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Long Thoracic Nerve and Medial Scapular Winging: Anatomy, Injury, Diagnosis, and Treatment скачать в хорошем качестве

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Long Thoracic Nerve and Medial Scapular Winging: Anatomy, Injury, Diagnosis, and Treatment
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Long Thoracic Nerve and Medial Scapular Winging: Anatomy, Injury, Diagnosis, and Treatment

The long thoracic nerve is a branch of the brachial plexus that arises directly from the cervical nerve roots C5, C6, and C7. It lies dorsal to the spinal nerves and innervates the serratus anterior. Why is it called the long thoracic nerve? Because the nerve is long and lies over the chest. The nerve travels in a distal direction behind the brachial plexus, between the anterior and middle scalene muscles, under the clavicle, over the first rib, and runs along the mid-axillary line for 22 to 24 centimeters to reach and innervate its target. The target is the serratus anterior. That’s why it’s called the long thoracic nerve. Because it is a long nerve, it is susceptible to traction injury. Injury can occur from axillary dissection or aggressive retraction of the middle scalene muscle. If the nerve is injured, it causes weakness or paralysis of the serratus anterior, leading to medial winging of the scapula. Function of the Serratus Anterior The serratus anterior pulls the scapula away from the midline and forward around the thorax. This is called scapular abduction. It also rotates the scapula upward. However, its most important function is stabilizing the scapula, allowing other muscles to work properly on it. Winging of the Scapula With long thoracic nerve injury, the inferomedial border of the scapula becomes prominent, with medial displacement and downward rotation. The resting position of the scapula becomes elevated and medially positioned, as the trapezius dominates the motion. This is why it is called medial winging of the scapula. If the trapezius is involved due to an accessory nerve injury, there will be lateral winging of the scapula. Therefore, long thoracic nerve injury leads to medial winging, while accessory nerve injury leads to lateral winging. Diagnosis of Long Thoracic Nerve Injury Diagnosis is based on clinical presentation. The patient typically complains of a dull shoulder ache, pain, and weakness. Scapular winging is evident, especially when the arm is pushed against resistance, such as pushing against a wall. A commonly used test involves pushing forward against resistance with the elbow extended and the shoulder protracted forward. In mild cases, this test can help reveal the winging. In severe cases, scapular winging will be very obvious without the need for special testing. Important clinical point: Scapular winging typically causes dull pain due to muscle fatigue. However, if there is severe acute pain along with winging of the scapula, you must consider brachial neuritis. Role of Imaging and Nerve Studies Imaging and electromyography (EMG) studies can be useful in confirming the diagnosis. These tests help assess serratus anterior involvement and differentiate long thoracic nerve injury from other causes of scapular winging. Treatment of Long Thoracic Nerve Injury Non-surgical treatment is the first line of management. Observation for at least six months Muscle strengthening and bracing Recovery can occur, but it may take one year or longer. Surgical Treatment Surgery is considered in persistent cases or when there is a space-occupying lesion compressing the nerve. Surgical options include: Decompression of the long thoracic nerve Pectoralis major transfer for cases of persistent medial winging that does not improve with conservative treatment In a pectoralis major transfer, the external head of the pectoralis major is transferred to the inferior border of the scapula to compensate for the loss of serratus anterior function. Quiz Questions: 1) Which nerve innervates the serratus anterior muscle? ✅ Long thoracic nerve Radial nerve Accessory nerve Suprascapular nerve Explanation: The long thoracic nerve arises from C5, C6, and C7 and innervates the serratus anterior, enabling scapular abduction and stabilization. 2) What is the primary function of the serratus anterior muscle? ✅ Scapular stabilization and abduction Shoulder external rotation Elbow extension Wrist flexion Explanation: The serratus anterior pulls the scapula forward and stabilizes it, allowing proper function of other shoulder muscles. 3) What is a common cause of long thoracic nerve injury? ✅ Traction injury during surgery or trauma Fracture of the clavicle Rotator cuff tear Glenohumeral dislocation Explanation: The long thoracic nerve is susceptible to traction injuries, often from axillary surgery or excessive retraction. 4) What type of scapular winging results from long thoracic nerve injury? ✅ Medial winging Lateral winging Superior winging Inferior winging Explanation: Damage to the long thoracic nerve leads to medial winging due to serratus anterior weakness. 5) How can you clinically test for long thoracic nerve injury? ✅ Ask the patient to push against a wall Perform a drop arm test Check for radial nerve sensation Assess the biceps reflex Explanation: Pushing against a wall reveals scapular winging due to the lack of serratus anterior stabilization.

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