Winged scapula

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Winged scapula
serratus anterior is labeled at left, and trapezius
is labeled at upper right.)

A winged scapula (scapula alata) is a skeletal

medical condition
in which the shoulder blade protrudes from a person's back in an abnormal position.

In rare conditions it has the potential to lead to limited functional activity in the upper extremity to which it is adjacent. It can affect a person's ability to lift, pull, and push weighty objects. In some serious cases, the ability to perform

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.

Signs and symptoms

winging of the right scapula
Winging of the left 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 (FSHD), 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 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 anchors 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 FSHD, 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]

Causes

Winging of the scapula is divided into two categories, medial and lateral, according to the direction of winging.

mastectomies with axillary node 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.

coarctation of the aorta.[1]

Secondary to

rhomboid muscle 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][8]

Diagnosis

In addition to

tumors.[1]

Treatment

There are a variety of classifications for winged scapula, and likewise several treatment options. Strength training, particularly of the

glenohumeral joint muscles, but if the muscles do not contract clinically and symptoms continue to be severe for more than 3–6 months, surgery may be the next choice.[9][10]

Physical therapy for a winged scapula will usually incorporate exercises aimed at strengthening the serratus anterior. The push-up plus (PUP) exercise is one of the most commonly prescribed for strengthening the serratus anterior. The push-up plus is usually done in either a push-up position either against a wall or progressed to the floor. Full scapular protraction (the plus) is added after full elbow extension at the end of the usual push-up exercise. The plus phase during the PUP exercise has been shown to elicit the highest average serratus anterior electromyographic (EMG) activity when compared with other SA-activating and closed kinetic chain exercises.[11]

Scapula-to-scapula scapulopexy, pre- and post-operation in person with FSHD. The scapulas are tethered together into a retracted position with an Achilles tendon graft. In the right image, the rhomboid major muscles are distinguishable.

Surgical options include neurolysis (

Eden-Lange procedure can be done for isolated trapezius palsy. When tendon transfer is not feasible, such as in the case of muscular dystrophy or multiple muscular deficits, remaining options include scapulothoracic fusion (also known as scapulodesis), which induces bony fusion between the scapula and the rib cage, and scapulothoracic fixation without arthrodesis (scapulopexy).[3][10] Even though scapulothoracic fusion has been shown to have successful outcomes, complications were present in over 40% of the 130 patients observed by Kord et al.[12]

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 examinations.[1]

References

  1. ^
    PMID 19468892
    .
  2. PMID 16778411
    .
  3. ^
    PMID 18056023
    .
  4. ^ "Serratus Anterior". ExRx.net.
  5. PMID 17343759
    .
  6. ISBN 9781455723584
    .
  7. PMID 24703793
    .
  8. PMID 19324173
    .
  9. PMID 18196359
    .
  10. ^ a b "Scapular Winging". NYU Medical Center. Archived from the original on September 29, 2012.
  11. PMID 31584855
    .
  12. PMID 32313557
    .

External links

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