Scapular winging may be caused by weakness of the muscles that attach to the scapula, either secondary to nerve laceration, nerve inflammation, or nerve stretch. In many cases it may resolve gradually over time, but if it does not, pain and limited shoulder function may necessitate tendon transfer surgery.

When paralysis of the serratus anterior exists, because of long thoracic nerve injury, winging inferiorly occurs--as the shoulder blade is no loger held against the thorax

When trapezial muscle paralysis occurs secondary to spinal accessory nerve palsy, winging of the superior medial scapula occurs

For isolated serratus paralysis,reconstruction can be effectively accomplished by transferring the pectoralis major tendon to the inferior scapula, extended by fascia lata. For isolated trapezial palsy, the Eden Lange procedure has been a useful salvage--relying on a more lateral transfer of the levator, rhomboid minor and major muscles. These 2 palsies result in different types of winging deformities 

Uncommonly, both types of palsy can occur together,resulting in tremendous dysfunction and inability to raise the arm (See preoperative video of Combined long thoracic and spinal accessory palsy).

Reconstruction utilized a pectoralis transfer  as well as stabilization of the upper medial scapula to ribs 3-5 with tibialia anterior allograft

This particular case highlights the immeasurable benefit of tendon transfer and scapular stabilization as treatment of severe scapular winging (See postoperative video 6 months after surgery).

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