Winged scapula as the presenting symptom of Chiari I malformation and syringomyelia

Scapular Winging: A Great Masquerader of Shoulder Disorders: AAOS Exhibit Selection

BACKGROUND

The incidence of scapular winging is unclear, but it may be more common than previously thought. It can be difficult to diagnose because the presenting complaint and physical examination may direct the practitioner toward more common shoulder and neck conditions. Ongoing scapular dysfunction may result in inappropriate or failed surgery. Our goals were to (1) describe the common misdiagnoses (instability, labral abnormality, impingement, and cervical spine disease), the clinical scenarios and examination findings leading to diagnostic difficulty, the definitive treatment options available, and the clinical outcomes and complications; and (2) review the important aspects of the patient history, physical examination of the scapula, and associated studies necessary to make the correct diagnosis of scapular winging.

METHODS

We reviewed the literature relative to, and our own experience with, the treatment of scapular winging and identified a series of patients with this condition who were initially misdiagnosed with other shoulder or spine abnormalities. In our literature search, only nine clinical studies reported on a series of patients with scapular winging that was initially misdiagnosed or had a delay in diagnosis (n = 53 patients). We examined these cases for presenting or preexisting diagnoses and for surgical procedures that had been performed before the diagnosis of scapular winging.

RESULTS

For patients ultimately diagnosed with scapular winging, initial presentations and diagnoses included rotator cuff disorders (20%), glenohumeral instability (8%), peripheral nerve disorders (6%), cervical spine disease (6%), acromioclavicular disorders (6%), thoracic outlet syndrome (4%), and unknown or unspecified (41%). The most common surgical procedures performed before definitive scapular winging treatment were rotator cuff (22%), instability (22%), nerve (14%), acromioclavicular (12%), cervical spine (5%), and thoracic outlet (4%) procedures.

CONCLUSIONS

Clinically, scapular winging often mimics more common shoulder abnormalities and can result in unnecessary or unsuccessful surgical procedures. Diagnosis can be readily achieved with simple physical examination and specific provocative maneuvers in conjunction with electromyography and nerve conduction studies. Prompt diagnosis and recognition can avoid substantial shoulder dysfunction.

Scapular Winging: Evaluation and Treatment: AAOS Exhibit Selection

Scapular winging is a rare, underreported, and debilitating disorder that produces abnormal scapulothoracic kinematics, which can lead to shoulder weakness, decreased range of motion, and substantial pain. Although there are numerous underlying etiologies, injuries to the long thoracic nerve or spinal accessory nerve are the most common, with resultant neuromuscular imbalance in the scapulothoracic stabilizing muscles. Early diagnosis followed by initiation of a treatment algorithm is important for successful outcomes. Most cases resolve with nonsurgical management. However, in patients with persistent symptoms despite nonsurgical management, appropriate dynamic muscle transfers can effectively treat the scapular winging, with good clinical outcomes.

Sudden unexpected death due to Chiari type I malformation in a road accident case

This case concerns a sudden death of a patient with Chiari I malformation. A 17-year-old female was seen unconscious then fell off a motorbike during the vehicle acceleration. The girl was confirmed dead on the way to hospital, being previously asymptomatic and with a clean medical record. Autopsy findings showed an extremely extra-long cerebellar tonsillar herniation in the left side and unexplained multiple small cavities in cerebral hemispheres. Microscopic findings revealed loss and abnormal migration of the Purkinje cells, as well as capillary congestion in the herniated tonsil. The cause and mechanisms of this sudden death are considered as the cardiopulmonary dysfunction and arrest resulted from compression of the medulla and cervical cord, which was induced by both the positional insult and minor head trauma. In addition, this study stresses the importance of cervical cord examination in the case of unexpected sudden death following road accidents.

Winged scapula in patients with myotonic dystrophy type 1

We report two patients with myotonic dystrophy type 1 (DM1) showing winged scapula in a single family. Genomic analysis revealed a marked expansion of CTG repeats in the 3' untranslated region; 1100 in patient 1 and 667 in patient 2. Muscle MRI revealed marked atrophy in the serratus anterior muscle in both patients. Muscle biopsy findings showed central nuclei and variations in fiber size. One of the patients showed ragged red fibers in muscles of the biceps brachii. To our knowledge, this is the first report of typical winged scapula in DM1.

Institutional experience with 500 cases of surgically treated pediatric Chiari malformation Type I

OBJECT

The diagnosis and treatment of Chiari malformation Type I (CM-I) has evolved over the last few decades. The authors present their surgical experience of over 2 decades of treating children with this form of hindbrain herniation.

METHODS

The authors conducted a retrospective review of their institutional experience with the surgical treatment of the pediatric CM-I from 1989 to 2010.

RESULTS

The 2 most common presentations were headache/neck pain (40%) and scoliosis (18%). Common associated diagnoses included neurofibromatosis Type 1 (5%) and idiopathic growth hormone deficiency (4.2%). Spine anomalies included scoliosis (18%), retroversion of the odontoid process (24%), Klippel-Feil anomaly (3%), and atlantooccipital fusion (8%). Approximately 3% of patients had a known family member with CM-I. Hydrocephalus was present in 48 patients (9.6%). Syringomyelia was present in 285 patients (57%), and at operation, 12% of patients with syringomyelia were found to have an arachnoid veil occluding the fourth ventricular outlet. Fifteen patients (3%) have undergone reoperation for continued symptoms or persistent large syringomyelia. The most likely symptoms and signs to resolve following surgery were Valsalva-induced headache and syringomyelia. The average hospital stay and "return to school" time were 3 and 12 days, respectively. The follow-up for this group ranged from 2 months to 15 years (mean 5 years). Complications occurred in 2.4% of cases; there was no mortality. No patient required acute return to the operating room, and no blood transfusions were performed.

CONCLUSIONS

The authors believe this to be the largest reported series of surgically treated pediatric CM-I patients and hope that their experience will be of use to others who treat this surgical entity.