Scapular Winging

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Search Strategy

1. SEARCH STRATEGY ARTICLES

Keywords:
• Coccyx fracture ( 55 results and 3 free full texts): Most successful search
• Coccygectomy (85 results and 16 free full texts)
• Coccygeoplasty (1 free full text).
• Coccyx fracture AND physiotherapy (1 result)

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It is also very useful to check the references of each usable article.

2. SEARCH STRATEGY BOOKS

Keywords:
• Traumatology
• Fractures
• Orthopaedics

Search engines: VUBIS catalogus / UA catalogus

Definition/Description

The term ‘winged scapula’ (also scapula alata) is used when the muscles of the scapula are too weak or paralyzed whereby the scapula doesn’t stabilise and especially when the medial border protrudes, like wings. The main reasons for this condition are: musculoskeletal- and neurological-related. (4) (10)

Neurological :
[3]

Musculoskeletal:
[4]

Clinically Relevant Anatomy

The most important anatomic structures who are involved in the winged scapula are: scapula,  M.trapezius, M.serratus anterior, Mm.romboideï, M.levator scapulae, M. Pectoralis minor, M.latissimus dorsi, N.accessorius, N.thoracicus longus and plexus brachialis.

Epidemiology /Etiology

Structures involving the musculoskeletal winged scapula: (9)
M.trapezius, M.serratus anterior, M.rhomboideus major, Mm.rhomboideï, M.levator scapulae, M.pectoralis minor, M.latissimus dorsi
Structures involving the neurological winged scapula: (4)
M.trapezius (pars descendens), M.serratus anterior, M.rhomboidei, N.accessories, N.thoracicus longus, Plexus brachialis.

The causes of both species of winged scapula are: (3) (10) (11)
• Acute traumas, for example a direct shock on the shoulder during a car accident with a sudden traction on the arm.
• Micro traumas, repeated stretching of the neck in later flexion as in tennis (N. Thoracicus longus) or by wearing a heavy backpack (N. Accessories)
• Post-infection, for example an influenza infection
• Injections
• From birth
• The result of post-surgical complications, like a chest tube placement (1)
• Idiopathic as in the case of the syndrome of Parsonage and Turner
Most of these patients describe a sever or excruciating pain, often keeping them awake. Most of the painful scapula alata are caused by a neurological trauma. But a winged scapula is not always painful, this is often with a muscular scapula alata. Other patients feel a moderate pain and some are experiencing no pain at all.  (4)

Any infringement of the plexus brachialis, N.accessorius or N. Thoracicus longus is susceptible to provoke the winging of the scapula. The causes are multiple and new ones are frequently discovered. (4)

Characteristics/Clinical Presentation

• Clinical presentation for the musculoskeletal winged scapula:
There are three types of scapular motion deviation: (9)

Type 1:
A visible angulus inferior and a pronounced anterior tilt of the scapula can be observed.
The causes for this type are: shortening of the M.pectoralis minor, shortening of the posterior joint-capsule and muscular unbalance of the M.Trapezius pars ascendens and the M.serratus anterior.
                                                                                                                                                                  [1]

Type 2:
A visible margo medialis and an intern rotation of scapula can be observed.
The causes are: shortening of the posterior joint-capsule, shortening of the M.latissimus dorsi and muscular unbalance of the M.trapezius and the M.serratus anterior.

                                                                                                                                                                 [2]

Type 3:
A visible angulus inferior and a downward rotation of scapula can be notified.
The causes are: shortening of the M.levator scapulae and muscular unbalance of the M.trapezius pars descendens and ascendens.

• Clinical presentation for the neurological winged scapula:
There are two types of scapular motion deviation: (8)

Type 1:
The characteristics of type 1 are a separated scapula of the thorax, elevation of scapula and the margo medialis comes closer to the spinal line. These causes are related to damage of the N.thoracicus longus and an insufficiency of the M.serratus anterior.

Type 2:
The characteristics of type 2 are a separated scapula of the thorax, lowering of the scapula and spreading of the margo medialis against the spinal line. The causes are damage to the N.accessorius and insufficiency of the M.trapezius pars descendens.

Diagnostic Procedures

• The therapist offers an isometric resistance against a scapular elevation in midrange of motion. With a type 1 the angulus inferior becomes visible. Then the therapist asks the patient to execute a protraction, afterwards he repeats the resistance-test. If the scapular posture deviation increases or stays the same, the conclusion would be: a dysfunction of the M. Serratus anterior. If it decreases then we have a dysfunction of the M. Trapezius pars ascendens. (9)
• The humerus is passively placed into endorotation behind the back. The capsular tension will bring the scapula to the front. It’s also a test to conclude a shortening of the M. Latissimus dorsi. (9)
• When the patient lifts his arm we see a charged excessive acromion, now we can explain that there is an excessive activity of the M. Trapezius pars ascendens and a low activity of the M. Trapezius pars descendens. This phenomenon is called the ‘shrug-phenomenon’. (9)

Outcome Measures

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Examination

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Medical Management

1. COCCYGEOPLASTY
By applying the novel techniques that are used in vertebroplasty and sacroplasty, coccygeoplasty is introduced as a new percutaneous treatment modality for fractures of the coccyx. This procedure can be helpful for patients with refractory pain resulting from a fracture of the coccyx and can be performed quickly and safely with high-resolution c-arm fluoroscopy. The coccygeal fracture treated with an injection of polymethylmethacrylate cement can provide early symptom relief. Although the promising results, an experience with a larger patient population is warranted. ( level of evidence C)

2. COCCYGECTOMY
Literature reports suggest that coccygectomy, partial or total removal of the coccyx, has been beneficial with success rates as high as 60-91%. However, coccygectomy is a more invasive procedure, with a common complication rate as high as 22%, and is usually associated with perineal contamination of the wound. Other complications could include persistent bleeding from the hemorrhoidal venous complex of the rectum. (level of evidence C)ix

Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 451-452, level of evidence D
YU-TSAI T., LI-WEN T., CHENG-HSIU L., SHIH-WEI C., The influence of human coccyx in body weight shifting, medicine and science in sport and exercise, 2011, Volume 43, Number 5, pag. 494-496, level of evidence B
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 332, level of evidence D
HAARMAN H.J.Th.M., Klinische traumatologie, Elsevier gezondheidszorg, 2006, pag. 117, level of evidence D
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 461, level of evidence D
TEKIN L. et al., Coccyx fracture in patients with spinal cord injury, European journal of physical and rehabilitation medicine, March 2010, Volume 46, Number 1, pag. 43-46, level of evidence C
RAISSAKI M.T.,Fracture dislocation of the sacro-coccygeal joint: MRI evaluation, Pediatric radiology, March 1999, pag. 642-643, level of evidence D
LONSDALE E.F., A practical treatise on fractures, Walton and Mitchell printers, 1838, pag. 269-270, level of evidence D
MIYAMOTO K. et al., Exposure to pulsed low intensity ultrasound stimulates extracellular matrix metabolism of bovine intervertebral dosc cells cultured in alginate beads, Spine, November 2005, level of evidence B
EBNEZAR J., Essentials of orthopaedics for physiotherapist, Jaypee, 2003, pag. 174, level of evidence D
DEAN L.M. et al., Coccygeoplasty : treatment for fractures of the coccyx, J. Vasc. Interv. Radiol, 2006, pag. 909-912, level of evidence C
COOPER G., HERRERA J.E., Manual of musculoskeletal medicine, Wolters kluwer, Lippincott Williams & Wilkins, 2008, pag. 144, level of evidence D