Scapular Winging

A 17-year-old boy came to the pediatric neurology clinic with right shoulder pain and “collar bone sticking out” for 2 months. His pain would radiate to the right upper arm and back, and he had difficult lifting his arm above the shoulder. There was no history of weakness of other limbs and no sensory symptoms. He had neck surgery for lymphadenopathy 1 month before onset of his symptoms. On examination, his cranial nerves were intact. He had right shoulder droop and wasting of trapezius muscle (Figure 1; available at www.jpeds.com). There was scapular winging on the right, accentuated on arm abduction (Figure 2). There was limitation of abduction beyond 90 degrees on the right compared with the left (Figure 3). He had right trapezius weakness with preserved sternocleidomastoid. The results of the remainder of his neurological examination, including reflexes and sensation, were normal. He underwent electromyography, by which decreased nerve conduction to trapezius with partial denervation changes and preserved sternocleidomastoid localizing the lesion on the spinal accessory nerve (SAN) distal to the branch supplying sternocleidomastoid were shown. He underwent exploration of the SAN, and with intraoperative testing, nerve continuity was confirmed so nerve grafting was not performed. He had since then partially regained his arm function with physical therapy.

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• Figure 2 

  Scapular winging on the right accentuated on arm abduction.

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• Figure 3 

  Limitation of abduction beyond 90 degrees on the right compared with the left.