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Concept: Long thoracic nerve

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INTRODUCTION: Although palsy of the long thoracic nerve is the classical pathogenesis of winging scapula, it may also be caused by osteochondroma. This rare etiopathology has previously been described in pediatric patients, but it is seldom observed in adults. CASE PRESENTATION: We describe three cases of static scapular winging with pain on movement. Case 1 is a Caucasian woman aged 35 years with a wing-like prominence of the medial margin of her right scapula due to an osteochondroma originating from the ventral omoplate. Histopathological evaluation after surgical resection confirmed the diagnosis. The postoperative course was unremarkable without signs of recurrence on examination at 2 years. Case 2 is a Caucasian woman aged 39 years with painful scapula alata and neuralgic pain projected along the left ribcage caused by an osteochondroma of the left scapula with contact to the 2nd and 3rd rib. Following surgical resection, the neuropathic pain continued, demanding neurolysis of the 3rd and 4th intercostal nerve after 8 months. The patient was free of symptoms 2 years after neurolysis. Case 3 is a Caucasian woman aged 48 years with scapular winging due to a large exostosis of the left ventral scapular surface with a broad cartilaginous cap and a large pseudobursa. Following exclusion of malignancy by an incisional biopsy, exostosis and pseudobursa were resected. The patient had an unremarkable postoperative course without signs of recurrence 1 year postoperatively. Based on these cases, we developed an algorithm for the diagnostic evaluation and therapeutic management of scapula alata due to osteochondroma. CONCLUSIONS: Orthopedic surgeons should be aware of this uncommon condition in the differential diagnosis of winged scapula not only in children, but also in adult patients.

Concepts: Pain, Long thoracic nerve, Physician, Medical terms, Serratus anterior muscle, Pathology, Winged scapula, Scapula

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Scapular winging secondary to serratus anterior muscle palsy is a rare pathology. It is usually due to a lesion in the thoracic part of the long thoracic nerve following violent upper-limb stretching with compression on the nerve by the anterior branch of thoracodorsal artery at the “crow’s foot landmark” where the artery crosses in front of the nerve. Scapular winging causes upper-limb pain, fatigability or impotence. Diagnosis is clinical and management initially conservative. When functional treatment by physiotherapy fails to bring recovery within 6months and electromyography (EMG) shows increased distal latencies, neurolysis may be suggested. Muscle transfer and scapula-thoracic arthrodesis are considered as palliative treatments. We report a single-surgeon experience of nine open neurolyses of the thoracic part of the long thoracic nerve in eight patients. At 6months' follow-up, no patients showed continuing signs of winged scapula. Control EMG showed significant reduction in distal latency; Constant scores showed improvement, and VAS-assessed pain was considerably reduced. Neurolysis would thus seem to be the first-line surgical attitude of choice in case of compression confirmed on EMG. The present results would need to be confirmed in larger studies with longer follow-up, but this is made difficult by the rarity of this pathology. LEVEL OF EVIDENCE: III.

Concepts: Muscle, Heart, Electromyography, Brachial plexus, Scapula, Long thoracic nerve, Winged scapula, Serratus anterior muscle

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Winging of scapula occurs most commonly due to injury to long thoracic nerve supplying serratus anterior muscle. Traumatic injury to serratus anterior muscle itself is very rare. We reported a case of traumatic winging of scapula due to tear of serratus anterior muscle in a 19-year-old male. Winging was present in neutral position and in extension of right shoulder joint but not on “push on wall” test. Patient was managed conservatively and achieved satisfactory result.

Concepts: Rhomboid minor muscle, Biceps brachii muscle, Rhomboid major muscle, Shoulder, Winged scapula, Scapula, Long thoracic nerve, Serratus anterior muscle

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Long thoracic nerve (LTN) injury can result in ipsilateral serratus anterior palsy and scapular winging. Traditional means of evaluating patients with suspected LTN injury include physical examination and electrodiagnostic studies. The purpose of our study is to describe high-resolution magnetic resonance (MR) findings in patients with clinical suspicion of LTN neuropathy.

Concepts: Nerve, Medical terms, Physical examination, Mental status examination, Magnetic resonance neurography, Long thoracic nerve, Winged scapula, Serratus anterior muscle

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Winged scapula is defined as the prominence of the medial border of the scapula. The classic etiopathology of scapular winging are injuries to the spinal accessory or long thoracic nerves resulting respectively in trapezius and serratus anterior palsy. To the best of our knowledge, there are only few reports of scapular lesions being mistaken for winging of the scapula. We report a rare case of a large scapular osteochondroma arising from the medial border and causing a pseudowinging of the scapula.

Concepts: Philosophy of science, Cranial nerves, Scapula, Accessory nerve, Long thoracic nerve, Winged scapula, Trapezius muscle, Serratus anterior muscle

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We report a large series of patients with unilateral winged scapula (WS), with special attention to long thoracic nerve (LTN) palsy.

Concepts: Brachial plexus, Winged scapula, Serratus anterior muscle, Long thoracic nerve

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Isolated long thoracic nerve palsy results in scapular winging and destabilization. In this study, we review the surgical management of isolated long thoracic nerve palsy and suggest a surgical technique and treatment algorithm to simplify management.

Concepts: Medicine, Winged scapula, Long thoracic nerve

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Two main hypotheses have been proposed for the pathophysiology of long thoracic nerve (LTN) palsy: nerve compression and nerve inflammation. We hypothesized that critical reinterpretation of electrodiagnostic (EDX) studies and MRIs of patients with a diagnosis of non-traumatic isolated LTN palsy could provide insight into the pathophysiology and, potentially, the treatment.

Concepts: Medical terms, Long thoracic nerve

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Thoracic outlet syndrome poses a difficult diagnostic entity with varied aetiology and clinical presentation. We present a 35-year-old gentleman with unilateral long thoracic nerve palsy and contralateral subscapular paralysis caused by aberrant scalenus medius anatomy. Thoracic outlet syndrome ought to be considered in patients presenting with isolated nerve palsies.

Concepts: The Canon of Medicine, Greek loanwords, Subclavian artery, Long thoracic nerve, Medical terms

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A 20-year-old male was evaluated for winging of the scapula and an enlarging axillary mass of 4 months' duration. Imaging demonstrated a multiloculated cystic lesion that extended into the axilla and superiorly displaced the brachial plexus and axillary vessels surrounding an exostotic mass arising from the scapula. Surgery confirmed the mass to be a benign osteochondroma with a reactive bursa. The long thoracic nerve was intact and the serratus anterior muscle contracted normally with nerve stimulation. The scapular winging resolved completely following resection of the osteochondroma, and shoulder and arm function remained normal. A literature review of causes of pseudo-winging of the scapula was performed. Scapular osteochondroma is a rarely reported cause of scapula winging.

Concepts: Causality, Axillary artery, Scapula, Axilla, Winged scapula, Long thoracic nerve, Brachial plexus, Serratus anterior muscle