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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 5  |  Page : 532

Axillary fold and scapular hump in spinal accessory nerve injury


Department of Neurology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India

Date of Web Publication3-Nov-2012

Correspondence Address:
Sujit A Jagtap
Department of Neurology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.103212

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How to cite this article:
Jagtap SA, Soni H, Nair MD. Axillary fold and scapular hump in spinal accessory nerve injury. Neurol India 2012;60:532

How to cite this URL:
Jagtap SA, Soni H, Nair MD. Axillary fold and scapular hump in spinal accessory nerve injury. Neurol India [serial online] 2012 [cited 2019 Sep 16];60:532. Available from: http://www.neurologyindia.com/text.asp?2012/60/5/532/103212


A 21- year-old volleyball player presented with difficulty in smashing the ball and excessive folds of shirt over right shoulder. He had undergone cervical lymph node biopsy three years back. On examination, there was drooped right shoulder, wasting of trapezius with scapular hump, and extra-axillary fold [Figure 1]a. Scar mark of biopsy was seen in the posterior triangle of neck. The trapezius has three distinct heads: upper, middle, and lower. The upper fibers elevate, the middle fibers retract, and the lower fiber depresses the scapula. Trapezius is supplied by spinal accessory nerve (SA) which is most commonly injured after neck dissection or lymph node excision, penetrating injuries, compression by tumors at the base of the skull, or carrying heavy objects on the shoulder. [1] Weakness of trapezius causes depression and protraction of the shoulder, producing an oblique pectoral crease. The upper and lower fiber weakness leads to loss of abduction beyond 80°. [2] Middle and lower fiber weakness raise the superior angle of the scapula to produce the "scapular hump" [Figure 1]a and winging of scapula. [3] Scapular winging in trapezius weakness causes upward and lateral displacement of spine of scapula while medial displacement of tip of scapula in serratus anterior weakness [Figure 1]b. SA nerve is vulnerable to injury due to its superficial location in the subcutaneous tissue on the floor of the posterior cervical triangle. Other associated signs with SA nerve injury are scapular flip sign and scapular dyskinesia. [4]
Figure 1: (a) Scapular hump (arrow head) and extra-axillary fold (arrow) (b) Upward and lateral displacement of spine of scapula on right side as compared to left (Comparison of distance between left and right from midline) with winging of right scapula (arrow)

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  References Top

1.Meininger AK, Figuerres BF, Goldberg BA. Scapular winging: An update. J Am Acad Orthop Surg 2011;19:453-62.  Back to cited text no. 1
    
2.Berry H, MacDonald EA, Mrazek AC. Accessory nerve palsy: A review of 23 cases. Can J Neurol Sci 1991;18:337-41.  Back to cited text no. 2
    
3.Nelson KR, Bicknell JM. Oblique pectoral crease and "scapular hump" in shoulder contour are signs of trapezius muscle weakness. J Neurol Neurosurg Psychiatry 1987;50:1082-3.  Back to cited text no. 3
    
4.Kelley MJ, Kane TE, Leggin BG. Spinal accessory nerve palsy: Associated signs and symptoms. J Orthop Sports Phys Ther 2008;38:78-86.  Back to cited text no. 4
    


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