Scapular Winging: Muscle Transfers—Split Pectoralis Major Transfer and Eden-Lange Procedures

William N. Levine

Charles M. Jobin

INDICATIONS

Both impairment of the trapezius, innervated by the spinal accessory nerve, and the serratus anterior, innervated by the long thoracic nerve, can lead to scapular winging.¹ Impairment of the trapezius, which acts to elevate and rotate the scapula, leads to lateral scapular winging,.²^,³ Impairment of the serratus anterior, which stabilizes the scapula on the chest wall, results in medial scapular winging, in which the inferior angle of the scapula rotates medially.²^,³ Winging of the scapula can result in a variety of symptoms, including pain, cosmetic deformity, decreased shoulder range of motion, and decreased shoulder strength.¹

Treatment of Lateral Scapular Winging

Treatment of lateral scapular winging depends on multiple factors, including etiology, timing of presentation, and individual patient characteristics. In the case of lateral scapular winging due to an early detected, identifiable injury to the spinal accessory nerve, nerve exploration, neurolysis, and nerve repair or grafting is indicated. Although there is debate regarding the time frame within which this treatment course is viable, it is generally agreed on that nerve repair or grafting is no longer indicated after 20 months.²^,⁴ For patients with lateral scapular winging in which nerve repair or grafting is not indicated, a 12-month trial of nonoperative management is recommended.²^,⁴ Although nonoperative treatment may provide pain relief, it is unlikely to result in significant functional improvement.²^,⁴ As such, nonoperative treatment may be appropriate in elderly, sedentary patients. However, surgical management is indicated in patients who fail nerve repair or nonoperative management.²^,⁴^,⁵

The Eden-Lange procedure and its variants are considered the gold-standard treatment for lateral scapular winging that has failed nonoperative management. The original Eden-Lange procedure, described in 1924 by Eden and corroborated in the 1950s by Lange, involves the transfer of the rhomboid minor and major from the medial scapular border to the infraspinatus fossa, as well as transfer of the levator scapulae to the scapular spine.⁶^,⁷ The original procedure was modified in 1996 by Bigliani et al, who described transfer of the rhomboid minor to the supraspinatus fossa to better recapitulate the force vector of the middle trapezius fibers.⁸ The described procedure, termed the “Modified Eden-Lange Procedure,” is the authors’ treatment of choice. In 2015, an additional modification, deemed the triple tendon transfer, was described by Elhassan and Wagner.⁹ In this modification, the rhomboid minor and major are also transferred to the scapular spine to better recapitulate the ability of the trapezius to upwardly rotate the scapula. Historically, scapulothoracic arthrodesis was used more regularly in the treatment of scapular winging, but is primarily used in salvage settings today.⁴

Treatment of Medial Scapular Winging

Treatment of medial scapular winging, likewise, depends on a multitude of factors. In the event of an acute serratus anterior avulsion, acute repair is indicated.¹⁰ In cases of medial scapular winging
due to an identifiable penetrating trauma or iatrogenic mechanism, nerve exploration, neurolysis, and repair or grafting may be indicated.¹⁰ In cases of neurapraxia, an extended trial of nonoperative management is recommended (up to 2 years).¹ Although nonoperative treatment can be effective, patients with persistent pain and/or dysfunction following a trial of nonoperative management are candidates for surgery.¹

The split pectoralis major transfer, in which the sternal head of the pectoralis major is transferred to the inferomedial scapular border, is the gold-standard treatment.¹^,¹⁰ Although not as commonly performed as the split pectoralis major transfer, long thoracic nerve neurolysis has also been reported as a viable treatment after failure of nonoperative management.¹⁰ Scapulothoracic fusion, also used as a surgical option for lateral scapular winging, is currently performed mainly as a salvage procedure.¹⁰

CONTRAINDICATIONS

Muscle transfer procedures for scapular winging are contraindicated in several settings. Intuitively, dysfunction of the muscle(s) that is to be transferred is a contraindication to muscle transfer. Such dysfunction may be present in the setting of neuromuscular disease, such as facioscapulohumeral muscular dystrophy.¹⁰ Additionally, the presence of a large chest wall defect is a contraindication to split pectoralis major transfer, as there is a risk of scapular entrapment in the defect.¹¹ Inability or unwillingness to comply with postoperative protocols, infections about the surgical area, and open wounds about the surgical area are also contraindications to surgery.¹¹

PREOPERATIVE PREPARATION

History

The patient history should include a thorough evaluation of the presenting symptoms. Symptoms can include pain, which may have a dull quality, vague location, radiate distally, and worsen with overhead activities.²^,¹² Patients may also report weakness, particularly with prolonged arm use and/or overhead activity, as well as difficulty controlling arm movement.² Occasionally, patients with injuries to the spinal accessory nerve may complain of paresthesias of the posterolateral neck.² Despite the breadth of possible presenting symptoms, it is worth noting that some patients do present with relatively few subjective symptoms.² A thorough assessment should also include inquiry regarding mechanism of injury, symptom progression, and completed treatments, as well as all standard components of a patient history, including medical and surgical history. Assessment of patients’ activity levels and functional goals are of particular importance.¹²

Physical Examination

The physical examination should include the standard components of inspection, palpation, range of motion testing, strength testing, and neurovascular assessment. Additionally, it is important to be aware of several nuances and special tests specific to the examination of scapular winging.

Inspection of the patient should be performed from both the front and the back, with the patient undressed.¹² Scapular winging and its direction, whether medial or lateral, should be noted. In the setting of CN XI palsy, atrophy of the trapezius and sternocleidomastoid, asymmetry of the neckline, and drooping of the affected shoulder may be appreciated² (Figures 8-1 and 8-2).

FIGURE 8-1 Sternocleidomastoid wasting.

(Courtesy of William N. Levine, MD.)

FIGURE 8-2 Lateral scapular winging.

(Courtesy of William N. Levine, MD.)

Additional testing may reveal a decrease in the range of motion, particularly in forward elevation and abduction, and weakness, also frequently with forward elevation and abduction.²^,¹² The scapular stabilization test, performed by assessing forward elevation with the scapula stabilized against the chest wall by the examiner, may partially alleviate the range of motion and strength deficits.¹² Scapular winging may be accentuated by forward elevation and/or abduction, as well as the performance of a wall push-up¹^,²^,¹² (Figure 8-3).

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