1. science
2. medicine
3. surgery

TREATMENT
OF WINGED
PECTORALIS
MAJOR
JOHN
From
We
report
Toronto
the transfer
SCAPULA
ICETON,
General
of the sternal
Hospital
part
BY
TRANSFER
W. R. HARRIS
and
the
University
of the pectoralis
major
of Toronto
to the lower
pole
of the scapula
in 15
patients
with winged scapula.
At follow-up
after 1 to 16 years nine had a satisfactory
result and were gainfully
employed,
though
in four of these re-operation
had been necessary.
Two patients
had fair results;
the
transplant
functioned,
but they had limited
voluntary
control.
Four were failures:
two had had paralysis
of
other shoulder
discussed.
of
Winging
paralysis
shoulder
the
girdle
scapula
is disabling;
during
abduction
muscles
in addition
caused
by
is usually
caused
which
stretches
serratus
serratus
anterior
patients
cannot
stabilise
the
and forward
flexion
and have
muscular
fatigue
pain. The cause
long thoracic
nerve or neuropathy
Injury
girdle,
to the
is either an injury
to the
of the brachial
plexus.
by depression
of the
the long thoracic
nerve
shoulder
over the
anterior.
The
indications
objects
heavy
usually
or
pulling
immunising
Mulder
In both
recover,
within
Swann
minor
on
a pyrexial
follows
recent
and
or repetitive
episodes
stiff
illness
by Marmor
Bechtol
and
of the tendon
Operative
publication
types
of winging
support
is helpful
(Johnson
correct
diagnosis
is often delayed
vative
management,
bodesis or muscle
consider
(Tsairis,
the majority
of patients
and
Kendall
; many
cases
to have had a rotator
patients
with a shoulder
injury
winging
of the scapula.
When
winging
has persisted
Of the
or
Dyck
influenza
1972).
are first considered
potential
Neuropathy
as
should
after
surgical
correction
transfer
is helpful.
it
because
offers
cuff injury.
be examined
prolonged
We
dynamic
by either
prefer
control
for nearly
normal
scapulothoracic
various
transfers
which
have been
that moving
the insertion
All
MD,
FRCS(C),
W. R. Harris,
MD,
EN.
1-234
Toronto
Ontario
M5G
2C4,
Requests
for
© 1987 British
030l-620X/87/1006
108
reprints
Orthopaedic
FRCS(C),
General
Canada.
details
have
(Gozna and
should
Editorial
$2.00
Surgeon
Elizabeth
be sent
W.R.
Street,
who
major
been
Harris
Society
of Bone
and
Harris.
Joint
Surgery
elongation
a fascia
described
1979).
there
of them
downward
been
had
depression
in
lata graft.
an earlier
in 1 3 men
1 to 16 years.
also caused
accidental
resection
a single
injury
causing
of the shoulder;
a brachiab
division
of the first
plexus
injury.
in one
One
of the long thoracic
rib for thoracic
outlet
had
2
and
In 10
severe
this
had
suffered
nerve
during
syndrome.
In
two cases the onset followed
repeated
minor
trauma,
one
had
brachial
plexus
neuropathy
and
one
had
facioscapubo-humeral
dystrophy.
The clinical
details
are
summarised
in Table I.
RESULTS
scapumuscle
and
the
part of
Patients
winging,
Toronto,
were
and
each ofthe
assessed
for
for the range
principal
shoulder
an electromyographic
muscle
was made.
further
operation,
four
were
the presence
of movement
functions.
assessment
In 1 5 patients,
nine
failures.
results
The
or absence
and power
In most
of the
four
of
in
patients
transplanted
of whom
were successful,
patients
with
had
had
a
two fair,
successful
results
had
no scapular
winging,
a normal
range
of
scapulohumeral
and
scapubothoracic
movement
and
normal
power of abduction
and forward
flexion,
but they
had
to Dr
described
with
We report
the results
of this operation
women,
who have been followed
from
conser-
Surgeon
Orthopaedic
Hospital,
200
are
PATIENTS
and
J. Iceton,
operation
for
movement.
described
we
of the sternal
(1963)
of pectoralis
lifting
usually
within
six months
after
injury
and
two years after brachiab
plexus neuritis
(Foo and
1983). Early treatment
is expectant
and the use of
a scapular
1955). The
transfer
levers.
such
in the arm
injections
when
the
the pectoralis
major to the lower pole of the scapula most
closely replaces the normal
function
of serratus
anterior.
This was first described
by Tubby (1904) and modified
prominence
of the second
rib (Gozna
and Harris
1979),
either a single severe incident
such as a weight
falling
on
the shoulder,
for
minor
weakness
of shoulder
their
former
fatigue
pain.
studies
normal
action
potentials
of
transplanted
In
adduction.
All were free
those who had EMG
were obtained
from the
muscle.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
TREATMENT
OF WINGED
SCAPULA
BY PECTORALIS
The two patients
with fair results had no winging
when their arms were adducted
against resistance,
but
showed
variable
and incomplete
control
of winging
Transfer
satisfactory
of the sternal
other.
In the
scapulodesis
be felt
EMG
While
but the patients
traces,
dystrophy
were
in the
completely
unable
scapular
winging.
Four
patients
had had a second
operation
initial failure.
In one case the fascia
lata extension
transfer
had avulsed
from the scapula
and in three
Table
Case
number
but
I. Details
two
of
remain
15 patients
transfer
of the
Age
(years)
Occupation
Cause
1
24
Welder
Repetitive
2
55
Carpenter
Fall
3
17
Student
Crashed
playing
4
29
Hairdresser
(male)
Brachial
5
33
Security
guard
latrogenic
division
long thoracic
nerve
6
54
Labourer
7
9
lifting
on shoulder
boards
ice hockey
plexus
Severe
of the
neuropathy
traumatic
of
depression
major
Student
Facio-scapulo-humeral
30
Miner
Severe
the
Utility
Arm
jerked
Fall
from
of shoulder
suddenly
downwards
(Whitman
at
of
1932).
1951)
it is a
and
pectoralis
major
transfer
does
not
work
and
some
of scapulodesis
is indicated.
All our patients
have slight
weakness
of shoulder
adduction.
Although
most were aware of it, none was
troubled
by it and
all
regarded
it as a minor
form
for
winged
scapula
Delay In
diagnosis
Onset to
first operation
Final
result
Comments
6 months
7 months
Good
working
17 months
20 months
Failure
Associated
working
2 weeks
2 years
Good
Working
as a prospector
None
14 months
Good
Working
as a hairdresser
None
17 months
Good
Working
as a security
I week
1 1 months
Fair
Not at work. Transplant
when arm adducted
(see
Failure
Re-operation
but remains
a failure.
Working
as a crop insurance
adjuster
dystrophy
depression
and, theoretically
the various
forms
that have been described
shoulder
18
28
pectoralis
is a
anterior
probably
functions
only as a tenodesis.
When
shoulder
girdle
muscles
other than serratus
anterior
are paretic,
after
of the
it had
as failures.
having
fashion
than
major
serratus
of the pectoralis
minor
(Chaves
also mimic the function
of serratus anterior,
muscle,
with
a short
range of contraction
weak
been replaced by scar. Substitution
of a new fascia lata
extension
was successful
in two patients,
both now fully
employed,
isolated
transfer
would
to control
for
It acts in a dynamic
is more
physiological
palsy.
least,
of the pectorabis
portion
treatment
other two failures, the transplanted
muscle could
to contract
by palpation
and showed
normal
muscular
109
TRANSFER
DISCUSSION
during
normal
active
movement.
Ofthe
four failures, two
had had associated
paralysis
of other
shoulder
girdle
muscles,
due to brachial
plexus injury
in one and facioscapulo-humeral
MAJOR
as a welder
brachial
plexus
injury,
not
guard
functions
text)
6 months
4 years
Good
Working
as an importer
13 months
23 months
Good
Working
as a technician
None
4 years
Failure
Successful
at first but winging
recurred
after loading
bales of hay. After reoperation
remains
a failure,
but works
a farmer
technician
10
20
Farmer
11
32
Labourer
Fall while
depressing
12
30
Car
13
42
Labourer
mechanic
motor
cycle
carrying
shoulder
wood,
2 days
2 years
Fair
Had primary
neurolysis,
and muscle
transfer
1 year later. Poor voluntary
control
but is at work
Shoulder
depressed
truck fell
when
1 year
1 year
Good
After re-operation,
as a mechanic
Shoulder
depressed
belt in collision
by seat
1 year
2.5 years
Good
Remains
14
21
Waitress
Fall downstairs,
ipsilateral
elbow
15
28
Seamstress
Repetitive
a machine
69-B,
No.
1,
JANUARY
1987
is working
litigation
not settled
dislocating
movement
operating
5 weeks
4 years
Good
Diagnosis
made when plaster
removed
from dislocated
elbow.
Wound
infection
with failure
but successful
one year after
re-operation.
Working
as cashier
18 months
2 years
Failure
Transplant
completely
unemployed
VOL.
unemployed,
as
functions
controlled.
but winging
Remains
is not
110
J. ICETON,
inconvenience
in exchange
for their
function.
Asymmetry
of the anterior
improved
axillary
obvious
in some patients
and negligible
two women
there was no asymmetry,
in others.
was not very
early
recovery
Electromyography
used to evaluate
because
electrodes
paralysis
that the
shoulder
fold was
physiotherapy
In the
nor any change in
or appearance
of the breast on the side of
There were no significant
cosmetic problems.
the height
operation.
be
W. R. HARRIS
helpful.
It cannot
from
the original
postoperative
evaluation
contraction
in the transplant
can easily be detected
by palpation.
It was of some use in
the assessment
of failure
since
the demonstration
of
normal
potentials
in the transplant
suggested
that other
factors
were responsible
for the poor result.
The four cases
which
required
re-operation
were
transplant
failed
after functionAt the first operation
the fascia
split into two tails each of which
instructive.
In one, the
ing well for 10 months.
lata extension
had been
was
inserted
At
the
re-operation
insertions
; they
extension.
and was
a separate
through
were
two
drill
tails
replaced
hole
had
by a new
Two years later the patient
working
as a mechanic.
In the second
winging
recurred
loading
several
the patient
their
fascia
lata
had
case also the initial
result
three
months
later
after
hundred
with
at
single
bales
of hay.
The
a good
dystrophy,
facio-scapulo-humeral
from the beginning
in the series, had had
infection,
and her transfer
functioned
well at
winging
slowly
recurred.
In each of these three
re-operation
the fascia lata extension
had been
transfer
fourth,
had not worked
one of two women
by a mass
of scar
of the transferred
which
muscle.
from
which
scar and attached
was passed through
Only
one
operations
had normal
gave
a good
prevented
This muscle
result,
although
and
forward
weaker
in all
and the
a wound
first but
cases at
replaced
free
three
and
intensive
It is interesting
his
transfer
anterior,
to note that
directly
must
to
have
the
provided
of attachment.
point
The question
which
of exploration
and possible
repair
of
the long
thoracic
nerve
arises
in the treatment
of
traumatic
winged
scapula.
The nerve was explored
in
one patient
in our
series
and
a 1 cm neuroma
in
continuity
was found
at the level of the second
rib.
Neurolysis
was performed,
but there was no recovery
and
a
successful.
pectoralis
major
transfer
transfer
major
isolated
serratus
subsequently
is a satisfactory
anterior
scapulodesis
was
palsy
method
and
of
can provide
is preferred.
3. Failed
transfers
are probably
desis if their scapular
winging
re-
a
best treated
by scapulocontinues
to be disabling.
REFERENCES
Chaves
JP.
anterior.
Pectoralis
J Bone
Foo CL, Swann
20 cases.
Gozna
be felt to contract,
and all
We have no satisfactory
flexion,
an even
these
whose
was dissected
of
and
almost
normal
function.
2. It is an unsatisfactory
procedure
for patients
who have
paresis
in muscles
in addition
to the serratus anterior.
In
The two fair results showed poor voluntary
control
of the transplant.
Scapular
winging
disappeared
when
the arm was adducted
against
resistance
but occurred
in
abduction
too slack.
attached
serratus
.
was
explanation
for these failures
and we now believe
that
failed
transplant
may be better
treated
by scapulodesis.
active
(1904)
1 Pectoralis
to a new
facia lata extension
a new drill hole in the scapula.
the transplant
could
EMG
recordings.
the transfer
making
Tubby
contraction
effective
tendon
major,
that when it is short sutures
do not hold well
it to pull partly out of the fascia lata extension,
treating
result
case
considerable
CONCLUSIONS
was good but
heavy
work
third
seen
the V-shaped
of pectoralis
speculate
and allow
in the scapula.
frayed
We have
the length
of
the sternal
part
of
paralysed
it is technically
difficult
to be certain
are in the serratus
anterior,
and in
not help.
did
in
variability
insertion
minor
transplant
for paralysis
Joint Surg [Br] 1951 ;33-B :228-30.
M. Isolated
J Bone Joint
paralysis
of the serratus
Surg [Br] 1983;65-B:552-6.
ER, Harris
WR. Traumatic
Surg [Am] 1979;6l-A:1230-3.
winging
Johnson
JTH,
Kendall
HO. Isolated
muscle.
J Bone Joint Surg [Am]
of the
P,
Dyck
PJ,
neuropathy:
Tubby
AH.
Mulder
report
scapula.
paralysis
of the
1955;37-A:567-74.
A case
the serratus
illustrating
magnus
DW.
Natural
the
by muscle
Arch
JOURNAL
Neurol
operative
grafting.
Whitman
A. Congenital
elevation
of
serratus
magnus
muscle:
operation.
THE
history
on 99 patients.
the
the
anterior
Marmor
L, Bechtol
CO. Paralysis
of the serratus
anterior
shock
relieved
by transplantation
of the pectoralis
case report.
J Bone Joint Surg [Am]
l963;45-A:l56-60.
Tsairis
of
treatment
Br MedJ
serratus
: a report
J Bone
Joint
serratus
anterior
due
major
to electric
muscle
:a
of brachial
plexus
1972;27:109-l7.
of paralysis
1904;ii
AND
JOINT
of
:1159-60.
scapula
and
paralysis
JAMA
1932;99:1332-4.
OF BONE
of
SURGERY
of