The scapula usually rests flat on the posterior thoracic wall. When the scapula sticks out, it is termed winged scapula. Scapular winging is a relatively rare condition resulting from either neurologic or musculoskeletal causes. Two neurologic causes are serratus anterior or trapezius muscle dysfunction. Between the two, serratus anterior dysfunction secondary to long thoracic nerve injury is more common resulting to medial scapular winging where the scapula assumes a position of medial rotation and superior translation of the inferior angle. On the other hand, trapezius dysfunction, mostly due to spinal accessory nerve palsy, results in inferior translation of the scapula, with the inferior angle rotating laterally. Musculoskeletal causes can be from direct trauma on the shoulder such as in car accidents with sudden traction on the arm. This can also happen to professional or amateur athletes of a variety of sports e.g. bowling, archery, wrestling, baseball, etc. It can also occur with micro trauma such as in repeated stretching of the neck in lateral flexion or by wearing a heavy backpack. Occupational injuries in individuals working as car mechanics, scaffolders, welders, carpenters, laborers, and a seamstress has also been reported.
Winging of the scapula affects the scapulo-humeral rhythm, resulting in decreased strength and limitation in motion, particularly flexion and abduction. It can be a source of considerable pain and can be incapacitating enough to affect the ability to lift, pull, and push heavy objects, as well as to perform daily activities of living, such as brushing one’s hair, dressing, and carrying grocery bags.
Currently, no treatment method is considered to be the first line for the resolution of scapular winging. The recommended treatment for initial treatment is pain control. Management is either conservative, thru physical therapy, or surgical. However, some studies prefer a non-operative treatment especially in case of older patients who are sedentary and with minimal symptoms. But if intervention is not initiated early on in the progression of the condition, patients can develop subsequent issues such as adhesive capsulitis, subacromial impingement, and other pathogenesis involving the brachial plexus.
Surgically, there are three methods available - Split Pectoralis Major Transfer, Modified version of the Eden-Lange Procedure, and Scapuloplexy. The case we are discussing today is surgical management of scapular winging using the Split Pectoralis major Transfer