Classification
Primary
Due to scapulothoracic articulation disorder
1. Neurological Origin
A. Spinal Accessory Nerve / Trapezius palsy
B. Long Thoracic Nerve / Serratus Anterior palsy
C. Dorsal Scapular Nerve / Rhomboids palsy (rare)
2. Osseous Origin
Osteochondromas (tangential x-rays, CT useful)
Fracture malunions
3. Soft Tissue Origin
Muscular Origin
- traumatic ruptures of Serratus Anterior
- iatrogenic during thoracotomy
Secondary
Due to GHJ articulation disorders
A. Erb's palsy
B. Deltoid fibrosis
C. Painful conditions i.e. RC tear, fracture, impingement
Voluntary
Rare
Trapezius Winging / Spinal Accessory Nerve
Anatomy
C3, 4
- supplies Sternocleidomastoid
- then runs in posterior triangle of neck to supply Trapezius (Upper 1/2)
Aetiology
Stab wounds to neck
Operations on posterior triangle (Lymph node biopsy)
Traction injuries
History
Pain
- will attempt to compensate by using levator scapulae
- can lead to disabling pain and spasm
- pain can also be from secondary effects (impingement / radiculopathy / Brachial plexus traction)
Examination
Shoulder depressed
- scapula translated lateral
- inferior angles rotated laterally
Trapezius wasting
- unable to shrug shoulders
- weakness with protraction
Non operative management
Reasonable for a time for traction injury
- physio
- wait 6 - 12 weeks
Operative
1. Neurorrhaphy
- direct repair for open laceration
2. Nerve Graft
3. Levator scapulae and Rhomboid transfer
- Eden-Lange procedure
- most common
Technique
- L. Scapulae to medial acromion
- R. minor upper 1/3
- R. major middle 1/3
4. Scapulothoracic Fusion
- reasonable pain relief
- poor function
- high complication rate
Serratus Anterior winging / Long Thoracic Nerve
Anatomy
C 5, 6, 7 from Roots
- runs down posterior axillary wall
- deep to fascia
- posterior to midaxillary line
- supplies Serratus Anterior
Action
- boxer's muscle
- protracts scapula
Origin
- fleshy slips
- upper 8 or 9 ribs
Insert
- costal aspect medial margin
Aetiology
Surgery
- shoulder or neck operations
- 1st rib resection
- mastectomy
Carrying loads on shoulder
Trauma
Repetitive microtrauma - swimming
Examination
Winging of scapula
- scapula medial
Management
1. Nerve Transfer
- TDN to LTN
2. Stabilisation of scapula / Marmor-Bechtol transfer
- transferring sternocostal head Pectoralis major to inferior corner scapula
- require fascia lata extension