Sage Journals: Discover world-class research

Abstract

This review explores the causes of scapula winging, with overview of the relevant anatomy, proposed aetiology and treatment. Particular focus is given to lesions of the long thoracic nerve, which is reported to be the most common aetiological factor.

Keywords

Scapular winging long thoracic nerve serratus anterior trapezius rhomboids

Get full access to this article

View all access options for this article.

References

Overpeck

Ghormley

. Paralysis of the serratus magnus muscle. J Am Med Assoc 1940; 114: 1994–6.

Kuhn

Plancher

Hawkins

. Scapular winging. J Am Acad Orthop Surg 1995; 3: 319–25.

Hamada

Igarashi

Akita

Mochizuki

. A cadaveric study of the serratus anterior muscle and the long thoracic nerve. J Shoulder Elbow Surg 2008; 17: 790–4.

Fery

Sommelet

. Serratus anterior paralysis. French J Orthop Surg 1987; 1: 168–79.

Ruland

III Ruland

Matthews

. Scapulothoracic anatomy for the arthroscopist. Arthroscopy 1995; 11: 52–6.

Kauppila

Vastamaki

. Iatrogenic serratus anterior paralysis: long-term outcome in 26 patients. Chest 1996; 109: 31–4.

Martin

Fish

. Scapular winging: anatomical review, diagnosis and treatments. Curr Rev Musculoskelet Med 2008; 1: 1–11.

Velpeau

. Luxations de l'epaule. Arch Gen Med 1837; 14: 269–305.

Fiddian

King

. The winged scapula. Clin Orthop Relat Res 1984; 185: 228–36.

10.

Galano

Bigliani

Ahmad

Levine

. Surgical treatment of winged scapula. Clin Orthop Relat Res 2008; 466: 652–60.

11.

Gregg

Labosky

Harty

, et al. Serratus anterior paralysis in the young athlete. J Bone Joint Surg Am 1979; 61: 825–32.

12.

Cuadros

Driscoll

Rothkopf

. The anatomy of the lower serratus anterior muscle: a fresh cadaver study. Plast Reconstr Surg 1995; 95: 93–7.

13.

Kauppila

. The long thoracic nerve: possible mechanisms of injury based on autopsy study. J Shoulder Elbow Surg 1993; 2: 244–8.

14.

Bagg

Forrest

. A biomechanical analysis of scapular rotation during arm abduction in the scapular plane. Am J Phys Med Rehabil 1988; 67: 238–45.

15.

Bell

. Anatomy and physiology of the human body. Vol. 1. Fifth edition. New York, NY: Collins, 1827.

16.

Johnson

Kendall

. Isolated paralysis of the serratus anterior muscle. J Bone Joint Surg Am 1955; 37: 567–74.

17.

Foo

Swann

. Isolated paralysis of the serratus anterior: a report of 20 cases. J Bone Joint Surg Br 1983; 65-B: 552–6.

18.

Tubbs

Salter

Custis

, et al. Surgical anatomy of the cervical and infraclavicular parts of the long thoracic nerve. J Neurosurg 2006; 104: 792–5.

19.

Goodman

Kenrick

Blum

. Long thoracic nerve palsy: a follow-up study. Arch Phys Med Rehabil 1975; 56: 352–8.

20.

White

Witten

. Long thoracic nerve palsy in a professional ballet dancer. Am J Sports Med 1993; 21: 626–8.

21.

Packer

McLatchie

Bowden

. Scapula winging in a sports injury clinic. Br J Sports Med 1993; 27: 90–1.

22.

Gozna

Harris

. Traumatic winging of the scapula. J Bone Joint Surg Am 1979; 61: 1230–3.

23.

Warner

Navarro

. Serratus anterior dysfunction. Recognition and treatment. Clin Orthop Relat Res 1998; 349: 139–48.

24.

Petrera

Trojaborg

. Conduction studies of the long thoracic nerve in serratus anterior palsy of different etiology. Neurology 1984; 34: 1033–7.

25.

Vastamäki

Kauppila

. Etiologic factors in isolated paralysis of the serratus anterior: a report of 197 cases. J Shoulder Elbow Surg 1993; 2: 240–3.

26.

Hester

Caborn

Nyland

. Cause of long thoracic nerve palsy: a possible dynamic fascial sling cause. J Shoulder Elbow Surg 2000; 9: 31–5.

27.

Parsonage

Turner

. Neuralgic amyotrophy; the shoulder-girdle syndrome. Lancet 1948; 1: 973–8.

28.

Mansha

Middleton

Rangan

. An unusual cause of scapular winging following trauma in an army personnel. J Shoulder Elbow Surg 2010; 19: e24–7.

29.

Hayes

Zehr

. Traumatic muscle avulsion causing winging of the scapula. A case report. J Bone Joint Surg Am 1981; 63: 495–7.

30.

Aksoy

Schrader

Ali

Borovansky

Ross

. Spinal accessory neuropathy associated with deep tissue massage: a case report. Arch Phys Med Rehabil 2009; 90: 1969–72.

31.

Friedenberg

Zimprich

Harper

. The natural history of long thoracic and spinal accessory neuropathies. Muscle Nerve 2002; 25: 535–9.

32.

Mah

Otsuka

. Scapular winging in young athletes. J Pediatr Orthop 1992; 12: 245–7.

33.

Horwitz

Tocantins

. Isolated paralysis of the serratus anterior (magnus) muscle. J Bone Joint Surg Am 1938; 20: 720–5.

34.

Horwitz

Tocantins

. An anatomical study of the role of the long thoracic nerve and the related scapular bursae in the pathogenesis of local paralysis of the serratus anterior muscle. Anat Rec 1938; 71: 375–85.

35.

Iceton

Harris

. Treatment of winged scapula by pectoralis major transfer. J Bone Joint Surg Br 1987; 69: 108–10.

36.

Nath

Lyons

Bietz

. Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: long-term results in 50 cases. BMC Musculoskelet Disord 2007; 8: 25.

37.

Nath

Melcher

. Rapid recovery of serratus anterior muscle function after microneurolysis of long thoracic nerve injury. J Brachial Plex Peripher Nerve Inj 2007; 2: 4.

38.

Disa

Wang

Dellon

. Correction of scapular winging by supraclavicular neurolysis of the long thoracic nerve. J Reconstr Microsurg 2001; 17: 79–84.

39.

Steinmann

Wood

. Pectoralis major transfer for serratus anterior paralysis. J Shoulder Elbow Surg 2003; 12: 555–60.

40.

Wiater

Flatow

. Long thoracic nerve injury. Clin Orthop Relat Res 1999; 368: 17–27.

41.

Faruqi

Raychaudhuri

Thirumaran

Blaxill

. Winging of the scapula: an unusual complication of needle thoracocentesis. Eur J Intern Med 2008; 19: 381–2.

42.

Osterman

Babhulkar

. Unusual compressive neuropathies of the upper limb. Orthop Clin North Am 1996; 27: 389–408.

43.

Wiater

Bigliani

. Spinal accessory nerve injury. Clin Orthop Relat Res 1999; 368: 5–16.

44.

Marmor

Bechtol

. 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: 156–60.

45.

Ilfeld

Holder

. Winged scapula: case occurring in soldier with knapsack. J Am Med Assoc 1942; 120: 448–9.

46.

Schultz

Jr Leonard

. Long thoracic neuropathy from athletic activity. Arch Phys Med Rehabil 1992; 73: 87–90.

47.

Wood

Frykman

. Winging of the scapula as a complication of first rib resection: a report of six cases. Clin Orthop Relat Res 1980; 149: 160–3.

48.

Tubby

. A case illustrating the operative treatment of paralysis of the serratus magnus by muscle grafting. J Bone Joint Surg Am 1904; S2–2:163–6.

49.

Post

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

50.

Connor

Yamaguchi

Manifold

, et al. Split pectoralis major transfer for serratus anterior palsy. Clin Orthop Relat Res 1997; 341: 134–42.

51.

Perlmutter

Leffert

. Results of transfer of the pectoralis major tendon to treat paralysis of the serratus anterior muscle. J Bone Joint Surg Am 1999; 81: 377–84.

52.

Durman

. An operation for paralysis of the serratus anterior. J Bone Joint Surg Am 1945; 27: 380–2.

53.

Povacz

Resch

. Dynamic stabilization of winging scapula by direct split pectoralis major transfer: a technical note. J Shoulder Elbow Surg 2000; 9: 76–8.

54.

Tauber

Moursy

Koller

Schwartz

Resch

. Direct pectoralis major muscle transfer for dynamic stabilization of scapular winging. J Shoulder Elbow Surg 2008; 17 (Suppl 1):29S–34.

55.

Herzmark

. Traumatic paralysis of the serratus anterior relieved by transplantation of the rhomboidei. J Bone Joint Surg Am 1951; 33: 235–8.

56.

Chaves

. Pectoralis minor transplant for paralysis of the serratus anterior. J Bone Joint Surg Br 1951; 33: 228–30.

57.

Bizot

Teboul

Nizard

Sedel

. Scapulothoracic fusion for serratus anterior paralysis. J Shoulder Elbow Surg 2003; 12: 561–5.

58.

Jeon

Neumann

Wallace

. Scapulothoracic fusion for painful winging of the scapula in nondystrophic patients. J Shoulder Elbow Surg 2005; 14: 400–6.

59.

Bunch

Siegel

. Scapulothoracic arthrodesis in facioscapulohumeral muscular dystrophy. Review of seventeen procedures with three to twenty-one-year follow-up. J Bone Joint Surg Am 1993; 75: 372–6.

60.

Rhee

. Long-term results of scapulothoracic arthrodesis of facioscapulohumeral muscular dystrophy. J Shoulder Elbow Surg 2006; 15: 445–50.

61.

Diab

Darras

Shapiro

. Scapulothoracic fusion for facioscapulohumeral muscular dystrophy. J Bone Joint Surg Am 2005; 87: 2267–75.

62.

Sewell

Higgs

Al-Hadithy

, et al. The outcome of scapulothoracic fusion for painful winging of the scapula in dystrophic and non-dystrophic conditions. J Bone Joint Surg Br 2012; 94-B: 1253–9.

63.

Uerpairojkit

Leechavengvongs

Witoonchart

Malungpaishorpe

Raksakulkiat

. Nerve transfer to serratus anterior muscle using the thoracodorsal nerve for winged scapula in C5 and C6 brachial plexus root avulsions. J Hand Surg 2009; 34A: 74–8.

64.

Raksakulkiat

Leechavengvongs

Malungpaishorpe

, et al. Restoration of winged scapula in upper arm type brachial plexus injury: anatomic feasibility. J Med Assoc Thai 2009; 92: S244–50.

65.

Suzuki

Doi

Hattori

Pagsaligan

. Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury. J Reconstr Microsurg 2007; 23: 295–9.

66.

Haman

Ebraheim

. Vulnerability of the spinal accessory nerve in the posterior triangle of the neck: a cadaveric study. Orthopedics 2002; 25: 71–4.

67.

Bigliani

Perez-Sanz

Wolfe

. Treatment of trapezius paralysis. J Bone Joint Surg Am 1985; 67: 871–7.

68.

Bigliani

Compito

Duralde

Wolfe

. Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius. J Bone Joint Surg Am 1996; 78: 1534–40.

69.

Donner

Kline

. Extracranial spinal accessory nerve injury. Neurosurgery 1993; 32: 907–10.

70.

Bodack

Tunkel

Marini

Nagler

. Spinal accessory nerve palsy as a cause of pain after whiplash injury: case report. J Pain Symptom Manage 1998; 15: 321–8.

71.

Teboul

Bizot

Kakkar

Sedel

. Surgical management of trapezius palsy. J Bone Joint Surg Am 2004; 86: 1884–90.

72.

London

Kay

. Iatrogenic accessory nerve injury. Ann R Coll Surg Engl 1996; 78: 146–50.

73.

Eden

. Zur Behandlung der Trapeziuslähmung mittelst Muselplastik. Dtsch Z Chir 1924; 184: 387–97.

74.

Lange

. Die Behandlung der irreparablen Trapeziuslähmung. Langenbecks Arch Klin Chir 1951; 270: 437–9.

75.

Romero

Gerber

. Levator scapulae and rhomboid transfer for paralysis of trapezius. The Eden-Lange procedure. J Bone Joint Surg Br 2003; 85: 1141–5.

76.

Moore

Dalley

. Clinically orientated anatomy. Fourth edition. Philadelphia: Lippincott Williams and Wilkins, 1999.

77.

Jerosch

Castro

Geske

. Damage of the long thoracic and dorsal scapular nerve after traumatic shoulder dislocation: case report and review of the literature. Acta Orthop Belg 1990; 56: 625–7.

78.

Ravindran

. Two cases of suprascapular neuropathy in a family. Br J Sports Med 2003; 37: 539–41.

79.

Yaguchi

Takahashi

Tashiro

, et al. Scapular winging as a symptom of cervical flexion myelopathy. Intern Med 2007; 46: 511–13.