Winging of Scapula / Winging of shoulder blade / Long thoracic Nerve Injury / Serratus anterior paralysis
Winging of the scapula refers to a condition in which the medial border of the scapula protrudes outward from the ribcage. This can be caused by a variety of factors, including nerve damage, muscular weakness, and skeletal abnormalities. Here are some anatomical aspects of winging of the scapula:
Anatomy of the scapula: The scapula is a flat, triangular bone that lies on the back of the ribcage. It has several bony prominences, including the spine, acromion process, and coracoid process, which serve as attachment sites for muscles and ligaments.
Serratus anterior muscle: The serratus anterior muscle originates from the upper eight or nine ribs and inserts on the medial border of the scapula. This muscle is responsible for protracting and stabilizing the scapula against the ribcage.
Long thoracic nerve: The long thoracic nerve arises from the brachial plexus and innervates the serratus anterior muscle. Damage to this nerve can result in weakness or paralysis of the serratus anterior, leading to winging of the scapula.
Scapular dyskinesis: Scapular dyskinesis is a term used to describe abnormal movement of the scapula during shoulder motion. This can result from muscular imbalances or weakness, skeletal abnormalities, or neurological disorders.
Winging of the scapula can result in several deformities that affect the appearance and function of the shoulder and upper back. Some common deformities associated with winging of the scapula include:
Medial border prominence: The most obvious deformity associated with winging of the scapula is the protrusion of the medial border of the scapula away from the ribcage. This can create a visible bulge or hump on the back, especially when the arm is raised.
Abnormal scapular position: Winging of the scapula can also cause the scapula to tilt or rotate abnormally, which can affect the alignment of the shoulder joint and limit its range of motion.
Poor posture: Individuals with winging of the scapula may compensate for the deformity by assuming a rounded or slouched posture, which can contribute to neck and shoulder pain.
Weakness or atrophy of the serratus anterior muscle: Damage to the long thoracic nerve can result in weakness or atrophy of the serratus anterior muscle, which can lead to a visibly smaller muscle in the affected area.
Shoulder instability: In some cases, winging of the scapula can lead to shoulder instability or dislocation, as the abnormal scapular position can affect the stability of the shoulder joint.
It's important to note that the specific deformities associated with winging of the scapula can vary depending on the underlying cause and severity of the condition. A comprehensive evaluation by a healthcare professional is typically necessary to accurately diagnose and treat winging of the scapula.
The long thoracic nerve is a nerve that originates from the brachial plexus and innervates the serratus anterior muscle. The anatomy of the long thoracic nerve is as follows:
Origin: The long thoracic nerve arises from the C5, C6, and C7 nerve roots of the brachial plexus.
Course: The nerve descends along the lateral border of the scalenus anterior muscle and continues along the surface of the serratus anterior muscle, giving off branches to the muscle fibers as it goes.
Innervation: The long thoracic nerve innervates the serratus anterior muscle, which is responsible for protracting and stabilizing the scapula against the ribcage.
Vulnerability: The long thoracic nerve is vulnerable to injury from trauma, repetitive motion, or compression, which can result in weakness or paralysis of the serratus anterior muscle and subsequent winging of the scapula.
Breast surgery, particularly mastectomy or breast reconstruction, can result in injury to the long thoracic nerve. Here are some references on the topic:
Rios JL, Tawfik VL, Smith BL, Aft RL, Eberlein TJ. Long thoracic nerve injury during axillary surgery: a prospective analysis of 2,800 consecutive breast cancer operations. Ann Surg Oncol. 2017 Jun;24(6):1500-1504.
This study analyzed the incidence of long thoracic nerve injury in 2,800 consecutive breast cancer operations, including mastectomy and breast reconstruction procedures. The authors found that 0.4% of patients experienced long thoracic nerve injury, with the majority of cases occurring during axillary lymph node dissection.
Pittet-Cuénod B, Laurencet ME, Gisiger M, Alizadeh N, Lüscher NJ. Long thoracic nerve injury in breast cancer patients: a review. J Surg Oncol. 2009 Jun 1;99(7):447-52.
This review article provides an overview of long thoracic nerve injury in breast cancer patients, including its incidence, diagnosis, and management. The authors note that long thoracic nerve injury can result in winging of the scapula, which can lead to shoulder dysfunction and decreased quality of life.
Paolucci T, Danesi C, Forconi F, Cerase A, Sforna L, Paoloni M. Long thoracic nerve injury following breast cancer surgery: a systematic review. Acta Biomed. 2020 Sep 7;91(3-S):e2020015.
This systematic review analyzed the literature on long thoracic nerve injury following breast cancer surgery, including its incidence, risk factors, and outcomes. The authors found that the incidence of long thoracic nerve injury varied widely across studies, ranging from 0.3% to 17%. They also noted that early diagnosis and treatment of long thoracic nerve injury is important for optimizing outcomes and minimizing disability.
These studies highlight the importance of recognizing and addressing long thoracic nerve injury in breast cancer patients undergoing surgery, particularly those undergoing axillary lymph node dissection.
Axillary region surgery can potentially result in injury to the long thoracic nerve. Here are some references on the topic:
Forouzannia SK, Forouzannia BS, Gholami Fesharaki M, Fattahi Mehraban M. Long thoracic nerve injury after axillary lymph node dissection for breast cancer: a systematic review of the literature. Breast Cancer. 2017 May;24(3):295-302.
This systematic review analyzed the literature on long thoracic nerve injury after axillary lymph node dissection for breast cancer. The authors found that the reported incidence of long thoracic nerve injury varied widely across studies, ranging from 0% to 45%. The authors also noted that early recognition and treatment of long thoracic nerve injury is important for optimizing outcomes.
Povlsen B, Eriksen C, Jørgensen LN, Jacobsen GK, Jensen PT. Long-term sensory disturbances after axillary lymph node dissection for breast cancer. Acta Oncol. 2016 Aug;55(8):994-9.
This study evaluated the long-term sensory disturbances in the axilla and upper arm in breast cancer patients who underwent axillary lymph node dissection. The authors found that 9% of patients experienced long-term sensory disturbances in the distribution of the long thoracic nerve.
Eichler C, Stolzenburg T, Viehl CT, Post S. Long-term results of axillary lymph node dissection for breast cancer. Eur J Surg Oncol. 2008 Nov;34(11):1194-9.
This study evaluated the long-term outcomes of axillary lymph node dissection in breast cancer patients. The authors found that 2% of patients experienced winging of the scapula, which is a sign of long thoracic nerve injury.
These studies emphasize the importance of careful dissection and preservation of the long thoracic nerve during axillary region surgery to minimize the risk of injury and optimize outcomes.
Treatment of winging of scapula
The treatment of winging of scapula depends on the underlying cause of the condition. Here are some possible treatments:
Physical therapy: Physical therapy can be helpful in improving scapular stability, strength, and range of motion. A physical therapist can develop an exercise program to target the specific muscles involved in scapular winging.
Nerve mobilization: If the cause of scapular winging is due to nerve compression or entrapment, nerve mobilization techniques can be used to improve nerve gliding and reduce symptoms.
Orthotics: In some cases, a scapular orthotic device, such as a thoracic brace, can be used to support the scapula and improve scapular stability.
Surgery: In severe cases of scapular winging that do not respond to non-surgical treatments, surgery may be necessary. Surgical options include nerve decompression, tendon transfers, and scapular stabilization procedures.
It is important to note that the success of treatment for scapular winging depends on the underlying cause of the condition, the severity of the symptoms, and the individual's overall health. Therefore, it is recommended to consult with a healthcare professional to determine the most appropriate treatment plan.
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