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J Korean Med Sci 2006; 21: 581-4 Copyright � The Korean Academy

ISSN 1011-8934 of Medical Sciences

Winged Scapula Caused by Rhomboideus and Trapezius Muscles
Rupture Associated with Repetitive Minor Trauma
: A Case Report

We experienced a rare case of winged scapula that was caused by the rupture of Sam-Gyu Lee, Jae-Hyung Kim*,
the rhomboideus major and the lower trapezius muscles without any nerve injury in So-Young Lee*, In-Sung Choi,
a 12 yr old female after she had carried a heavy backpack. Electrodiagnostic study Eun-Sun Moon�
revealed that the onset latencies, amplitudes and conduction velocities were normal Department of Physical Medicine & Rehabilitation,
in the long thoracic nerve, the spinal accessory nerve and the dorsal scapular nerve. Research Institute of Medical Sciences, Chonnam
The needle EMG findings were normal as well. An explorative operation was per- National University Medical School & Hospital,
formed and the rupture of the rhomboideus major and lower trapezius muscles was Hwasun Hospital*, Department of Orthopedic Surgery,
Chonnam National University Medical School &
detected. Direct surgical repair of the ruptured muscle was carried out and the defor- �
Hospital , Gwangju, Korea
mity was corrected. The anatomical and functional restoration was satisfactorily ac-
complished. Received : 7 April 2005
Accepted : 20 June 2005

Address for correspondence
Jae-Hyung, Kim, M.D.
Department of Physical Medicine & Rehabilitation,
Chonnam National University, Hwasun Hospital,
160 Ilsim-ri, Hwasun-eup, Hwasun-gun,
Jeollanam-do 519-809, Korea
Tel : +82.61-379-8280, Fax : +82.61-379-7779
E-mail : rehabkjh@hanmail.net

*This study was financially supported by Regional
Key Words : Scapula; Muscle, Skeletal; Wounds and Injuries; Rhomboideus Muscle; Trapezius Muscle Research Centers Program from the Ministry of Edu-
Shoulder cation and Human Resources Development.

INTRODUCTION weight was 38 kg. This condition abruptly developed after
climbing a mountain for 2 hr with a rucksack/back-pack
Winged scapula is one of the more common scapulothoracic weighing about 20 kg at 2 months previous to her hospital
disorders, and it is caused by a number of pathologic condi- visit. At a certain moment, she felt the drooping shoulder
tions. It can be classified as primary and secondary; primary with a popping sound. She was born via spontaneous full-term
winged scapula may be due to neurologic injury, pathologic vaginal delivery with a normal APGAR score. She had no
changes in the bone or because of periscapular soft-tissue ab- specific family history of nerve or muscle diseases. Her growth
normalities. Secondary winged scapula occurs as a result of and developmental history was nonspecific before the onset
glenohumeral and subacromial conditions, and it resolves of winged scapula. Upon the physical examination, a wing-
after the primary pathologic condition has been addressed (1). ing deformity of the right scapula was noticed with the lat-
Traumatic winged scapula is not a common malady, and only eral deviation and upward rotation of the inferior angle, as
rarely has winged scapula been attributed to muscular injury. observed on the erect neutral posture (Fig. 1A). This abnor-
We report here on a patient with winged scapula that was mality was not detected when both shoulders were abducted
caused by rhomboideus and trapezius muscles rupture asso- (Fig. 1B), but it was aggravated by shoulder flexion (Fig. 1C).
ciated with repetitive minor trauma. The motor and sensory functions of the upper extremities
were normal and no side to side differences were revealed. The
deep tendon reflexes of the biceps and triceps muscles were
CASE REPORT normoactive and symmetrical. No significant muscle atrophy
in the shoulder girdles and the upper extremities was obser-
A 12-yr-old female presented to our outpatient department ved. On the laboratory tests, the routine complete blood count
with a right winged scapula. Her height was 139 cm and her with differential counting, erythrocyte sedimentation rate, C-

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including the chest muscles including serratus anterior. both the shoulder anterior-posterior and rhomboideus and so on. . nosis.-Y. lactate dehydrogenase and transaminase. Simple radiological studies. as examined with the patient in an erect neutral posture. (A) The intraoperative findings revealed the rupture of some portions of the right rhomboideus major and lower trapezius muscles (white arrow). J. (B) shows no detectable asymmetry on shoulder abduction. A B C Fig. (C) C shows a more prominent winging of the right scapula on shoulder flexion. Winged scapula caused by the rupture of the right rhom- boideus major and lower trapezius muscles: (A) shows the later- al deviation and upward rotation of the inferior angle of the right scapula. and the muscle enzyme tests. S. including serum tic examination that included the long thoracic nerve. et al. reactive protein.-G. A B Fig. were dorsal scapular nerve and the spinal accessory nerves and the also normal. (B) Postoperative illustration of the rhomboideus major and lower trapezius repair and reefing. Lee. Kim. 2. rheumatoid arthritis factor and urinalysis We examined the nerves by conducting an electrodiagnos- were normal. 1. were nonspecific except for the that indicated any neuropathy or myopathy on electrodiag- slight scapular asymmetry. levator scapula. the creatine kinase. Lee. there were no definitive evidences views and the scapular view. (C) Postoperative findings showed restoration of scapular symmetry with the patient in a neutral erect posture. trapezius posterior-anterior view.-H.582 S.

at 2 months after the opera.e. She was nostic testing. The right scapula was lation and positive sharp wave) after nerve injury. Long thoracic nerve injury. Flatow EL. The winged scapula. The most common 4. 11. J Trauma 2004. reported that the accuracy of electrodiag- der and strengthening exercise of the rhomboideus muscles. They also said that muscular injury should be gical intervention then became appropriate. especial. Warner GC. Copeland SA. 5. Winged scapula is defined as a prominence of the medial border of the scapula and it is the most common scapulotho- racic disorder (2). Singh S. Yamaguchi K. 2C). Spinal accessory nerve injury. 368: 17-27. Gatens PF Jr. winged scapula caused by 7. Manifold SG. 341: 134-42 ius muscle. B). We can observed that the sibilities to explain these findings. we confirmed that the winged scapula was caused by the Bigliani LU. Danielsson LG. REFERENCES and they include brachial plexus injury (2. velop due to subscapular osteochonroma (7). 12: 245-7. Flatow EL. An explorative considered as a very rare cause of winged scapula. Wiater JM. Am Fam dystrophy (5) or injury to the long thoracic nerve that occurs Physician 1981. King RJ. Winged scapula due to osteochondro- direct rupture of rhomboideus and trapezius muscles. fascioscapulohumeral muscular 1. Nardin et al. 3). Further. The same operation was done. Postoperatively. Clin Orthop . they insisted on the possibility of an undetected partial neu. Evaluation and treatment of the winged scapula. the winged scapula depends on the specific nerve injury and 185: 228-36. The first. Clin Orthop Relat Res 1980. 13) and a disordered rhom. Posner B. it takes some rhomboidius major was ruptured and trapezius lower thoracic time for an abnormal electrical potential to appear (i. Wood VE. 57: 402-3. Wiater JM. based on the history and the operative find. The reported anec. 24: 139-43. Split pectoralis major transfer for serratus anterior palsy. Until now. The shoulder dotal cases of traumatic winged scapula were almost always in patients with muscular dystrophy. The position of 3. the electrodiagnostic findings of our was made parallel to the vertebral border of the scapula. ings. 368: 80-91. Scapular winging in young athletes. J Pediatr “popping” injury. Connor PM. ma. Gupta V. After the muscle nerve injury 7 days after the injury. the scapula was stable to chest wall at the time of the proximal part by day 14 and in the distal part by day 21 (16). ty of inappropriate placing of the needles on the electrodiag- der and no pain nor limitation of shoulder motion. tions.Winged Scapula Caused by Muscle Rupture 583 When the pain and functional impairment persisted. Saeed MA. operation. The second possibility her right shoulder and she received rehabilitative treatment would be a technical error of the electrodiagnostic examina- for 2 weeks including range of motion exercise of the shoul. isolated paral- ysis of the serratus anterior (4). 4: 38-52. Our case had enough time not to observe abnormal findings Postoperatively. Arch Phys Med Rehab 1992. J South outlet compression syndrome (6). trapezius muscle paralysis that usually resulted from injury 6. there was no weakness or deformity of the affected shoul. ropraxic lesion. Bigliani LU. Clin Orthop Relat Res 1999. ated scapula winging in a low-velocity rear-end automobile colli- grams was reported by Sanitate and Jurist in 1995 (15). Frykman GK. cle weakness (17). el-Haddad I. Fiddian NJ.. Winging of the scapula as a complication to the spinal accessory nerve (12. Duralde XA. and the repetitive minor trauma to the muscles. Clin Orthop Relat Res 1997. Orthop 1992. Mah JY. Orthop Assoc 1995. the resulting pattern of muscle paralysis. 60: 728-9. Otsuka NY. Long thoracic neuropathy from athletic downward traction force on the arm by her heavy back-pack activity. related with traction injury to the long thoracic nerve (9-11). Report of 3 children. Clin Orthop Relat cause is the paralysis of the serratus anterior muscle that is Res 1999. sur. The causes of this condition are well-known. Acta Orthop Scand 1989. Schultz JS. In our 8. Winging of the scapula. of first rib resection: a report of six cases. innervated by the long thoracic nerve (8). Levy O. case. Rhomboideus major and trapezius electrical potentials were seen both proximal and distal to the muscle repair and reefing were performed. This condition can also de. satisfied with the recovery of her shoulder function (Fig. 2A. 12. and this was most likely associated with the acute 9. fibril- bundle displayed thinning (Fig. Leonard JA Jr. ly without scapular fracture. rupture of rhomboideus major muscle and the lower trapez. Dodenhoff RM. nostic testing was 91% in patients who presented with mus- On the follow up examination. Clin Orthop Relat Res 1984. Pollock RG. and they appeared in the repair. We thought that the winged scapula resulted from the 10. We thought that there were two pos- subcutaneous tissue was divided. has not been reported on. boideus muscle that generally resulted from injury to the dor. during resection of the first rib for decompression of thoracic 2. we could not rule out the possibili- tion. Abnormal unstable to the chest wall. and sion. sal scapular nerve (14). 73: 87-90. Trauma to the long thoracic nerve and associ- A winged scapular in a patient with normal electromyo. she achieved the anatomical restoration of on electrodiagnostic examinations. A posterior longitudinal skin incision as their case findings. the anatomical restoration was achieved and functional restoration of the right shoulder was satisfac- torily accomplished by rehabilitative measures that included DISCUSSION range of motion exercises for the shoulder and strengthening exercise for the rhomboideus and trapezius muscles. 149: 160-3. The case were nonspecific.

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