Winged scapula

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Winged scapula
Classification and external resources

The left side of the thorax. (Winging not illustrated but serratus anterior is
labeled at left, and trapezius is labeled at upper right.)

ICD-9

736.89

A winged scapula (scapula alata) is a condition in which the shoulder blade, or shoulder bone, protrudes from
a persons back in an abnormal position. It is a rare condition with the potential to lead to limited functional
activity in the upper extremity with which it is adjacent. It can affect a persons ability to lift, pull, and push
weighty objects. In some serious cases, the ability to perform activities of daily living such as changing ones
clothes and washing ones hair may be hindered. The name of this condition comes from its appearance, a
wing-like resemblance, due to the medial border of the scapula sticking straight out from the back. Scapular
winging has been observed to disrupt scapulohumeral rhythm, contributing to
decreased flexion and abduction of the upper extremity, as well as a loss in power and the source of
considerable pain.[1] A winged scapula is considered normal posture in young children, but not older children
and adults.

[edit]Signs

and symptoms
1

winging of scapula

Winging scapula

The severity and appearance of the winged scapula varies by individuals as well as the muscles and/or nerves
that were affected.[2][3] Pain is not seen in every case. In a study of 13 individuals with facioscapulohumeral
muscular dystrophy (FSH), none of the individuals complained of pain. Fatigue, however, was a common
characteristic and all had noted that there were limitations in their activities of daily life. [3]
In most cases of winged scapula, damage to the serratus anterior causes the deformation of the back.
The serratus anterior muscle attaches to the medial anterior aspect of the scapula (i.e. it attaches on the side
closest to the spine and runs along the side of the scapula that faces the ribcage) and normally anchor the
scapula against the rib cage. When the serratus anterior contracts, upward rotation, abduction, and weak
elevation of the scapula occurs, allowing the arm to be raised above the head. [4] The long thoracic
nerve innervates the serratus anterior; therefore, damage to or impingement of this nerve can result in
weakening or paralysis of the muscle.[5] If this occurs, the scapula may slip away from the rib cage, giving it the
wing-like appearance on the upper back. This characteristic may particularly be seen when the affected person
pushes against resistance. The person may also have limited ability to lift their arm above their head.

In facioscapulohumeral muscular dystrophy (FSH), the winged scapula is detected during contraction of the
glenohumeral joint. In this movement, the glenohumeral joint atypically and concurrently abducts and the
scapula internally rotates.[3]

[edit]Causes
The most common cause of scapular winging is serratus anterior paralysis. This is typically caused by damage
(i.e. lesions) to the long thoracic nerve. This nerve supplies the serratus anterior, which is located on the side of
the thorax and acts to pull the scapula forward. Serratus anterior palsy is a dysfunction that is characteristic
of traumatic, non-traumatic, and idiopathic injury to the long thoracic nerve.[1]
There are numerous ways in which the long thoracic nerve can sustain trauma-induced injury. These include,
but are not limited to, blunt trauma (e.g. blow to the neck or shoulder, sudden depression of the shoulder girdle,
unusual twisting of the neck and shoulder), repetitive movements (as observed in athletic activities such as
weight lifting or sports that involve throwing), and household activities (e.g. gardening, digging, car washing,
prolonged abduction of the arms when sleeping, propping up the head to read, etc.). Sometimes, other
structures in the body such as inflamed and enlarged subcorocoid or subscapular bursapress on the nerve.
Clinical treatments may also cause injury to the long thoracic nerve (iatrogenesis from forceful
manipulation, mastectomies with axillarynode dissection, surgical treatment of spontaneous pneumothorax,
post-general anesthesia for various clinical reasons, and electrical shock, amongst others). [1]
Non-traumatic induced injury to the long thoracic nerve includes, but is not limited to, causes such as viral
illness (e.g. influenza, tonsillitis-bronchitis, polio), allergic-drug reactions, drug overdose, toxic exposure
(e.g. herbicides, tetanus), C7 radiculopathy, and coarctation of the aorta.[1]
Secondary to serratus anterior palsy, a winged scapula is also caused by trapezius and rhomboid palsy
involving the accessory nerve and the dorsal scapular nerve, respectively.[1]
Though the most common causes of a winged scapula is due to serratus anterior palsy, and less commonly
trapezius and rhomboid palsy, there are still other circumstances that present the ailment. These incidences
include direct injuries to the scapulothoracic muscles (i.e. trapezius and rhomboid muscles), and structural
abnormalities (e.g. rotator cuff pathology, shoulder instability, etc.).[1][6]

[edit]Treatment
Since there are a variety of classifications of winged scapula, there is also more than one type of treatment.
Time and occupational therapy or physical therapy is the best treatment if there is weakness of
the glenohumeral joint muscles but if the muscles do not contract clinically and symptoms continue to be
severe for more than 36 months, surgery may be the next choice.[7][8] Surgery by fixation of the scapula to
the rib cage can be done for those with isolated scapular winging. Some options are neurolysis (chordotomy),

intercostal nerve transfer, scapulothoracic fusion, arthrodesis(scapulodesis), or scapulothoracis fixation without

arthrodesis (scapulopexy).[3][8]

[edit]Epidemiology
A winged scapula due to serratus anterior palsy is rare. In one report (Fardin et al.), there was an incidence of
15 cases out of 7,000 patients seen in the electromyographical laboratory. In another report (Overpeck and
Ghormley), there was only one case out of 38,500 patients observed at the Mayo Clinic. In yet another report
(Remak), there were three diagnoses of serratus anterior paralysis throughout a series of 12,000 neurological
examination