Skip to main content
SpringerLink
Log in

Surgical Treatment of Winged Scapula

  • Symposium: New Approaches to Shoulder Surgery
  • Published:
Clinical Orthopaedics and Related Research

Abstract

Injuries to the long thoracic and spinal accessory nerves present challenges in diagnosis and treatment. Palsies of the serratus anterior and trapezius muscles lead to destabilization of the scapula with medial and lateral scapular winging, respectively. Although nonoperative treatment is successful in some patients, failures have led to the evolution of surgical techniques involving various combinations of fascial graft and/or transfer of adjacent muscles. Our preferred method of reconstruction for serratus anterior palsy is a two-incision, split pectoralis major transfer without fascial graft. For trapezius palsy, we prefer a modified version of the Eden-Lange procedure. At a minimum followup of 16 months (mean, 47 months), six patients who underwent the Eden-Lange procedure showed improvement in mean American Shoulder and Elbow Surgeons Shoulder scores (33.3–64.6), forward elevation (141.7–151.0), and visual analog scale (7.0–2.3). At a minimum followup of 16 months (mean, 44 months), 10 patients (11 shoulders) who underwent split pectoralis transfer also improved American Shoulder and Elbow Surgeons Shoulder scores (53.3–63.8), forward elevation (158.2–164.5), and visual analog scale (5.0–2.9). We encountered two complications, both superficial wound infections. These tendon transfers were effective for treating scapular winging in patients who did not respond to nonoperative treatment.

Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

References

  1. Ball C. Paralysis following injection of antitetanic serum. Case report with serratus magnus involved. US Naval Med Bull. 1939;37:305–309.

    Google Scholar 

  2. Bigliani LU, Compito CA, Duralde XA, Wolfe IN. Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius. J Bone Joint Surg Am. 1996;78:1534–1540.

    PubMed  CAS  Google Scholar 

  3. Bigliani LU, Perez-Sanz JR, Wolfe IN. Treatment of trapezius paralysis. J Bone Joint Surg Am. 1985;67:871–877.

    PubMed  CAS  Google Scholar 

  4. Brandenburg JH, Lee CY. The eleventh nerve in radical neck surgery. Laryngoscope. 1981;91:1851–1859.

    Article  PubMed  CAS  Google Scholar 

  5. Chaves JP. Pectoralis minor transplant for paralysis of the serratus anterior. J Bone Joint Surg Br. 1951;33:228–230.

    Google Scholar 

  6. Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa. Boston, MA: Thomas Todd; 1934.

    Google Scholar 

  7. Connor PM, Yamaguchi K, Manifold SG, Pollock RG, Flatow EL, Bigliani LU. Split pectoralis major transfer for serratus anterior palsy. Clin Orthop Relat Res. 1997;341:134–142.

    Article  PubMed  Google Scholar 

  8. Dewar FP, Harris RI. Restoration of function of the shoulder following paralysis of the trapezius by fascial sling fixation and transplantation of the levator scapulae. Ann Surg. 1950;132:1111–1115.

    Article  PubMed  CAS  Google Scholar 

  9. Dickson FD. Fascial transplants in paralytic and other conditions. J Bone Joint Surg Am. 1937;19:405–412.

    Google Scholar 

  10. Durman DC. An operation for paralysis of the serratus anterior. J Bone Joint Surg Am. 1945;27:380–382.

    Google Scholar 

  11. Eden R. Zür behandlung der Trapeziuslahmung mittelst muskelplastik. Deutsche Zeitschr Chir. 1924;184:387–397.

    Google Scholar 

  12. Foo CL, Swann M. Isolated paralysis of the serratus anterior. A report of 20 cases. J Bone Joint Surg Br. 1983;65:552–556.

    PubMed  CAS  Google Scholar 

  13. Gabel G. Spinal accessory nerve. In: Gelberman RH, ed. Operative Nerve Repair and Reconstruction. Philadelphia, PA: JB Lippincott Co; 1991:445–452.

    Google Scholar 

  14. Gozna ER, Harris WR. Traumatic winging of the scapula. J Bone Joint Surg Am. 1979;61:1230–1233.

    PubMed  CAS  Google Scholar 

  15. Gregg JR, Labosky D, Harty M, Lotke P, Ecker M, DiStefano V, Das M. Serratus anterior paralysis in the young athlete. J Bone Joint Surg Am. 1979;61:825–832.

    PubMed  CAS  Google Scholar 

  16. Herzmark MH. Traumatic paralysis of the serratus anterior relieved by transplantation of the rhomboidei. J Bone Joint Surg Am. 1951;33:235–238.

    PubMed  CAS  Google Scholar 

  17. Hollinshead WH. Anatomy for Surgeons. Vol 1. Philadelphia, PA: Harper & Row; 1982.

    Google Scholar 

  18. Kauppila LI, Vastamaki M. Iatrogenic serratus anterior paralysis. Long-term outcome in 26 patients. Chest. 1996;109:31–34.

    Article  PubMed  CAS  Google Scholar 

  19. King GJ, Richards RR, Zuckerman JD, Blasier R, Dillman C, Friedman RJ, Gartsman GM, Iannotti JP, Murnaham JP, Mow VC, Woo SL. A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999;8:351–354.

    Article  PubMed  CAS  Google Scholar 

  20. Kuhn JE, Plancher KD, Hawkins RJ. Scapular winging. J Am Acad Orthop Surg. 1995;3:319–325.

    PubMed  Google Scholar 

  21. Lange M. Die behandlung der irreparablem trapeziuslahmung. Langenbecks Arch Klin Chir Ver Dtsch Z Chir. 1951;270:437–439.

    Article  PubMed  CAS  Google Scholar 

  22. Lange M. Die operative Behandlung der irreparablem Trapeziuslahmung. TIP Fakult Mecmuasi. 1959;22:137–141.

    CAS  Google Scholar 

  23. Langenskiold A, Ryoppy S. Treatment of paralysis of the trapezius muscle by the Eden-Lange operation. Acta Orthop Scand. 1973;44:383–388.

    Article  PubMed  CAS  Google Scholar 

  24. Makin GJ, Brown WF, Ebers GC. C7 radiculopathy: importance of scapular winging in clinical diagnosis. J Neurol Neurosurg Psychiatry. 1986;49:640–644.

    Article  PubMed  CAS  Google Scholar 

  25. Marmor L, Bechtol CO. Paralysis of the serratus anterior due to electric shock relieved by transplantation of the pectoralis major muscle. A case report. J Bone Joint Surg Am. 1963;45:156–160.

    Google Scholar 

  26. Norden A. Peripheral injuries to the spinal accessory nerve. Acta Chir Scand. 1946;94:515–532.

    CAS  PubMed  Google Scholar 

  27. Novak CB, Mackinnon SE. Surgical treatment of a long thoracic nerve palsy. Ann Thorac Surg. 2002;73:1643–1645.

    Article  PubMed  Google Scholar 

  28. Parsonage MJ, Turner JWA. Neuralgic amyotrophy. The shoulder-girdle syndrome. Lancet. 1948;1:973–978.

    Article  PubMed  CAS  Google Scholar 

  29. Post M. Pectoralis major transfer for winging of the scapula. J Shoulder Elbow Surg. 1995;4:1–9.

    PubMed  CAS  Google Scholar 

  30. Post M, Morrey BF, Hawkins RJ, eds. Surgery of the Shoulder. St Louis, MO: Mosby-Year Book; 1990.

    Google Scholar 

  31. Povacz P, Resch H. Dynamic stabilization of winging scapula by direct split pectoralis major transfer: a technical note. J Shoulder Elbow Surg. 2000;9:76–78.

    Article  PubMed  CAS  Google Scholar 

  32. Radin EL. Peripheral neuritis as a complication of infectious mononucleosis. Report of a case. J Bone Joint Surg Am. 1967;49:535–538.

    PubMed  CAS  Google Scholar 

  33. Remmler D, Byers R, Scheetz J, Shell B, White G, Zimmerman S, Goepfert H. A prospective study of shoulder disability resulting from radical and modified neck dissections. Head Neck Surg. 1986;8:280–286.

    PubMed  CAS  Google Scholar 

  34. Romero J, Gerber C. Levator scapulae and rhomboid transfer for paralysis of trapezius. The Eden-Lange procedure. J Bone Joint Surg Br. 2003;85:1141–1145.

    Article  PubMed  CAS  Google Scholar 

  35. Shiozaki K, Abe S, Agematsu H, Mitarashi S, Sakiyama K, Hashimoto M, Ide Y. Anatomical study of accessory nerve innervation relating to functional neck dissection. J Oral Maxillofac Surg. 2007;65:22–29.

    Article  PubMed  Google Scholar 

  36. Teboul F, Bizot P, Kakkar R, Sedel L. Surgical management of trapezius palsy. J Bone Joint Surg Am. 2004;86:1884–1890.

    PubMed  Google Scholar 

  37. Tomaino MM. Neurophysiologic and clinical outcome following medial pectoral to long thoracic nerve transfer for scapular winging: a case report. Microsurgery. 2002;22:254–257.

    Article  PubMed  Google Scholar 

  38. Tubby AH. A case illustrating the operative treatment of paralysis of the serratus magnus by muscle grafting. J Bone Joint Surg Am. 1904;s2–2:163–166.

    Google Scholar 

  39. Velpeau A. Luxations de l’epaule. Arch Gen Med. 1837;14:269–305.

    Google Scholar 

  40. Warner JJP, Iannotti JP, Gerber C, eds. Complex, Revision Problems in Shoulder Surgery. Philadelphia PA: Lippincott-Raven; 1997.

    Google Scholar 

  41. Whitman A. Congenital elevation of the scapula and paralysis of the serratus magnus muscle. JAMA. 1932;99:1332–1334.

    Google Scholar 

  42. Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop Relat Res. 1999;368:17–27.

    PubMed  Google Scholar 

  43. Winslow J. Observations anatomiques sur, quelques mouvements extraordinaires des omoplates et des bras, et sur une nouveau espece de muscles. Mem Acad Royale Sci. 172;3:98–112.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, 622 West 168th Street, PH-1117, New York, NY, 10032, USA

    Gregory J. Galano MD, Louis U. Bigliani MD, Christopher S. Ahmad MD & William N. Levine MD

Authors
  1. Gregory J. Galano MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Louis U. Bigliani MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christopher S. Ahmad MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. William N. Levine MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to William N. Levine MD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution has approved the reporting of this case report, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Galano, G.J., Bigliani, L.U., Ahmad, C.S. et al. Surgical Treatment of Winged Scapula. Clin Orthop Relat Res 466, 652–660 (2008). https://doi.org/10.1007/s11999-007-0086-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-007-0086-2

Keywords

Search

Navigation