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Thoracodorsal to long thoracic nerve transfer. Thoracodorsal donor nerve is indicated by solid arrow and long thoracic recipient nerve is indicated by open arrow (click on illustration to enlarge). (From Mackinnon SE, Novak CB. Nerve Transfers. Hand Clinics. 2008:24(4):355. Courtesy of Stephen H. Colbert, MD, Columbia, MO, and Elsevier.)

A winged scapula is an injury in which the scapula (shoulder blade) sticks out in the back. Sports injuries or any trauma to the neck and shoulder can result in a winged scapula. This can be painful and disabling because of the resulting limitation of shoulder elevation.

This condition can result from two causes: either a compression of the long thoracic nerve at the level of the brachial plexus (up high in the neck) or a complete injury to that nerve. Sometimes the compression injuries can be corrected with proper physical therapy. When therapy is ineffective, this type of injury can be addressed by a procedure similar to the thoracic outlet surgery. In this case, muscle, fascia or vascular structures that may be found compressing the nerve are cut and removed until the nerve is once again free. Oftentimes, patients will very quickly recover their strength and experience pain relief after this operation.

When the nerve is found to be completely injured, surgeons at the Center for Nerve Injury and Paralysis can perform a nerve transfer procedure to correct a winged scapula when more conservative treatment fails.

Nerve transfers involve taking nerves with less important roles — or branches of a nerve that perform redundant functions to other nerves — and “transferring” them to restore function in a more crucial nerve that has been severely damaged.

In patients with winged scapulas, surgeons cut branches of the thoracodorsal nerve, which innervates the latissimus dorsi muscle, and plug them into (transfer them) to the long thoracic nerve, which provides function to the serratus anterior muscle. The latissimus dorsi muscle is located in the back beneath the shoulder, like a wing, and pulls the shoulder down and back. The serratus anterior muscle is located on the side of the chest under the armpit (it wraps around behind and under the scapula and attaches on its inside border).

After surgery, patients will still be able to use their latissimus dorsi muscle, pulling their shoulder down. However, as they regain function from the nerve transfer, they also will be trained to use this muscle to raise the arm in front of their body over their head. The brain then learns this trick and the patient is able to move the shoulder simply by thinking about moving the shoulder.

Recovery of function after nerve transfer is a long process. Patients generally see small signs of recovery three to six months after the operation, but in most cases, return of movement takes six to 12 months