZERSİZİ SONRASI GELİŞEN KANAT SKAPULA: OLGU SUNUMU

Winging scapula (WS) is one of the disorders of the scapulothoracic region, in which the medial edge or the inferior corner of the scapula is displaced away from the posterior chest wall. Although it is rare, it is an important cause of the restriction of upper extremity functions. WS which can be classified as primary and secondary, manifests itself as shoulder pain, loss of function and strength, deformity in the shoulder. It can be diagnosed by imaging and electrodiagnostic tests after detailed physical examination. Here, a 20-year-old male patient who has been exercising intensely for a long time and was diagnosed with WS due to pain and deformity in the right shoulder after weight lifting is presented

Convergence of patient- and physician-reported outcomes in the French National Registry of Facioscapulohumeral Dystrophy

BackgroundFacioscapulohumeral muscular dystrophy (FSHD) is among the most prevalent muscular dystrophies and currently has no treatment. Clinical and genetic heterogeneity are the main challenges to a full comprehension of the physiopathological mechanism. Improving our knowledge of FSHD is crucial to the development of future therapeutic trials and standards of care. National FSHD registries have been set up to this end. The French National Registry of FSHD combines a clinical evaluation form (CEF) and a self-report questionnaire (SRQ), filled out by a physician with expertise in neuromuscular dystrophies and by the patient, respectively. Aside from favoring recruitment, our strategy was devised to improve data quality. Indeed, the pairwise comparison of data from 281 patients for 39 items allowed for evaluating data accuracy. Kappa or intra-class coefficient (ICC) values were calculated to determine the correlation between answers provided in both the CEF and SRQ.ResultsPatients and physicians agreed on a majority of questions common to the SRQ and CEF (24 out of 39). Demographic, diagnosis- and care-related questions were generally answered consistently by the patient and the medical practitioner (kappa or ICC values of most items in these groups were greater than 0.8). Muscle function-related items, i.e. FSHD-specific signs, showed an overall medium to poor correlation between data provided in the two forms; the distribution of agreements in this section was markedly spread out and ranged from poor to good. In particular, there was very little agreement regarding the assessment of facial motricity and the presence of a winged scapula. However, patients and physicians agreed very well on the Vignos and Brooke scores. The report of symptoms not specific to FSHD showed general poor consistency.ConclusionsPatient and physician answers are largely concordant when addressing quantitative and objective items. Consequently, we updated collection forms by relying more on patient-reported data where appropriate. We hope the revised forms will reduce data collection time while ensuring the same quality standard. With the advent of artificial intelligence and automated decision-making, high-quality and reliable data are critical to develop top-performing algorithms to improve diagnosis, care, and evaluate the efficiency of upcoming treatments.

Transfer of the coracoid and conjoined tendon for failed, unstable, short clavicle following excessive outer clavicle resection.

Nineteen patients presented with an unsightly deformity of the shoulder, pain or discomfort at the medial scapular border, pseudo nonparalytic scapular winging, and thoracic outlet symptoms after excessive resection of the clavicle for either complete acromioclavicular separation or displaced fracture of the outer clavicle, which allows the scapula and shoulder to rotate anteriorly and inferiorly on the chest creating traction on the medial scapular muscles and the brachial plexus resulting in pseudo nonparalytic winging and thoracic outlet symptoms. RESULTS: All underwent transfer of the coracoid process with the attached conjoined tendon to the end of the clavicle, restoring length and alignment. Eighteen patients were evaluated at a mean of 13.3 years. Seventeen had resolution of symptoms, restored alignment of the clavicle with the shoulder, improved appearance, healed transfer, and were pleased with the outcome. One patient was lost to follow-up but was considered a failure at his last visit. In a second patient, the transfer healed in a tilted position and the patient was dissatisfied with the appearance but otherwise had resolution of his symptoms. The mean American Shoulder and Elbow Surgeons Outcome Score improved from 53.2 preoperatively to 87.4 postoperatively (P < .02). CONCLUSION: This is the first report of using this transfer to restore length and alignment of an excessively short, unstable clavicle. The transfer succeeded in improving the appearance and symptoms in this complication of an excessively short, unstable clavicle.

Scapular osteochondroma: An unusual cause of static winged scapula in a pre-teen

Winged scapula is most commonly caused by injury of the long thoracic nerve which results in paralysis of the serratus anterior muscle. Scapular osteochondroma is uncommon and rarely presents as winged scapula in the skeletally matured patients. We report a 9-year-old female with progressive winging of the left scapula due to osteochondroma on its costal surface. The clinical diagnosis of the cause of the scapular winging was difficult because the tumor was non-palpable, mainly cartilaginous, and not visible on a plain radiograph but was unraveled with ultrasonography. Diagnosis of osteochondroma in a pre-teen is unusual but should be considered in the differential diagnosis for static-winged scapula in a child.

SERRATUS ANTERIOR MUSCLE FLAP FOR RECONSTRUCTION OF EXTREMITY INJURIES.

ABSTRACTObjective:To report the use of the serratus anterior free tissue transfer in the treatment of traumatic injuries.Methods:Twenty-six free flaps or serratus pedicled flaps were performed for reconstruction of traumatic extremity injuries.Results:Complete flap survival was recorded in 20 limbs and 3 patients had circulatory complications. Even with the review of vascular anastomoses, partial flap necrosis could not be prevented and required a skin graft after debridement in the necrotic area. Another flap also required reexploration as a result of heavy congestion due to impaired venous return. Superficial wound infection was found in three patients and treated with conservative measures. Regarding the donor area, seroma formation was found in 8 cases; drainage was necessary in 2, and the others were resolved spontaneously. In 2, bruises formed and were later drained. In 1 limb there was long thoracic nerve injury and scapular winging.Conclusion:According to this study, the serratus anterior muscle flap is an excellent tool for treating small complex lesions in the extremities. Level of Evidence IV; Case series .

Translational aspects of novel findings in genetics of male infertility—status quo 2021 and diagnosis and epidemiology of winged scapula in breast cancer patients: a systematic review and meta-analysis

Translational aspects of novel findings in genetics of male infertility—<i>status quo</i> 2021 <i>and</i> diagnosis and epidemiology of winged scapula in breast cancer patients: a systematic review and meta-analysis

Endometriosis: a guide to investigations and treatment in the emergency department.

Endometriosis is an oestrogen-dependent disorder where endometrial tissue forms lesions outside the uterus, causing chronic inflammation and scarring. Women who have endometriosis may experience a highly variable range of non-specific signs and symptoms, including pelvic pain. Endometriosis is often misdiagnosed, partly because its signs and symptoms can easily be attributed to more common conditions that cause pelvic pain in women, resulting in delayed diagnosis and treatment. This article describes the pathophysiology, aetiology, risk factors for, and signs and symptoms of endometriosis. It also outlines how endometriosis should be investigated and treated in the emergency department (ED). Its aim is to support nurses to deliver effective care to women of reproductive age presenting to the ED with severe pelvic pain.