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Static winging of the scapula caused by osteochondroma in adults: a case series
© Orth et al.; licensee BioMed Central Ltd. 2012
Received: 6 July 2012
Accepted: 28 September 2012
Published: 25 October 2012
Although palsy of the long thoracic nerve is the classical pathogenesis of winging scapula, it may also be caused by osteochondroma. This rare etiopathology has previously been described in pediatric patients, but it is seldom observed in adults.
We describe three cases of static scapular winging with pain on movement.
Case 1 is a Caucasian woman aged 35 years with a wing-like prominence of the medial margin of her right scapula due to an osteochondroma originating from the ventral omoplate. Histopathological evaluation after surgical resection confirmed the diagnosis. The postoperative course was unremarkable without signs of recurrence on examination at 2 years.
Case 2 is a Caucasian woman aged 39 years with painful scapula alata and neuralgic pain projected along the left ribcage caused by an osteochondroma of the left scapula with contact to the 2nd and 3rd rib. Following surgical resection, the neuropathic pain continued, demanding neurolysis of the 3rd and 4th intercostal nerve after 8 months. The patient was free of symptoms 2 years after neurolysis.
Case 3 is a Caucasian woman aged 48 years with scapular winging due to a large exostosis of the left ventral scapular surface with a broad cartilaginous cap and a large pseudobursa. Following exclusion of malignancy by an incisional biopsy, exostosis and pseudobursa were resected. The patient had an unremarkable postoperative course without signs of recurrence 1 year postoperatively.
Based on these cases, we developed an algorithm for the diagnostic evaluation and therapeutic management of scapula alata due to osteochondroma.
Orthopedic surgeons should be aware of this uncommon condition in the differential diagnosis of winged scapula not only in children, but also in adult patients.
Winging of the scapula (scapula alata) is defined as the prominence of the medial (vertebral) border of the scapula. This entity was first described by Velpeau . Serratus anterior muscle impairment is the classic etiopathology, secondary to long thoracic nerve palsy . However, because a broad variety of different lesions may also account for winging of the scapula , Fiddian and King  proposed a classification of scapula alata on an anatomic basis: type I lesions are caused by nerve pathology, type II lesions relate to muscle pathology, type III lesions relate to an osseous etiology, and type IV lesions include joint diseases.
Scapular tumors, such as osteochondroma (osteocartilaginous exostosis), have rarely been described as causes of pseudowinging [3, 4, 6–8]. Osteochondroma usually appear in the long bones of the limbs, and particularly in the distal part of the femur and the proximal part of humerus and tibia. Although the scapula is rarely involved , osteochondroma is the most common tumor of the scapula . These neoplasms are usually painless, but symptoms may result from complications such as mechanical restriction, fracture of the bony stalk of the tumor, nerve impingement syndromes, malignant transformation of the cartilaginous cap, and large bursa formation [4, 8, 9]. In the literature, winged scapula due to osteochondroma is seldom described and most of these cases are pediatric patients between 18 months and 16 years of age [3, 6, 7]. This corresponds well with the average age of 6 to 20 years in which exostoses are generally first noticed . To the best of our knowledge, only few reports have described scapula alata due to osteochondroma in adults [8, 11].
Age at presentation (years)
Hereditary multiple exostoses
Localization on ventral scapular surface
Size of exostosis (cm)
Deformity of ribcage
Preoperative biopsy performed
Indication for surgery
Swelling, inflammation and pain on abduction
Static scapular winging, no snapping, free ROM
Right margo superior close to angulus superior
5.0 × 3.5 × 5.0
Pain on movement
Neuropathic pain left ribcage
Static scapular winging, no snapping, pain at maximal abduction
Left margo medialis with contact to 2nd and 3rd rib
4.0 × 3.0 × 3.0
Pain on movement and neuropathic pain
Increasing swelling and pain on movement
Static scapular winging, swelling, no snapping, free ROM
Left margo lateralis and fossa subscapularis
4.0 × 3.0 × 4.0
Pain on movement
Surgical resection of the exostosis was performed through a medial approach (Figure 3). Histopathological evaluation confirmed the diagnosis of an osteochondroma. The patient had an unremarkable postoperative course. On examination after 2 years, the patient was doing well, free of pain, the wing-like prominence of her right scapula had disappeared and no signs of a recurrence were present on radiographs.
After surgical resection (Figure 4), the histological evaluation verified the diagnosis of an osteochondroma. Intraoperatively, the exostosis was in close contact with the 3rd rib. Postoperatively, the patient continued to experience neuropathic pain projected along the 3rd and 4th intercostal nerve without any amelioration over time. Therefore, a neurolysis was performed on both intercostal nerves 8 months after the first surgical intervention. On 2 years after this second operation, the pain had disappeared, range of motion was unlimited and there were no signs of a recurrence.
Because of suspected malignancy, an incisional biopsy of this soft-tissue tumor was performed initially. Histopathological examination revealed the presence of a pseudobursa and excluded malignancy. The exostosis and the pseudobursa were then removed though a medial approach. The patient had an unremarkable postoperative course. At follow up after 1 year, she was doing well and had no complaints or limitation of movement. No signs of a recurrence were present on radiographs.
The differential diagnosis of winged scapula can be complicated. When treating patients with scapular winging, orthopedic surgeons should be aware of the different etiopathologies (Figure 1). In the present study, we describe three cases of scapula alata caused by osteochondroma originating from the omoplate. Although comprising 35.8% of benign bone tumors and 8.5% of all bone tumors, only 6.4% of all solitary exostoses are located at the scapula . Patients having osteochondroma or exostoses most commonly present in childhood [3, 6] or in the second decade of life [7, 9]. Of interest, all our patients were older.
Although scapula alata usually is indolent, patients with subscapular osteochondroma often complain of pain and grating originating from the scapulothoracic articulation [3, 4]. On orthopedic examination, an exostosis may be localized by internally rotating the shoulder joint to produce grating or snapping; accentuated if a large accompanying bursa is formed. Audible crepitus may be produced with active abduction and internal rotation of the shoulder . Some authors suggest that diagnostic evaluation in all cases of positional scapular deformity should include electromyography and nerve conduction studies as both diagnostic and prognostic procedure . Electrodiagnostic studies also allow locating the exact site of injury when nerve palsy is suspected to cause scapular winging, for example following patient positioning for anterior spinal surgery (lateral decubitus position) . In the present report, however, all patients were neurologically intact; because of that, no necessity was seen for further neurological evaluation.
As anteroposterior radiography may not always delineate the subscapular osteochondroma, a true lateral X-ray or a CT scan is necessary to demonstrate the mass and confirm the diagnosis: the pathognomonic radiographic feature is the cortex of the host bone flaring into the cortex of the exostosis and the cancellous bones blending into each other. Furthermore, a CT is not only helpful for confirming the diagnosis but also for preoperative planning. Moreover, a non- or poorly mineralized mass of a large osteochondroma may indicate the presence of secondary chondrosarcoma in the exostosis . MRI is recommended if malignancy is suspected (Figure 2): the rapid formation of a benign accompanying bursa might be misinterpreted as malignant transformation of the cartilaginous cap of the osteochondroma [5, 7]. Furthermore, MR images allow for a measurement of the thickness of the cartilaginous cap, which is a significant predictor for malignant transformation: a cap thinner than 1cm usually indicates a benign condition, whereas a cap thicker than 2cm generally corresponds to malignant transformation [5, 9]. The differential diagnosis between bursa and malignant transformation is important and facilitated by MRI, especially in patients with multiple osteochondroma: malignant transformation to chondrosarcoma occurs in approximately 1% of solitary osteochondroma in adult life . Of interest, in patients with multiple hereditary exostoses, up to 27% may develop malignant transformation . Finally, MRI visualizes the effect of the lesion on surrounding structures . A bone scintigraphy is weakly positive or negative in inactive exostoses of the adult but positive during malignant transformation and may be taken into consideration to exclude malignancy . As biopsies carry the risk, for example, of spreading the tumor content, this option is recommended only if imaging techniques are insufficient to assess the malignancy of the mass (Figure 2).
In cases of painful winged scapula caused by entities other than osteochondroma, the usual treatment options consist of scapulothoracic fusion  or pectoralis major transfer . On the contrary, resection of the osteochondroma is the treatment of choice for winged scapula caused by a cartilaginous exostosis [7, 11]. Operative treatment is recommended in the case of pain, decreased range of motion of the shoulder or local compression of nervous or vascular structures . If malignancy is suspected, operative resection is inevitable. Only the cartilage component is capable of growth and should be completely removed with its capsule. Ideally, after circular incision and elevation of the periosteum, the stalk of the exostosis is osteotomized early, allowing easy mobilization and dissection from the soft tissues. Furthermore, arthroscopically assisted resection of the tumor has been described . It is not necessary, instead, to entirely excise the osseous component which is incapable of any growth. In some cases, a large bursa can be cosmetically disturbing and indicate an operation.
The prognosis of (solitary) osteochondroma is excellent. Local recurrence after surgery is very rare . However, large tumors, in particular those that are malignant, may further enlarge and deform the entire scapula rather than winging .
Osteochondroma of the ventral scapula should be excluded not only in children [3, 6, 7], but also in adult patients that present with static winged scapula [8, 11]. Whenever static winging of undetermined etiology is detected, a thorough clinical examination has to be performed. A CT scan or an MRI of the scapula is recommended. Operative removal is the treatment of choice in case of pain, reduced range of motion, suspected malignancy and if neurovascular symptoms are present.
Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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