Scapular winging: anatomical review, diagnosis, and treatments

Abstract

Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. It is the result of numerous causes, including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made upon visible inspection of the scapula, with serratus anterior paralysis resulting in medial winging of the scapula. This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. A conservative course of treatment is usually followed for rhomboid paralysis. To allow time for spontaneous recovery, a 6-24 month course of conservative treatment is often recommended, after which if there is no recovery, patients become candidates for corrective surgery.

Fig. 1

Anatomical relationship of the serratus anterior, trapezius, and rhomboid muscles around the scapula, with the rhomboids just deep to the trapezius. Modified from Ref. [, p. 52, Fig. 2.43]

Fig. 2

Course of the long thoracic nerve to its innervations of the serratus anterior muscle. Proposed vulnerable sites for injury include compression of the nerve between the clavicle and first rib and traction within the nerve’s fascial sheath [, Fig. 1]

Fig. 3

Winging of the right scapula due to serratus anterior palsy, accentuated by active flexion of the arms. In addition to the medial border lifting off the posterior thoracic wall, note the medial and superior translation of the right scapula when compared to the normal left side [, Fig. A]

Fig. 4

A patient with pronounced winging of the left scapula during active external rotation against resistance, typical of trapezius palsy. Note the lateral displacement of the scapula with the superior angle more lateral to the midline than the inferior angle [, Fig. 4A]

Fig. 5

A treatment option for scapular winging due to serratus anterior or trapezius muscle paralysis, the winger’s brace is designed to manually press the scapula against the posterior thoracic wall, preventing stretching of the paralyzed muscle and providing limited functional recovery [, Figs. 1 and 2]