MR Neurography and Quantitative Muscle MRI of Parsonage Turner Syndrome Involving the Long Thoracic Nerve

BACKGROUND

Parsonage-Turner syndrome (PTS) is characterized by severe, acute upper extremity pain and subsequent paresis and most commonly involves the long thoracic nerve (LTN). While MR neurography (MRN) can detect LTN hourglass-like constrictions (HGCs), quantitative muscle MRI (qMRI) can quantify serratus anterior muscle (SAM) neurogenic changes.

PURPOSE/HYPOTHESIS

1) To characterize qMRI findings in LTN-involved PTS. 2) To investigate associations between qMRI and clinical assessments of HGCs/electromyography (EMG).

STUDY TYPE

Prospective.

POPULATION

30 PTS subjects (25 M/5 F, mean/range age = 39/15-67 years) with LTN involvement who underwent bilateral chest wall qMRI and unilateral brachial plexus MRN.

FIELD STRENGTH/SEQUENCES

3.0 Tesla/multiecho spin-echo T2-mapping, diffusion-weighted echo-planar-imaging, multiecho gradient echo.

ASSESSMENT

qMRI was performed to obtain T2, muscle diameter fat fraction (FF), and cross-sectional area of the SAM. Clinical reports of MRN and EMG were obtained; from MRN, the number of HGCs; from EMG, SAM measurements of motor unit recruitment levels, fibrillations, and positive sharp waves. qMRI/MRN were performed within 90 days of EMG. EMG was performed on average 185 days from symptom onset (all ≥2 weeks from symptom onset) and 5 days preceding MRI.

STATISTICAL TESTS

Paired t-tests were used to compare qMRI measures in the affected SAM versus the contralateral, unaffected side (P < 0.05 deemed statistically significant). Kendall's tau was used to determine associations between qMRI against HGCs and EMG.

RESULTS

Relative to the unaffected SAM, the affected SAM had increased T2 (50.42 ± 6.62 vs. 39.09 ± 4.23 msec) and FF (8.45 ± 9.69 vs. 4.03% ± 1.97%), and decreased muscle diameter (74.26 ± 21.54 vs. 88.73 ± 17.61 μm) and cross-sectional area (9.21 ± 3.75 vs. 16.77 ± 6.40 mm2). There were weak to negligible associations (tau = -0.229 to <0.001, P = 0.054-1.00) between individual qMRI biomarkers and clinical assessments of HGCs and EMG.

DATA CONCLUSION

qMRI changes in the SAM were observed in subjects with PTS involving the LTN.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 1.

Topographic and morphometric anatomy of the proximal part of the dorsal scapular nerve

The dorsal scapular nerve (DSN) entrapment neuropathy has recently been recognized as a common cause of circumscapular pain and cases of winged scapula. Course of the nerve is important because the middle scalene muscle is frequently accessed for surgical treatments. Studies in the literature have not focused on the morphometric relationship of the DSN with the scalene muscles and its relationship with the long thoracic nerve (LTN). The neck regions of 13 adult cadavers were dissected bilaterally. The relationship of DSN with scalene muscles and LTN was evaluated. Cervical spinal nerves involved in the formation of the DSN were identified. Three types of DSN were observed based on the cervical spinal nerves from which it originates, five types of DSN from its relationship with the scalene muscles, and two types of DSN from its relationship with the LTN. The distance from where the nerve pierces the scalene muscle to the mastoid process was found to be greater in DSNs originating from C4 and C5 (93.85 ± 4.11 mm, p = 0.033). In DSNs not connected with LTN, the distance from where the nerve pierces the scalene muscle to the superior trunk/C5 (12.74 ± 7.73 mm, p = 0.008) and the length of the nerve within the scalene muscle (14.94 ± 5.5 mm, p = 0.029) were found to be statistically significantly greater. The topographic and morphometric anatomy of the proximal part of the DSN is important, especially for scalene muscles-focused surgical treatments and interscalene nerve blocks. We believe our results may guide clinical approaches and surgery.

The Aberrant Origin of the Suprascapular Artery May Hide Neural Covariants: A Cadaveric Finding

The axillary artery is the continuation of the subclavian artery. Occasionally, some of the subclavian artery's distal branches may atypically originate from the axillary artery, such as the suprascapular artery. The suprascapular artery's distal (low) origin from the axillary artery, instead of the subclavian artery, may also be characterized as an aberrant suprascapular artery. The current cadaveric report describes the coexistence of an aberrant suprascapular artery (of axillary origin), variant course, and termination with atypically formatted nerves originating from the cervical (the phrenic nerve) and the brachial (the long thoracic and the median nerves) plexus. An unusual interconnection between the phrenic and the long thoracic nerves was also described. The aberrant suprascapular artery had an atypical termination below the superior transverse scapular ligament, along with the suprascapular vein and nerve. Except for the atypically formatted phrenic and long thoracic nerves, the aberrant suprascapular artery coexisted with an atypical passage of the anterior ramus of the C6 spinal nerve, through the middle scalene muscle, before the long thoracic nerve formation, and a variant formation of the median nerve. Understanding neurovascular variants is crucial for interventionists and surgeons who work in the supra- and infraclavicular areas. Being aware of the different origins of the brachial plexus branches, in the supraclavicular part, may help reduce the occurrence of iatrogenic axillary injury. Efforts should be made to expand the number of cadaveric studies that investigate the origin, course, interconnection, and branching patterns of these nerves and related covariants, in a systematic way, thus unifying their study and comprehension.

Optimal needle electromyography approach to the serratus anterior muscle

INTRODUCTION/AIMS

There are two conventional needle electromyography (EMG) approaches to the serratus anterior (SA), both of which can result in erroneous insertion into adjacent structures such as the latissimus dorsi (LD), teres major, or external oblique abdominis muscles and pose a risk of long thoracic nerve (LTN) injury. Therefore, we identified a novel needle insertion point for the SA in cadavers that avoids other muscles and LTN injury.

METHODS

This study included 17 cadavers: 12 to devise the new method and 5 to verify its accuracy. Novel landmarks were the inferior angle of the scapula (I), sternal notch (S), and xiphoid process (X). The relationships of the LD, pectoralis major (PM), SA, and LTN were determined relative to these landmarks.

RESULTS

When inserting a needle into the proximal one third along the line connecting points I and X, there were adequate safety margins around the LD, PM, and LTN, and the new method had excellent accuracy.

DISCUSSION

Compared to the conventional midaxillary method, our novel method improved the accuracy of needle EMG of the SA. Follow-up studies using clinical imaging techniques are needed to verify whether above findings are equally applicable in living subjects.

Rapid Functional Recovery After Thoracic Outlet Decompression in a Series of Adolescent Athletes With Chronic Atraumatic Shoulder-Girdle Pain, Scapular Winging/Dyskinesis, and Normal Electrodiagnostic Studies

BACKGROUND

Spontaneous shoulder-girdle pain and scapular winging/dyskinesis can be caused by several neuromuscular disorders identifiable by electrodiagnostic studies (EDX). We describe a group of adolescent athletes with this clinical presentation but normal EDX, followed by later development of neurogenic thoracic outlet syndrome (NTOS).

METHODS

We identified patients referred for evaluation of NTOS that had a history of chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX. Each was refractory to conservative management and underwent supraclavicular decompression and brachial plexus neurolysis for NTOS. Functional disability was quantified by Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores.

RESULTS

There were 5 female patients with a mean age at symptom onset of 14.2 ± 0.4 years, including spontaneous severe pain in the shoulder, scapula, and arm, along with prominent scapular winging/dyskinesis, and normal EDX. Symptoms had persisted for 18.9 ± 4.0 months prior to referral, with pronounced upper extremity disability (mean QuickDASH, 54.6 ± 6.9). By 3 months after surgical treatment for NTOS, all 5 patients experienced near-complete symptom resolution, including scapular winging/dyskinesis, with markedly improved function (mean QuickDASH, 2.2 ± 1.3) and a return to normal activity.

CONCLUSIONS

A subset of patients with chronic atraumatic shoulder-girdle pain, scapular winging/dyskinesis, and normal EDX may develop dynamic brachial plexus compression characteristic of NTOS, exhibiting an ischemic "Sunderland-zero" nerve conduction block for which surgical decompression can result in rapid and substantial clinical improvement. The presence of surgically treatable NTOS should be considered for selected patients with long-standing scapular winging/dyskinesis who fail conservative management.

Scapula winging secondary to prone plank exercise: a case report

Background: Scapular winging occurs when the muscles responsible for the stabilization of the scapula (serratus anterior, trapezius, rhomboid major and minor) are paralyzed due to any reason. The most frequently observed neurological aetiology is serratus anterior muscle dysfunction due to long thoracic nerve palsy. The cause of long thoracic nerve palsy may be traumatic or atraumatic. It has been previously reported that a wide variety of sports can cause long thoracic nerve palsy.Clinical presentation: In this article, we report a case of unilateral winging of the scapula due to injury to the long thoracic nerve which occurred secondary to performing prone plank exercises; the likes of which has not previously been described in the literature and which may have occurred due to the exercise being performed incorrectly. In this patient, nerve recovery became evident one month following conservative treatment and cessation of plank exercises.Conclusion: Long thoracic nerve injury may have occurred due to increased and incorrect scapula loading during plank exercises. In order to prevent compression neuropathies caused by load transfer imbalance, attention should be paid to correct positioning whilst performing core stabilization exercises such as the prone plank.

Treatment of neurogenic scapular winging: a systematic review on outcomes after nonsurgical management and tendon transfer surgery

BACKGROUND

Scapular winging is a rare condition of the shoulder girdle that presents challenging treatment decisions for clinicians. To inform clinical practice, clinicians need guidance on what the best treatment decision is for their patients, and such recommendations should be based on the total evidence available. Therefore, the purpose of this review was to systematically review the evidence regarding nonsurgical management and tendon transfer surgery of patients with neurologic scapular winging due to serratus anterior (SA) or trapezius (TP) palsy.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, Emcare, and Academic Search Premier were searched up to April 5, 2022, for studies reporting on clinical outcomes after nonsurgical management and tendon transfer surgery of scapular winging due to weakness of the SA or TP muscle. The Integrated quality Criteria for Review Of Multiple Study (ICROMS) tool was used to classify the quality of the studies. Primary outcomes were the fraction of patients with spontaneous recovery after nonsurgical management and improvement in shoulder function, pain scores, and shoulder scores after tendon transfer surgery. Data were pooled if data on the same outcome were available for at least 3 studies, using random-effects meta-analysis.

RESULTS

Twenty-three (10 moderate-quality [MQ] and 13 low-quality) studies were included. Six studies (3 MQ; 234 shoulders) reported on outcomes after nonsurgical management of SA palsy, whereas 12 (6 MQ; 221 shoulders) and 6 studies (1 MQ; 80 shoulders) evaluated the outcomes of tendon transfer for SA or TP palsy (1 study addressed both). Spontaneous recovery of scapular winging with nonsurgical management varied between 21% and 78% across studies after a median follow-up of 72 months. For surgical management of SA palsy, pooling data in a meta-analysis showed that patients on average improved by 47° (95% confidence interval [CI]: 34-61, P ≤ .001) in active forward flexion, had lower visual analog scale scores for pain (mean difference [MD]: -3.0, 95% CI: -4.9 to -1.0, P = .003), and had substantial improvements in American Shoulder and Elbow Surgeons (MD: 24, 95% CI: 9-39, P = .002) and Constant scores (MD: 45, 95% CI: 39-51, P ≤ .001). Patients with TP palsy on average improved by 36° (95% CI: 21-51, P ≤ .001) in active forward flexion after tendon transfer. Statistical pooling was not possible for other outcome measures as insufficient data were available.

CONCLUSION

A substantial part of nonsurgically managed patients with scapular winging seem to have persistent complaints, which should be part of the information provided to patients. Data pooling demonstrated significant improvements in shoulder function, pain scores, and shoulder scores after tendon transfer surgery, but higher quality evidence is needed to allow for more robust recommendations and guide clinical decision-making on when to perform such functional surgery.

Two clinical tests assessing long thoracic nerve function to determine C5 and C6 root graft eligibility in patients with brachial plexus injury

OBJECTIVE

Identifying roots available for grafting is of paramount importance prior to reconstructing complex injuries involving the brachial plexus. This is traditionally achieved by combining input from both clinical examinations and imaging studies. In this paper, the authors describe and evaluate two new clinical tests to study long thoracic nerve function and, consequently, to predict the status of the C5 and C6 roots after global brachial plexus injuries.

METHODS

From March 2020 to December 2020, in 41 patients undergoing brachial plexus repair, preoperative clinical assessments were performed using modified C5 and C6 protraction tests, C5 and C6 Tinel's signs, and MRI findings to predict whether graft-eligible C5 and C6 roots would be identified intraoperatively. Findings from these three assessments were then combined in a logistic regression model to predict graft eligibility, with overall predictive accuracies calculated as areas under receiver operating characteristic curves.

RESULTS

In the 41 patients, the pretest probability of C5 root availability for grafting was 85% but increased to 92% with a positive C5 protraction test and to 100% when that finding was combined with a positive C5 Tinel's sign and favorable MRI findings. The pretest probability of C6 root availability was 40%, which increased to 84% after a positive C6 protraction test and to 93% when the protraction test result concurred with Tinel's test and MRI findings.

CONCLUSIONS

Combining observations of the protraction tests with Tinel's sign and MRI findings accurately predicts C5 and C6 root graft eligibility.

Variation of surgical anatomy of the thoracic portion of the long thoracic nerve

Decompression of the long thoracic nerve (LTN) is a potentially beneficial procedure for selected patients with LTN palsy. The aim of this work is to describe the surgical anatomy of the thoracic part of the LTN and highlight its variations. A retrospective review of patients undergoing exploration of the LTN was performed. Preoperatively, all patients had serratus anterior dysfunction and underwent electromyographic (EMG) assessment. All patients had an initial trial of nonoperative management. The surgical procedures were undertaken by the senior author. The anatomy of the LTN and the associated vasculature was recorded in patient records, and with digital photography. Forty-five patients underwent LTN exploration. Two patients with iatrogenic injury were excluded, leaving 43 patients for analysis. Mean age was 36 years. Sixty-seven percent of cases involved the dominant side. Trauma was the commonest cause, followed by neuralgic amyotrophy. Four patients had typical features of serratus anterior dysfunction but with normal EMG studies. Two distinct patterns of LTN anatomy were noted. In 79% of cases, a single major nerve trunk coursing along serratus anterior was observed and classified as a type I LTN. In 21% of cases, two equal major branches of the nerve were identified, which was classified as a type II LTN. Approximately one in five patients may have two major branches of the LTN. This is of clinical relevance to those who undertake any thoracic procedures, as well as those who are considering exploration of the LTN.

Risk Analysis of Needle Injury to the Long Thoracic Nerve during Ultrasound-Guided C7 Selective Nerve Root Block

Background and Objectives: Ultrasound (US)-guided cervical selective nerve root block (SNRB) is a widely used treatment for upper limb radicular pain. The long thoracic nerve (LTN) passes through the middle scalene muscle (MSM) at the C7 level. The needle trajectory of US-guided C7 SNRB pierces the MSM, therefore indicating a high probability of injury to the LTN. We aimed to identify the LTN and to investigate the risk of needle injury to the nerve during US-guided C7 SNRB. Materials and Methods: This retrospective observational study included 30 patients who underwent US-guided SNRB at the C7 level in a university hospital. We measured the maximal cross-sectional diameter (MCSD) of the LTN and cross-sectional area (CSA) of the C7 nerve root and assessed the injury risk of LTN during US-guided C7 SNRB by simulating the trajectory of the needle in the ultrasound image. Results: The LTN was detectable in all the cases, located inside and outside the MSM in 19 (63.3%) and 11 (36.7%) of cases, respectively. The LTN’s mean MCSD was 2.10 mm (SD 0.13), and the C7 root’s CSA was 10.78 mm² (SD 1.05). The LTN location was within the simulated risk zone in 86.7% (26/30) of cases. Conclusion: Our findings suggest a high potential for LTN injury during US-guided C7 SNRB. The clear visualization of LTNs in the US images implies that US guidance may help avoid nerve damage and make the procedure safer. When performing US-guided C7 SNRB, physicians should take into consideration the location of the LTN.

Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury

BACKGROUND

Preoperative diagnosis of long thoracic nerve (LTN) palsy is important for shoulder reconstruction after a traumatic brachial plexus injury (BPI). In the present study, we developed an objective diagnostic method for LTN palsy for patients with traumatic BPI.

METHODS

This is a retrospective review of 56 patients with traumatic BPI who had been receiving treatment at a single institution for over 8 years. The patients were divided into 2 groups: an LTN palsy group (n = 30) and a no palsy control group (n = 26). The LTN palsy group had 21 different palsy types with 4 and 5 C5-7 and C5-8, whereas the no palsy group had 18 different palsy types with 5 and 3 C5-6 and C5-8, respectively. Preoperative plain anteroposterior radiographs were taken in shoulder adduction and shrug positions. Scapulothoracic (ST) upward rotation and clavicle lateral (CL) rotation angles were measured on X-rays. The differences between the adduction and shrug positions for the respective angles were calculated and defined as Φ_ST and Φ_CL, respectively. The differences in the Φ_ST and Φ_CL values due to the presence or absence of LTN palsy were examined, the cutoff values of Φ_ST and Φ_CL for the diagnosis of LTN palsy were determined, and further sensitivity and specificity were calculated.

RESULTS

Both Φ_ST and Φ_CL were significantly decreased in the LTN palsy group compared with the no palsy control group. The sensitivity and specificity for LTN palsy were 0.833 and 1.000 for Φ_ST and 0.833 and 0.840 for Φ_CL, respectively, when the cutoff value was set as Φ_ST = 15° and Φ_CL ≤ 24°.

CONCLUSION

Dynamic shrug radiographs provide a useful objective diagnosis of LTN palsy after traumatic BPI.

Voluntary winging of the scapula: Proposed diagnostic criteria

We report a series of 10 patients with unilateral, dynamic, winged scapula (WS), without cause, that was diagnosed as voluntary winging of the scapula (VWS). We compared clinical, electrodiagnostic, and other examination data for 10 patients with VWS and 146 with dynamic WS-related neuromuscular disorders, to establish a detailed pattern of the VWS subtype. In VWS, electrodiagnostic and other examinations did not reveal any neuromuscular or orthopedic cause. Winging was dynamic, obvious, neither medial nor lateral, and mainly involved the inferior angle of the scapula, in young patients. VWS never appeared during floor push-ups. Patients could produce WS at will with the index and healthy shoulder, between 25° and 65° of anterior elevation, or with shoulder internal rotation. VWS is a benign disorder that can be distinguished from neuromuscular WS by normal electrodiagnostic results for muscles and nerves of both shoulders and two specific clinical tests.

Analysis of the positional relationship of the long thoracic nerve considering clinical treatment

INTRODUCTION

The long thoracic nerve (LTN) has a risk of being damaged during chest surgery and should be considered when performing anesthesia such as a serratus anterior plane block (SAPB). We analyzed the relationship between landmarks-the fourth to ninth intercostal space (ICS) at the midaxillary line (MAL), through which the distal part of the LTN passes-and the LTN.

MATERIALS AND METHODS

We used 25 specimens from 17 embalmed Korean cadavers. The MAL, level of rib and ICS, and regions 5 cm anteroposterior to the MAL (aMAL/pMAL) were established to measure the position of the LTN crossing the MAL, pathway of the LTN, and entering points of the LTN to the SA.

RESULTS

The LTN crossed the MAL in 76% of the specimens. The LTN crossed the MAL within the fifth to sixth rib level in 70.8%. Seventy-six percent of the branches entered the SA within the fourth to sixth ICS. The fifth rib and ICS were the most frequent regions aMAL; however, several branches were found pMAL. The LTN entered the SA in 92.6% of the specimens within 3 cm anterior and 1 cm posterior to the MAL.

CONCLUSIONS

We set the danger zone as 4 cm near the MAL at the fourth to sixth ICS for thoracotomy. In addition, we proposed the fifth ICS in aMAL at the superficial plane as the alternative injection point for SAPB when blocking the LTN, and the fifth ICS in pMAL at the deep plane to prevent blocking the LTN.

Schwannoma of the long thoracic nerve in the left axilla: a case report

Schwannoma, which is also known as neurilemmoma, is a type of tumor that arises from the peripheral nerve sheaths. Cases of schwannomas located in different regions have been reported. Some schwannomas present as asymptomatic masses, while others cause discomfort, such as pain and numbness. Magnetic resonance imaging (MRI) is a valuable diagnostic tool. A 23-year-old woman presented to our hospital with a mass in the left axilla that was misdiagnosed as mammae erraticae. The patient also considered the condition to be mammae erraticae for approximately 14 months because of a lack of symptoms. MRI was recommended by a surgeon from the galactophore department. A giant schwannoma was found. The mass was surgically excised, while preserving the continuity of the long thoracic nerve. Routine histopathological analysis confirmed the presence of a benign schwannoma. Schwannomas located in the axilla are rare and may be easily misdiagnosed as mammae erraticae or enlarged lymph nodes. Early investigation is necessary to make the diagnosis, and surgical excision is usually curative.

Surgical and Clinical Decision Making in Isolated Long Thoracic Nerve Palsy

BACKGROUND

Isolated long thoracic nerve palsy results in scapular winging and destabilization. In this study, we review the surgical management of isolated long thoracic nerve palsy and suggest a surgical technique and treatment algorithm to simplify management.

METHODS

In total, 19 patients who required surgery for an isolated long thoracic nerve palsy were reviewed retrospectively. Preoperative demographics, electromyography (EMG), and physical examinations were reviewed. Intraoperative nerve stimulation, surgical decision making, and postoperative outcomes were reviewed.

RESULTS

In total, 19 patients with an average age of 32 were included in the study. All patients had an isolated long thoracic nerve palsy caused by either an injury (58%), Parsonage-Turner syndrome (32%), or shoulder surgery (10%); 18 patients (95%) underwent preoperative EMG; 10 with evidence of denervation (56%); and 13 patients had motor unit potentials in the serratus anterior (72%). The preoperative EMG did not correlate with intraoperative nerve stimulation in 13 patients (72%) and did correlate in 5 patients (28%); 3 patients had a nerve transfer (3 thoracodorsal to long thoracic at lateral chest, 1 pec to long thoracic at supraclavicular incision). In the 3 patients who had a nerve transfer, there was return of full forward flexion of the shoulder at an average of 2.5 months.

CONCLUSIONS

A treatment algorithm based on intraoperative nerve stimulation will help guide surgeons in their clinical decision making in patients with isolated long thoracic nerve palsy. Intraoperative nerve stimulation is the gold standard in the management of isolated long thoracic nerve palsy.

Winged Scapula: A Comprehensive Review of Surgical Treatment

Winged scapula is caused by paralysis of the serratus anterior or trapezius muscles due to damage to the long thoracic or accessory nerves, resulting in loss of strength and range of motion of the shoulder. Because this nerve damage can happen in a variety of ways, initial diagnosis may be overlooked. This paper discusses the anatomical structures involved in several variations of winged scapula, the pathogenesis of winged scapula, and several historical and contemporary surgical procedures used to treat this condition. Additionally, this review builds upon the conclusions of several studies in order to suggest areas for continued research regarding the treatment of winged scapula.

Intercostal Nerve to Long Thoracic Nerve Transfer for the Treatment of Winged Scapula: A Cadaveric Feasibility Study

There are very few surgical options available for treating a patient with winged scapula caused by a long thoracic nerve (LTN) injury. Therefore, we devised a novel technique based on a cadaveric dissection whereby regional intercostal nerves (ICN) were harvested and transposed to the adjacent LTN in 10 embalmed cadavers (20 sides). The LTN was identified along the lateral border of the serratus anterior and ICNs were identified at the mid-axillary line inferior to the lower edge of the pectoralis major muscle. Along the mid-clavicular line, each ICN was transected and transposed to the adjacent LTN. The length and diameter of each ICN available for mobilization to the LTN were measured. All measurements were made with microcalipers. Within the operative site, the mean proximal and distal diameters of the LTN were 1.6 and 1.1 mm, respectively. The adjacent ICN had a mean diameter of 1.3 mm. On all sides, the ICN branches were easily transposed to the adjacent LTN without any tension. Anastomosis to the LTN was performed to the third through sixth ICN provided each intercostal was preserved and mobilized anteriorly at least as far as the midclavicular line. The end to end size match between donor and LTN was appropriate on all sides. We found that it is feasible to harvest adjacent ICNs and move these to the adjacent LTN. Such a procedure, after being confirmed in patients, might offer a new technique for restoring protraction following an LTN injury.

Scratch Collapse Test Is a Useful Clinical Sign in Assessing Long Thoracic Nerve Entrapment

The scratch collapse test (SCT) is a relatively new clinical test in which a positive result implies entrapment neuropathy of the nerve tested. Initially described for carpal and cubital tunnel syndromes, subsequent authors have found it useful for the assessment of median, ulna, radial, axillary, and common peroneal nerves. We report a case illustrating the value of the SCT in the clinical assessment of thoracic nerve entrapment.

Scapular Winging

This review explores the causes of scapula winging, with overview of the relevant anatomy, proposed aetiology and treatment. Particular focus is given to lesions of the long thoracic nerve, which is reported to be the most common aetiological factor.

Incidence and risk factors for winged scapula after surgical treatment for breast cancer

AIMS AND OBJECTIVES

To evaluate the incidence of winged scapula following surgical breast cancer treatment, determine its evolution over time and correlate factors that might influence this incidence.

BACKGROUND

Winged scapula is a complication that may occur as a result of exposing the long thoracic nerve during axillary lymphadenectomy for the treatment for breast cancer. There is no consensus in the literature about the incidence of this complication after surgical treatment for breast cancer, and complication rates range from 1·5-74%.

DESIGN

This is a prospective cohort study.

METHODS

A prospective cohort study was conducted including 57 patients with breast cancer who underwent surgical treatment. Each patient was assessed before and after the surgery, by means of Hoppenfeld manoeuvre. The incidence rate of winged scapula was calculated at four different times.

RESULTS

At the preoperative assessment, none of the patients presented with winged scapula, while 16 patients (28·1%) were shown to have this complication after the procedure. The incidence of winged scapula decreased over time. Factors associated with winged scapula were as follows: patients younger than 50 years, clinical stage I and II and no neoadjuvant chemotherapy. Other factors that were evaluated, such as type of surgery, number of lymph nodes compromised and removed, as well as body mass index, were not associated with the risk of winged scapula.

CONCLUSIONS

This study demonstrated that the incidence of winged scapula is low and decreased over time. Furthermore, a greater incidence of winged scapula was noted in young women at an initial stage of the disease who had not been treated with neoadjuvant chemotherapy.

RELEVANCE TO CLINICAL PRACTICE

The result of this work may have great impact, for demonstrating what risk factors are significantly associated with winged scapula after surgical treatment for breast cancer.

Neurologic Injuries in the Athlete's Shoulder

OBJECTIVE

To review the presentation, evaluation, treatment, and prognosis of various nerve injuries about the shoulder in the athletic population. Included are injuries to the axillary, suprascapular, musculocutaneous, long thoracic, and spinal accessory nerves.

DATA SOURCES

This article represents a review of the literature regarding incidence, presentation, and results of treatment of these various nerve injuries. The clinically pertinent anatomy is also presented to better relate mechanism of injury to the occurrence of nerve injury. I searched MEDLINE from 1966 through 1999 and the Journal of Shoulder and Elbow Surgery from 1992 through 1999 for the key words "nerve" and "shoulder."

DATA SYNTHESIS

A historical review of treatment results is presented as well as a review of treatment options and the results of studies using modern techniques in the management of nerve injuries.

CONCLUSIONS/RECOMMENDATIONS

Nerve injuries about the shoulder present as distinct clinical syndromes, although signs and symptoms can be subtle. The athletic trainer and team physician must be able to recognize the presentation of these injuries so that adequate evaluation and prompt treatment can be instituted to maximize the athlete's chance for early return to sport.