 Welcome to the reading from Trichy Assaram, today I am going to present a case regarding scapula winging, a book of case series. Myself, Bhagadalavek, Nammasartha 1st year, author to R. Chandru, not 3, V. Kavukovalan, our guide, Professor K. Venkateshallam, in his three chiefs, Department of Authorities. Introduction, scapula winging is a finding seen with clinical examination of the shoulder. The shoulder blade effectually sticks out rather than lying flat along the back. This outward and upward motion causes the scapula to resemble a person. Trauma is usually the inciting cause, although a variety of etiologies can cause injury to the associated nerves, including viral illness, allergic reactions, toxic exposure, and surgical complications, medications, and pre-existing or developmental medical conditions. Another injury results in subsequent weakness and paralysis. Causes of scapula winging. The condition of scapula winging or scapula protection occurs because of injury to one of the three medial stabilizing muscles that include the serratus anterior, trapezius, and rhombus. Causes of scapula winging. The function of these three muscles is to keep the scapula stabilized medially against a posterior chest wall, with injury to these muscles causing the scapula to lift from the chest wall. Based upon which muscle is involved, the scapula can deviate either medially or laterally due to the unopposed contraction of the remaining functioning muscles. Medial winging occurs from injury to the serratus anterior, and lateral occurs from trapezius or rhombus. Medial stabilizers are scapula. In the diagram, we can see the trapezius, rhombus, and the serratus anterior muscles, which are the primary medial stabilizer muscles of the scapula. Here, the anatomy of variations of the lateral lines can be seen. Case illustration 1 of trapezius. An 18-year-old was involved in a motor vehicle accident 8 weeks prior. He reports pain and weakness with deformity of the scapula. MRI was performed as the muscle tear or other injury. The A.P. frontal X-ray is non-contributory. MR imaging. A coronal fat suppressed free-to-weighted sequence demonstrates diffuse abnormal and homogenous hypointome signal within the right trapezius muscle without atrophy, which can be seen with the red arrow. Diagnosis. Isolated trapezius muscular denogation from injury to the spinal axary nerve. It is a 11th cranial nerve, clinically representing the scapula winging. Case illustration 2 of serratus anterior. The serratus anterior is critical for allowing the shoulder to take and move forward, increasing upward reach. This movement is exaggerated with activities such as punching a bag or swimming crawl and butterfly strokes. Conditions affecting the nerve and producing winging include blood trauma caused by pressure from crutches, sharp trauma from the causes, such as shoulder surgery, most commonly repetitive action trauma from sports activities. Other non-parametric causes include infections such as influenza, tumor, toxin, autoimmune, and inflammatory conditions of nerves, such as personage-turner syndrome. A long thoracic nerve in the real is its changes in the muscle, and this nerve is particularly susceptible given its superficial course along the side of the chest hole. Condensation. The axial STIR remains through the right thorax of a 22-year-old weight. Weakness and decreased mobility demonstrates increased signal within the serratus anterior to present with the arrow, positioned between the right scapula and posterior lateral chest hole. Case illustration 3. Surgical post-conversation even weighted fat suppress image in a 50-year-old with left anterior chest pain, chest wall pain, and snapping scapula syndrome. The serratus anterior muscle between the second rib and scapula demonstrate enhancement. Case illustration 4. Colonial oblique T1 weighted image centered over the scapula in a 23-year-old with needle scapula pain for five years. There is a loss of muscle bulk and intervening fat intensity within the serratus muscle belly represented with this arrow. Case illustration 5. Serratal oblique STIR image parallel to the scapula rashes and middle to the scapula shows hyperintensity throughout the trapezius muscle. Represent with the arrow, with the maintained bulk suggesting acute denomination. The muscle lies immediately superficial to the rhombidinosis. Case illustration 6. 15-year-old main presence is trapezius pain with C34 denomination on EMI. Coronal STIR image showing asymmetrical diffuse left trapezius muscle edema. Corresponding to denomination injury of the spinal accessory nerve. Case illustration 7. The rhombidinosis lies deep to the trapezius and both the major and minor components pass inferior lateral from the vertebrae to the middle scapula margin. Denomination of this muscle is caused by injury to the dorsal scapula nerve which is often thought to occur as the nerve passes through the scapula. This is a rare injury with the incitinous cause, usually sports activities. Damage causes the swinging of the scapula and results in difficulty with throwing and overhead movement. American short denomination changes both acute and chronic. Continuation. Accelative and weighted image through the upper thoracic level reveals month atrophy and fat infiltration of the right rhombidinosis represent with the arrow and compared to the contralateral side. Case illustration 8. Alastrofibroma or scapula winging simulator differential diagrams. Accelative and weighted image demonstrates the mass lesion between the chest wall and more superficial serratus anterior at the level of the inferior angle of the scapula containing internal elements of lower signal and increased signal corresponding to fibrous and fatty elements of an alastrofibroma. Case illustration 9. Scapular osteocondroma or scapula winging simulator differential diagrams. Scapular osteocondroma is a rare finding resulting in scapula winging. These benign humans, contiguous with the bone cortex, can arise from the internal margin of the scapula, producing mass effect within the constricted scapula thoracic space. Continued, surgical detu weighted image in a 16-year old female demolishates a large one excrements contiguous with inferior ventral scapula cortex represented with an arrow, projecting intricately to about the chest wall. Notice the dissonant scapula thoracic bursa with the thick wall pseudo-capsular concession with bursaries. Case illustration 10. Venus malformation. Exile XT IR, trillium in the top, and exile P1 weighted at the bottom images revealing a mixed signal Venus malformation situated anterior to the rhombide major and medial to the serratus anterior. There was no scapula winging and this was discovered incidentally. Case illustration 11. Dissecting intramuscular ganglion cyst. Exile T1 weighted sequential images represented on the top, demonstrated dissecting intramuscular ganglion cyst within the trapezius emanating from the AC joint and coarsen medial. Serital and coronal fat suppressed T2 weighted images represented in the bottom reveal the intramuscular position in 60 characters of the lesion. Case illustration 11. Serratus antidive lipoma. Exile T1 weighted and exile fat suppressed proton density weighted images demonstrate an forward lesion following fat intensity on all sequences consistent with serratus anterior lipoma. Case illustration 13. Plexiform neurophoropoma deep to left trapezius. Fat suppressed sexual post contrast T1 weighted and exile T2 weighted images reveal a large infiltrating enhancing mass represented with an arrow deep to the left trapezius muscle remodeling the left P6 lip extending from the left mural foramen consistent with the plexiform neurophoropoma. Case illustration 11. Intramuscular mass in right trapezius. Serratus fat suppressed T2 weighted and coronal fat suppressed proton density weighted images in a 23-year-old female with an enlarging mass over 3 months reveals an intramuscular mass within the right trapezius. The differential included tumor and sarcoma with the pathological diagnosis of proliferative myositis. We can in the diagram we can notice the preserved low signal of hyperindex striations. Case illustration 15. Muscular strain in inferior trapezius. In the diagram, exile fat suppressed proton density weighted image in a 41-year-old with posterior periscabular pain demonstrating myelidoma related to a muscular pain at inferior trapezius. Scab-lovinging treatment. Needle scab-lovinging is usually treated conservatively with observation for at least 6 months taller for nerve healing. During this time, physical therapy for muscle strengthening and tapping or bracing is performed. This is a long process and recovery can usually take up to a year or longer for resolution but is successful in great majority of patients. Surgical options for failure of conservative treatment include a split pectoralis major transfer whereby the sternum head of the pectoralis major it transferred to the inferior border of the scapula. Later scapula winging from the injury to the axary nerve often does not respond to conservative treatment. Here we can see the diagram of the lateral winging and medial winging and its treatment. Continued surgical considerations for failed conservative treatment include exploration of the injury site with muralizes often more favorable results compared to end-on-end switchering and now report. Most patients post-recovery from surgery continue to have a wing deformity. The injury is isolated to the trapezius muscle a special procedure called Eden-Lang muscle transfer can be performed whereby portion of the levator scapulae rhombite major and rhombite minor are diverted to the sites of terapia attachment. The lateral scapula winging from the injury to the rhombite muscle scapula nerve is usually treated conservatively with a cervical spine stabilization and physical therapy. Stiller injections and massaging have been noted to occasionally help. Suggesting this condition involves two facial lateral wings, the first connecting the lower medial border of the scapula to the spinal muscle and the second spanning from inferior angle of the scapula to the latissimus cluster. Conclusion, the scapula winging is a dysmorphic abnormality usually caused by injury to one of the innovative nerves of the posterior medial muscle stabilizers of the scapula. This condition causes pain and produces significant complications of the movement, thereby making activities of daily living difficult. Weakness is a commonality amongst all patients with scapula winging. The diagnosis of scapula wing is usually made cleanly, but inciting cause is often not obvious. Continued, electromiographic studies can help localize the muscle involvement produced in the scapula winging. Signistic imaging is not always necessary but high resolution imaging such as MRI can assist in identifying muscle involvement and allow localization of affected area where nerve impingement or damage occurs. Treatment is usually conservative and focuses on strengthening the surrounding non-affected muscles while providing pain relief. Sometimes, surgeries perform from refracted cases that do not respond to less invasive treatments. Here are the references which I have been using. Thank you.