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Long Thoracic Nerve Palsy

Long thoracic nerve palsy is a medical condition involving the damage of the long thoracic nerve, due to an acute injury to the nerve itself, or other circumstances not related to traumatization.


Presentation

The long thoracic nerve is responsible for supplying the serratus anterior muscle, whose function is to maintain the scapula in a balanced position while upper extremity movements are performed [1]. A case of long thoracic nerve palsy (LTNP) corresponds to a weakened serratus anterior muscle [2] [3]. The most easily observed manifestation related to the long thoracic nerve palsy is winging of the scapula (a protrusion of the scapula from the back) [1] [4].

Patients are mainly adults which are between 20 and 60 years old. They present with marked scapular winging and inability to elevate the arm or push efficiently [3]. Loss of normal shoulder mobility is the primary complaint of the affected patients, that can also be followed by a feeling of instability. Athletes experience a restriction in their exercising potential, whereas non-athletic patients report a significant difficulty in performing everyday tasks, such as getting dressed or pushing. Pain in the shoulder region is also experienced when the back is resting upon a firm surface.

Long thoracic nerve palsy and subsequent paralysis of the serratus anterior muscle is a medical condition encountered frequently which, in general, leads to a considerable disability in everyday activities [5] [6]. Tendonitis may also arise in the affected shoulder joint, and so may brachial plexus radiculitis, adhesive capsulitis, and subacromial impingement [7]. Paresthesia of the shoulder girdle is another possible symptom [8].

Disability
  • Abstract Twelve patients who had previously been treated for palsy of the long thoracic nerve of Bell and resultant serratus anterior paralysis were examined in a follow-up study designed to determine their extent of recovery and/or residual disability[ncbi.nlm.nih.gov]
  • Long thoracic nerve palsy and subsequent paralysis of the serratus anterior muscle is a medical condition encountered frequently which, in general, leads to a considerable disability in everyday activities.[symptoma.com]
  • Abstract Injury to the long thoracic nerve causing paralysis or weakness of the serratus anterior muscle can be disabling.[ncbi.nlm.nih.gov]
  • This can be painful and disabling because of the resulting limitation of shoulder elevation.[nerve.wustl.edu]
  • Rhomboids(dorsal scapular nerve) can also cause winging Scapular Winging Clinical Evaluation May cause disabling pain, decrease in active flexion, abduction and cosmetic deformity.[eorif.com]
Fatigue
  • This shows abnormal fatigue properties of the reinnervated muscle and a dissociation between the frequency and amplitude manifestations of fatigue.[ncbi.nlm.nih.gov]
  • This condition may be further exacerbated with medial and upward migration of the superior aspect of the scapula as is commonly seen with scapulothoracic dyskinesia and fatigue of the scapular stabilizers.[ncbi.nlm.nih.gov]
  • The long thoracic nerve is probably trying to reinnervate and if you work the muscle to fatigue it is possible that you could effect this negatively.[physicaltherapy.rehabedge.com]
  • […] primary shoulder pathology is as follows: Primary glenohumeral or subacromial pathology, leading to Limited glenohumeral motion, leading to Increased compensatory scapulothoracic motion, leading to Increased demand on periscapular muscles, leading to Fatigue[musculoskeletalkey.com]
  • When combined with rotator cuff tendonitis, patients describe fatigue and increasing weakness in the shoulder developing over a month or two. Eventually the fatigue leads to dull and sharp shoulder pain in the compensating muscles and tendons.[laserneuropathypaintreatment.com]
Swelling
  • Treatment for quadrilateral space syndrome is usually rest for the shoulder, anti-inflammatory medications to reduce any swelling and relieve pain, cortisone injections into the area, and Physical Therapy.[humpalphysicaltherapy.com]
Pleural Effusion
  • Risks and complications Although scapulothoracic fusion is a safe procedure, various risks and complications have been reported that include: Metalwork failure Adhesive capsulitis Nonunion of bone Pneumothorax Pleural effusion Thoracic outlet syndrome[mistysurimd.com]
Pneumonia
  • Risks and complications Although scapulothoracic fusion is a safe procedure, various risks and complications have been reported that include: Metalwork failure Adhesive capsulitis Nonunion of bone Pneumothorax Pleural effusion Thoracic outlet syndrome Pneumonia[mistysurimd.com]
Thrombosis
  • […] scapulothoracic fusion is a safe procedure, various risks and complications have been reported that include: Metalwork failure Adhesive capsulitis Nonunion of bone Pneumothorax Pleural effusion Thoracic outlet syndrome Pneumonia Scapula fracture Deep venous thrombosi[mistysurimd.com]
Ulcer
  • After years of taking a variety of NSAIDs like ibuprofen and naproxen multiple ulcers have formed in my stomach. Turmeric has been known to have anti-inflammation effects. I also take fish oil for its joint and heart health benefits.[chrisshort.net]
Red Eye
  • 6 March 2005 Meaning of each component Y Cb Cr does not exist Image compression mode 4 APEX exposure bias 0 Maximum land aperture 3 APEX (f/2.83) Metering mode Pattern Light source Unknown Flash Flash fired, strobe return light detected, auto mode, red-eye[commons.wikimedia.org]
Winged Scapula
  • This procedure resulted in near-total improvement of the winged scapula deformity, and a return of excellent shoulder function.[ncbi.nlm.nih.gov]
  • Damage of the long thoracic nerve may result in abnormal protruding of the scapula or shoulder blade, commonly known as winged scapula.[mistysurimd.com]
  • This odd positioning has led to the name “winged scapula.” Shoulder pain and loss of movement occur as the imbalance in muscle functioning causes stress to the muscles of the shoulder.[chrisshort.net]
  • This odd positioning has led to the name " winged scapula ." Shoulder pain and loss of movement occur as the imbalance in muscle functioning causes stress to the muscles of the shoulder.[wisegeek.com]
Right Shoulder Pain
  • A little bit of history- 41y/o male with an onset of right shoulder pain- has hx of pos labral tear in shoulder- He started having pain at the end of his day- he is a cop.[physicaltherapy.rehabedge.com]
Elbow Pain
  • . ¶ 26 In Weldele, the claimant suffered from shoulder, wrist, and elbow pain. Treating physicians noted the possibility of thoracic outlet syndrome, but ultimately dismissed it as a cause of the claimant's injuries.[caselaw.findlaw.com]
Suggestibility
  • CONCLUSION: In our series, all 7 patients, originally diagnosed as having an isolated LTN, on reinterpretation, were found to have a more diffuse muscle/nerve involvement pattern, without MR findings to suggest nerve compression.[ncbi.nlm.nih.gov]
  • Analysis of 10 Level IV studies (131 shoulders) revealed that patients who underwent indirect transfer were significantly more likely to develop recurrent winging (P .009) and had lower active forward elevation (P CONCLUSIONS: Level V and III evidence suggests[ncbi.nlm.nih.gov]
  • Also, if you have any suggestions on exercises that I can give him for strengthening- it would be very helpful.[physicaltherapy.rehabedge.com]
  • Our results suggest that indirect transfer of the sternal head of the pectoralis major with interposition of the autogenous semitendinosus tendon can effectively treat scapular winging due to long thoracic nerve palsy with limited sequelae.[ncbi.nlm.nih.gov]
Peripheral Neuropathy
  • In: Dyck PJ, Thomas PK, Griffin JW, et al (eds) Peripheral Neuropathy, vol 2. 3rd edition. WB Saunders, Philadelphia, p 911 Google Scholar 10. Narakas AO (1988) Pain syndromes in brachial plexus injuries.[link.springer.com]
  • Focal peripheral neuropathies in instrumental musicians. Phys Med Rehabil Clin N Am. 2006;17(4):761–79. CrossRef PubMed Google Scholar 14. Bizzarri F, Davoli G, Bouklas D, Oncchio L, Frati G, Neri E.[link.springer.com]
Radiculitis
  • Tendonitis may also arise in the affected shoulder joint, and so may brachial plexus radiculitis, adhesive capsulitis, and subacromial impingement. Paresthesia of the shoulder girdle is another possible symptom.[symptoma.com]
  • Resultant secondary conditions include muscle imbalances and tendonitis around the shoulder joint, adhesive capsulitis, sub acromial impingement and brachial plexus radiculitis. Direct trauma to the nerve is more rare but does occur.[neuropaxclinic.com]
Dysesthesia
  • He did not complain of decreased sensation, paresthesia, or dysesthesia in the periscapular area. He did occasionally experience mild right periscapular pain and right-sided neck stiffness, however.[neupsykey.com]
Neck Stiffness
  • He did occasionally experience mild right periscapular pain and right-sided neck stiffness, however. His past medical history was unremarkable except for an allergy to acetylsalicylic acid. He took no medications.[neupsykey.com]

Workup

Long thoracic nerve palsy is typically diagnosed clinically; even though electromyography can provide a clear confirmation of the diagnosis, it brings desired results only after 6 weeks from the initial symptomatology.

The following clinical findings constitute sufficient evidence for the existence of LTNP:

  • Inability to fully flex the upper limb forward
  • Scapular winging, visible from the lateral or posterior side
  • Asymmetry of the scapulae during arm elevation, viewed from the posterior side.
  • Positive scapular compression test: pressure is applied on the scapula from the posterior side, while the thorax is stabilized from the anterior side with the other hand. The patient is asked to flex the presumably affected arm forward. The test is compatible with long thoracic nerve palsy when this maneuver alleviates pain and enables better movements.
  • Manual muscle testing (MMT) and shoulder joint range of motion (ROM) should also be performed [8].

Radiographs are not expected to illustrate abnormalities in a case of LTNP, except for an occasional, slight discrepancy in the positioning of the scapulae. They are obtained in order to exclude the possibility of a scapular mass. Electromyography is carried out at least six weeks after the symptoms have developed and offers the final confirmation of LTNP.

Pleural Effusion
  • Risks and complications Although scapulothoracic fusion is a safe procedure, various risks and complications have been reported that include: Metalwork failure Adhesive capsulitis Nonunion of bone Pneumothorax Pleural effusion Thoracic outlet syndrome[mistysurimd.com]

Treatment

  • No cases have been reported after the more recent treatment for breast cancer, lumpectomy with axillary dissection. This more recent surgical procedure is customarily followed by aggressive radiation therapy to the remaining breast tissue.[ncbi.nlm.nih.gov]
  • Although the incidence of isolated long thoracic nerve palsy following acute spinal trauma is rare, one such case is presented with discussion of injury and treatment.[ncbi.nlm.nih.gov]
  • @article{11d0a4e634f94d84bb06699bb34a3178, title "A comprehensive analysis of pectoralis major transfer for long thoracic nerve palsy", abstract "Background: In the treatment of long thoracic nerve palsy with pectoralis major transfer, it remains unknown[uthealth.influuent.utsystem.edu]
  • CONCLUSIONS: PMT transfer is an effective treatment for painful scapular winging resulting from LTN palsy. This is the largest reported series of consecutive patients treated with PMT transfer for the correction of scapular winging.[ncbi.nlm.nih.gov]
  • We hypothesized that critical reinterpretation of electrodiagnostic (EDX) studies and MRIs of patients with a diagnosis of non-traumatic isolated LTN palsy could provide insight into the pathophysiology and, potentially, the treatment.[ncbi.nlm.nih.gov]

Prognosis

  • The occurrence of a prolonged interval between onset of symptoms and institution of therapy was found to adversely affect prognosis.[ncbi.nlm.nih.gov]
  • The prognosis for long thoracic neuropathy is quite variable with some authors reporting spontaneous recovery while other cases fail to respond to any treatment, including surgery. Initial management is typically conservative.[chiroup.com]
  • The indications for operation seem meager in a condition in which there is such a relatively good prognosis on a conservative regimen.[oandplibrary.org]
  • It is conceivable that the fact that the parties relied on Keller's incorrectly diagnosed injuries rather than her correctly diagnosed injuries would not rise to the level of a material fact, were the treatment, prognosis, and symptoms of the injuries[caselaw.findlaw.com]

Etiology

  • It was found that those patients whose lesions were due to acute trauma had only partial or no recovery of serratus function, while those with infectious, toxic, allergic or idiopathic etiologies had partial or complete recovery.[ncbi.nlm.nih.gov]
  • Trojaborg First published August 1, 1984, DOI: Abstract We studied nerve conduction in 24 patients with serratus anterior palsy of different etiology.[neurology.org]
  • You could also look for the following: Role of scapular stabilizers in etiology and treatment of impingement syndrome. Schmitt L, Snyder-Mackler L. J Orthop Sports Phys Ther. 1999 Jan;29(1):31-8.[physicaltherapy.rehabedge.com]
  • Further imaging with computed tomography or magnetic resonance imaging might then be relevant, depending on the radiographic findings and suspected etiology of the condition. Imaging, however, is usually normal.[neupsykey.com]
  • Thirteen were of unknown etiology. In addition. Hansson ascribed thirteen cases to exposure to cold.[oandplibrary.org]

Epidemiology

  • Midha R (1997) Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery 40;1182–1189 PubMed CrossRef Google Scholar 6.[link.springer.com]
  • […] shoulder and upper arm level, left arm, initial encounter A- initial encounter D- subsequent encounter S- sequela Scapular Winging ICD-9 907.4 (Late effect of injury to peripheral nerve of shoulder girdle and upper limb) Scapular Winging Etiology / Epidemiology[eorif.com]
Sex distribution
Age distribution

Pathophysiology

  • INTRODUCTION: Two main hypotheses have been proposed for the pathophysiology of long thoracic nerve (LTN) palsy: nerve compression and nerve inflammation.[ncbi.nlm.nih.gov]

Prevention

  • Additional studies are needed to confirm the conclusion that the device's benefits derive from proprioceptive feedback that prevents muscle overuse or overstretch and from its transfer of contralateral shoulder protraction force to the affected scapula[ncbi.nlm.nih.gov]
  • Eliminating muscle spasms leads to a better life experience overall and prevents nasty flare ups before they even start. It took ten years to realize this and hopefully others can learn from this.[chrisshort.net]
  • If memory serves, this is the article that incorporated a brace to support the scapula and prevent winging in active shoulder exercises. _____________________________ Charles Sheets PT OCS Dip MDT Re: Long thoracic nerve palsy - February 15, 2006 9:52[physicaltherapy.rehabedge.com]
  • Collaborative Meta-Analysis of Randomised Trials of Antiplatelet Therapy for Prevention of Death, Myocardial Infarction, and Stroke in High Risk Patients. ‎[books.google.es]
  • Read more for treatments and exercises to help ease and prevent this shoulder pain. Winged scapula symptoms A winged scapular is usually fairly obvious as the scapular or shoulder blade protrudes outwards sticking out of the back.[sportsinjuryclinic.net]

References

Article

  1. Hollinshead WH. Anatomy for Surgeons. 3. Harper and Row; 1998.
  2. Bertelli JA, Ghizoni MF. J Bone Joint Surg Am. 2005. pp. 993–998.
  3. Gozna ER, Harris WR. Traumatic winging of the scapula. J Bone Joint Surg Am. 1979;61:1230–1233.
  4. Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop Relat Res. 1999;368:17–27.
  5. Gregg JR, Labosky D, Harty M, et al. Serratus anterior paralysis in the young athlete. J Bone Joint Surg Am. 1979;61:825–832.
  6. Pugliese GN, Green RF, Antonacci A. Radiation-induced long thoracic nerve palsy. Cancer. 1987;60:1247–1248.
  7. Kuhn JE, Plancher KD, Hawkins RJ. Scapular Winging. J Am Acad Orthop Surg. 1995;3:319–325.
  8. Shiro Nawa. Scapular Winging Secondary to Apparent Long Thoracic Nerve Palsy in a Young Female Swimmer. J Brachial Plex Peripher Nerve Inj. 2015;10(1):e57–e61.

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Last updated: 2019-06-28 10:14