Winging Scapula

What is a Winging Scapula?

 A winging scapula is a shoulder injury or condition in which the scapula or shoulder blade sticks out at the back, particular when lifting the arm up or pushing against something. Often patients complain of pressure on the shoulder blade from the back of their chair when sitting.

What are the symptoms of a winged scapula?

• Winging of the scapular or shoulder blade.
• Pain and limited shoulder elevation.
• Difficulty in lifting heavy objects.

What causes a winging scapula?

A winging scapula is associated with damage or a contusion to the long thoracic nerve of the shoulder and / or weakness in the serratus anterior muscle. If the long thoracic nerve is damaged or bruised it can cause paralysis of the serratus anterior muscle and winging of the scapular or shoulder blade.

Damage to the nerve can be caused by a contusion or blunt trauma of the shoulder, heavy weight lifting, repetitive throwing, traction of the neck or can also sometimes follow a viral illness. Some cases of long thoracic nerve injury are of unknown origin.

Treatment

Your surgeon will arrange nerve conduction studies to help assess the extent of damage to the long thoracic nerve and plan appropriate treatment.

Physiotherapy

A full rehabilitation programme aimed at re-educating the serratus anterior muscle can be successful when damage to the long thoracic nerve is mild. However, treatment can take 6 to 12 months to achieve a good outcome.

Surgery

If nerve conduction studies confirm that there is marked damage to the long thoracic nerve your surgeon may suggest an operation called a long thoracic nerve decompression to help the nerve recover. Current evidence shows that long thoracic nerve decompression results in good or excellent results in 92% of cases.

You will have a small incision approximately a hands breadth down from the middle of your armpit. This will allow your surgeon to access and decompress the affected nerve.

What are the risks of having a long thoracic nerve decompression?

All operations involve an element of risk, these are very small but you need to be aware of them and can discuss them with your doctor at any time.
The risks are;

• Complications relating to the anaesthetic
• Infection (less than 1%)
• Stiffness and or pain around the shoulder (less than 1%)
• Damage to nerves or blood vessels around the shoulder

What sort of anaesthetic will be given to me?

You will usually be given a general anaesthetic. General anaesthesia is drug-induced unconsciousness: it is always provided by an anaesthetist, who is a doctor with specialist training.

Unfortunately, general anaesthesia can cause side effects and complications. Side effects are common, but are usually short-lived: they include nausea, confusion and pain. Complications are very rare, but can cause lasting injury: they include awareness, paralysis and death.

The risks of anaesthesia and surgery are lower for those who are undergoing minor surgery, and who are young, fit, active and well.

You will be given an opportunity to discuss anaesthetic options and risks with your anaesthetist before your surgery.

If you are worried about any of these risks, please speak to your Consultant or a member of his team.

Getting ready for your operation

You will usually be seen in the pre-operative clinic before you are admitted to hospital. Here you will have blood tests, a chest x-ray, and sometimes a heart trace, if required, as part of your anaesthetic assessment.

The nurse will ask routine questions about your health, the medicine you take at the moment and any allergies you may have. You will be given instructions on eating and drinking.

Prior to your surgery, you will be asked to sign a consent form to confirm that you understand the procedure, and what the operation involves. You will be able to further discuss the operation with Mr. Brownson at this time.

The day of your operation

• You will come into hospital on the day of your operation.

• Please leave body piercings at home. Acrylic nails and nail polish will also need to be removed.

• If you are on regular medication, you will be told to take this if necessary.

• You will be asked to take a shower and put on a gown and disposable underwear.

• A bracelet with your personal details will be attached to your wrist.

• You may be prescribed some medication to take before your operation by the anaesthetist. A member of the nursing staff will give this to you.

• A nurse and porters will take you to the operating theatre.

• Your dentures, glasses or hearing aid can stay with you on your journey to the operating theatre.

• When you arrive in the waiting area, a theatre nurse will check your details with you. You will then be asked to put on a disposable hat. The ward nurse will then leave you and you will then be taken to the anaesthetic room.

What should I expect after my operation?

• After your operation you will be kept in the theatre recovery room before being transferred to the ward.

• A nurse will check your pulse, blood pressure, and breathing rate regularly.   It is important that if you feel any pain you must tell the nursing staff, who can give you painkillers to help.

• The nursing staff will also advise you when you can start taking sips of water. Anaesthetics can make some people sick. If you feel sick we advise you not to drink until this feeling has passed. The nursing staff may offer an injection to help this sick feeling go away.

• The ward physiotherapist will see you before you are discharged home to:
  • Assess your shoulder
  • Show you use of the sling and advise on when to wear it
  • Teach you the exercises you need to do immediately
  • Arrange an out-patient physiotherapy appointment at your local hospital

Going Home

Your doctor will normally discharge you on the day of your surgery or the morning after if your pain is well controlled.

Your exercises will be supervised by outpatient physiotherapy appointments, which will be arranged for you before you leave hospital. Physiotherapy is an essential part of your treatment as you will need to reeducate the serratus anterior muscle to prevent the shoulder blade winging i.e. teach it how to work properly again.

Discharge Information

Pain relief & medication

The nursing staff will advise you about painkillers before you leave the hospital. Please tell the nurses what painkilling tablets you have at home.

Your wound

Your wounds must remain covered with dressings until your outpatient appointment, where your sutures will be removed.

Getting back to normal

Remember that you have just had an operation. It is normal to feel more tired than usual for a few days after having an operation.
Your shoulder is likely to be uncomfortable in the first few days post-surgery. This is normal but can be helped by;

• Sleeping can be uncomfortable if you try and lie on your operated arm. We would recommend that initially you lie on your back or on the opposite side. If you lie on your back support the operated arm with a folded pillow under your lower arm. Make sure that your elbow is above your shoulder. If you are on your side then a folded pillow supports your operated arm from your elbow to your wrist.

• Posture can make a significant difference to your pain post surgery. Avoid 'hitching' your shoulder or holding it in an elevated position. Also try to avoid slumping or standing/sitting with round shoulders.

Your physiotherapist will give you further guidance to optimize your recovery. Rehabilitation is an essential component of your recovery to reeducate the serratus anterior muscle.