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Results of Transfer of the Pectoralis Major Tendon to Treat Paralysis of the Serratus Anterior Muscle*

GARY S. PERLMUTTER, M.D. and ROBERT D. LEFFERT, M.D., BOSTON, MASSACHUSETTS

Investigation performed at the Orthopaedic Surgery Service, Massachusetts General Hospital, Boston

	Abstract

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Background: Paralysis of the serratus anterior muscle can be functionally disabling. As a result of the scapular winging associated with such paralysis, the scapula does not remain apposed to the thorax when the upper extremity is elevated forward at the shoulder. This produces functional disability associated with pain and loss of a stable base for movement of the upper extremity. Methods: We reviewed the results of transfer of the pectoralis major tendon with the addition of a fascial graft in sixteen patients who had paralysis of the serratus anterior. The average age of the patients at the time of the operation was thirty-three years (range, twenty to fifty-five years). Electrodiagnostic studies confirmed the presence of an isolated injury of the long thoracic nerve. The index operation was performed sixteen months to eleven years after the onset of pain and weakness. The etiology of the paralysis was idiopathic in two patients, traumatic in seven, and secondary to operative intervention in seven. All patients had pain in the shoulder on the side of the paralysis. Results: The result was excellent for eight patients, good for five, and fair for one at an average of four years and three months (range, two years and one month to nine years) postoperatively. There were two failures, both of which occurred after a traumatic event. Of the fourteen patients in whom the procedure did not fail, eight were asymptomatic and had normal function, five had intermittent mild discomfort, and one had frequent mild pain without any winging of the scapula. The average Constant and Murley score for the fourteen patients in whom the procedure did not fail increased from 36 points preoperatively to 92 points postoperatively. Conclusions: The index procedure successfully alleviated the functional disability caused by paralysis of the serratus anterior muscle.

	Introduction

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Paralysis of the serratus anterior muscle may result from a variety of causes. A review of the literature revealed that eleven instances of such paralysis have been reported after strenuous athletic activities^9,10,24. Acute traumatic and traction injuries have been implicated in sixty-eight cases, and viral illness has been implicated in seventeen^9,13,24. Paralysis of the serratus anterior associated with brachial neuritis has been reported in twelve patients^{5,14,16,18,22}, and iatrogenic injury during decompression of the thoracic outlet has been reported in sixteen^24,26.

The normal function of the serratus anterior is to maintain the scapula in apposition to the thorax when the arm is elevated forward at the shoulder. In addition, the trapezius and rhomboid muscles control scapular rotation and provide a mobile yet stable base for movement of the upper extremity. Paralysis of the serratus anterior causes the scapula to rotate posteriorly on its vertical axis, producing the characteristic appearance of winging of the scapula. Although the paralysis often resolves in six to eighteen months^15,16,18,22, the scapular winging is often functionally disabling. We believe that pain and fatigue result from the strain on the remaining periscapular muscles and that functional weakness of the upper extremity is secondary to loss of a stable base for movements of the upper extremity.

Function of the serratus anterior usually returns spontaneously; however, many patients continue to have pain and weakness in the shoulder. Operative stabilization may be indicated in these patients. Several procedures have been described, including transplantation of the pectoralis muscle into the serratus anterior itself²³, fascial sling suspension⁹, and multiple muscle-transfer procedures^{1,6-8,11,15,17,19,21}.

We report here the results of transfer of the pectoralis major tendon in patients who had palsy of the long thoracic nerve.

	Materials and Methods

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Transfer of the pectoralis major tendon was performed in sixteen patients (seven men and nine women), from January 1986 to August 1995, to treat unilateral paralysis of the serratus anterior muscle (Table I). The average age of the patients at the time of the operation was thirty-three years (range, twenty to fifty-five years). The initial eight patients were managed with strips of fascia lata autogenous graft. The technique was changed after two procedures failed because of stretching of the fascial strip grafts. Thus, the remaining eight patients were managed with a rectangular fascia lata graft that had been fashioned into a tubular configuration. Twelve patients had involvement of the dominant limb. The etiology of the paralysis was idiopathic in two patients; traumatic in seven, six of whom had sustained the injury in a work-related incident; and secondary to operative intervention in seven. Of the seven patients in whom the paralysis was secondary to operative intervention, five had had transaxillary resection of the first rib, one had had anterior cervical discectomy and arthrodesis, and one had had mastectomy and dissection of axillary nodes. All of the patients had weakness on forward elevation and were unable to forcibly elevate the arm above the plane of the shoulder. Fourteen patients had moderate-to-severe pain in the medial part of the scapula and in the trapezius muscle with attempted elevation of the arm. The electrodiagnostic findings were consistent with isolated chronic denervation of the serratus anterior. The average duration from the onset of the pain and weakness in the shoulder to the index operation was three years and four months (range, sixteen months to eleven years).

Although all of the patients were referred for evaluation of pain and scapular winging, it was not possible to determine the actual onset of the scapular winging because it usually was not noted until several months after the onset of pain and weakness even though the patients had complained about the associated scapular prominence. Patients were selected for transfer of the pectoralis major when marked scapular winging, loss of strength of the shoulder, difficulty with activities of daily living, and electrodiagnostic evidence of chronic denervation of the serratus anterior had been present for twelve to eighteen months.

The result was considered to be excellent when the patient was fully satisfied with the outcome, was pain-free, had full use of the arm for activities of daily living, and had no scapular winging. A good result indicated that the patient was fully satisfied with the outcome, had intermittent mild pain, had full use of the arm for activities of daily living, and had no or mild painless scapular winging. A fair result indicated that the patient was satisfied with the outcome, had frequent mild pain, had at least good use of the arm for activities of daily living, and had mild painful scapular winging. The result was considered a failure if none of these criteria were met. Preoperatively, all patients had marked scapular winging and poor use of the arm for activities of daily living.

A modified Constant and Murley score³ was used to assess pain, activities of daily living, range of motion, and strength. This scoring system assigns 35 points for subjective assessment and 65 points for objective assessment. Pain is rated on a scale of 0 points (severe) to 15 points (none). An unrestricted ability to perform activities of daily living is assigned 20 points. A full range of forward elevation, abduction, external rotation, and internal rotation are each assigned 10 points (for a maximum of 40 points for range of motion). We modified the evaluation of abduction strength from the original description by using manual muscle-testing and grading the results according to the recommendations of the Nerve Injuries Committee of the British Medical Research Council²⁰. The muscle-testing was performed with the shoulder abducted 90 degrees in the scapular plane. Five points were assigned for grade-I strength; 10 points, for grade-II strength; 15 points, for grade-III strength; 20 points, for grade-IV strength; and 25 points, for grade-V strength.

Operative Treatment
The patient is placed in a lateral decubitus position after induction of general endotracheal anesthesia. The affected forequarter and the lateral aspect of the ipsilateral thigh are prepared in sterile fashion and are draped with the arm left free. An eight-centimeter-long incision following the deltopectoral groove is made in the anterior axillary line and is continued distally and posteriorly distal to the axillary hairline. The deltopectoral interval is identified, and the insertion of the pectoralis major is isolated. Care is taken to avoid injury to the neurovascular bundle. The tendon is incised from its insertion on the lateral lip of the intertubercular groove of the humerus, and the muscle is mobilized gently and is kept moist during the remainder of the procedure. Both the clavicular portion and the sternal portion of the pectoralis major are utilized.

A tunnel is created between the anterior aspect of the scapula and the thorax, with use of a finger, and the exact location of the brachial plexus and the axillary vessels is kept in mind. A long DeBakey vascular clamp is passed through the tunnel so that it exits at the junction of the middle and inferior thirds of the vertebral border of the scapula. The tip of the clamp should be seen to tent the subcutaneous tissue medial to the scapula. A four-centimeter-long incision is made posteriorly to expose the clamp and the vertebral border of the scapula. The muscles are cleared from the body of the scapula so that an eight-millimeter-wide hole can be made two centimeters lateral to the thickened vertebral border. Another long DeBakey vascular clamp is then clamped to the tip of the first clamp where it exits the posterior wound and is brought in a retrograde fashion into the anterior wound by withdrawal of the first clamp.

A fifteen-centimeter-long incision is made over the midline of the lateral aspect of the thigh just anterior to the intermuscular septum. The fascia lata is identified and is dissected free from the subcutaneous tissue. A fifteen-by-five-centimeter rectangular graft is obtained, with care taken to incise the posterior portion of the fascia lata just anterior to the intermuscular septum. Use of the posterior portion is preferred because it is thicker and stronger. However, care should be taken to avoid transection of the perforating vessels when the posterior incision is made because these vessels may retract beyond the intermuscular septum, making it difficult to control any bleeding that occurs. The fascial graft is kept moist, and the wound in the thigh is closed.

In the first eight patients in the present study, fascial strip grafts were obtained from the lateral aspect of the thigh through a three-centimeter-long transverse incision. The underlying fascia lata was exposed, and a one and one-half-centimeter-long transverse incision was made in the fascia. A small tongue of fascia was elevated and was fed through the eye of a fascial stripper that was bluntly directed superiorly, and a twenty-centimeter-long strip was removed. The strip graft was amputated by placing tension on the graft and activating the cutting device in the fascial stripper. A second strip was obtained in a similar manner.

The rectangular fascial graft is sutured in a tubular configuration with use of number-5 nonabsorbable suture. The graft is then woven through the pectoralis tendon and is secured with nonabsorbable suture (Fig. 1). This technique is a modification of that described by Post¹⁹. When strip grafts are used, the two grafts are woven separately through the pectoralis tendon and are secured in a similar manner. The lead suture attached to the fascial graft is then grasped with the vascular clamp and is redirected into the previously developed tunnel, exiting medial to the scapula. The fascial graft is pulled through the tunnel, with monitoring of the position of the graft in relation to the brachial plexus and the axillary vessels (Fig. 2). The graft is drawn through the drill-hole and is secured to itself with several nonabsorbable sutures (Fig. 3). As with all tendon transfers, it is difficult to determine the tension of the transfer. Tension is adjusted so that a soft end point is felt and the junction of the tendon and fascia is displaced into the tunnel along the chest wall. The pectoralis major should be at its resting-muscle length at the time of fixation of the graft. Given the constraints created by the use of two incisions, there is not enough excursion of the pectoralis major to attach it directly to the vertebral border of the scapula. The wounds are closed in the usual fashion. Drains are rarely indicated unless there is excessive bleeding. The arm is placed in a sling for four weeks postoperatively, and the patient is instructed to remove the sling only when bathing.

View larger version (104K): [in this window] [in a new window]   FIG1: Fig. 1 Photograph showing the pectoralis major attached to the fascia lata autogenous graft, which was sutured into a tubular configuration.

View larger version (81K): [in this window] [in a new window]   FIG2: Fig. 2 Illustration showing passage of the lengthened tendon between the scapula and the chest wall, medial to the axillary vessels and the brachial plexus, to the medial border of the scapula.

View larger version (41K): [in this window] [in a new window]   FIG3: Fig. 3 Illustration showing fixation of the graft into the drill-hole in the medial aspect of the scapula. The graft is sutured to itself with several nonabsorbable sutures.

	Results

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The average duration of follow-up was four years and three months (range, two years and one month to nine years). The result was excellent for eight patients, good for five, and fair for one. The two remaining patients had a failure: one had recurrence of the scapular winging after a violent manipulation by a physical therapist, and the other had giving way of the tendon transfer while working as a sheep farmer. Both failures were associated with use of fascia lata strip grafts. The two patients subsequently had arthrodesis of the scapulothoracic articulation, which reduced the symptoms but decreased the motion of the shoulder. Of the remaining fourteen patients, eight were asymptomatic and had normal function, five had intermittent mild discomfort, and one had frequent mild pain. All fourteen patients had full active elevation of the shoulder. Twelve patients had no evidence of scapular winging, and two had intermittent mild winging that was much less severe than that present preoperatively (Figs. 4-A and 4-B).

View larger version (110K): [in this window] [in a new window]   FIG4-A: Figs. 4-A and 4-B: Photographs of a patient who had palsy of the long thoracic nerve and scapular winging. Fig. 4-A: Preoperative appearance.

View larger version (116K): [in this window] [in a new window]   FIG4-B: Fig. 4-B After transfer of the pectoralis major tendon, there was resolution of the winging.

Fourteen of the sixteen patients returned to their former employment outside the home. One patient, who had been a homemaker before the injury, returned to the level of function that she had had before the injury, and another patient, who had been employed as a truck driver, was still receiving Workers' Compensation at the time of the latest follow-up examination.

There were no intraoperative complications. Of the two patients in whom a previous transfer of the pectoralis minor had failed, one had an excellent result after the index procedure and the other had a failure of the index procedure because of overuse in her job as a sheep farmer, as described.

	Discussion

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The serratus anterior is a broad muscle that has its origin at the first through ninth ribs. The muscle extends posteriorly and inserts on the medial border of the scapula. The long thoracic nerve, which is derived from the ventral rami of the fifth, sixth, and seventh cervical nerve roots, travels over the first rib and descends on the lateral aspect of the chest wall, where it divides and innervates the serratus anterior. The function of the serratus anterior is to stabilize the scapula against the chest wall during elevation of the shoulder. The scapular winging associated with paralysis of the serratus anterior can be functionally disabling. Fortunately, most palsies of the long thoracic nerve resolve spontaneously with time, and even when paralysis persists patients may compensate for the winging of the scapula and have only a mild functional deficit.

During the symptomatic winging phase, a patient should be managed nonoperatively and be instructed to avoid activities that produce pain. We found bracing to be ineffective and therefore abandoned its use. Although there is a good chance that an idiopathic palsy of the long thoracic nerve will resolve, the paralysis may be considered permanent if there is no clinical or electrodiagnostic evidence of recovery of function of the serratus anterior by eighteen months after the onset of symptoms. The exception is nerve palsy resulting from Parsonage-Turner syndrome¹⁸ (brachial neuritis), in which the onset of paralysis is preceded by severe pain in the shoulder. Such paralysis may take three years or more to resolve. Lacerations of the nerve, if they are recognized early, may be successfully repaired; however, operative exposure is difficult, and most iatrogenic injuries are not diagnosed for several months, which makes primary repair less successful.

In the present study, the injury of the long thoracic nerve was an operative complication in seven patients. Five of these patients had had transaxillary resection of the first rib. It is imperative that surgeons who perform decompression of the thoracic outlet know the anatomy of the long thoracic nerve, given the relationship of the nerve to the first rib. The palsy in another patient was the result of a mastectomy and dissection of the axillary nodes. Four similar cases have been documented in the literature²⁴. The location of the nerve along the chest wall makes it susceptible to direct injury during these types of operative procedures. The palsy in the seventh patient was the result of anterior cervical decompression and arthrodesis. Vastamaki and Kauppila²⁴ believed that positioning under general anesthesia played a role in compression or traction of the long thoracic nerve in ten patients.

Several operative procedures have been used for correction of scapular winging. In 1904, Tubby²³ managed one patient by dividing the pectoralis major into several fasciculi and suturing them to the serratus anterior. Whitman²⁵ and Dickson⁴ used fascial slings to compensate for paralysis of the serratus anterior in two patients and one patient, respectively. Our experience with this procedure has been poor secondary to stretching of the fascial suspension grafts. Steindler²¹, in 1946, described transfer of the clavicular head of the pectoralis major to the scapula in one patient. Durman⁶ and Ober¹⁷ performed transfer of the pectoralis major tendon lengthened with use of fascia lata in two patients each. Marmor and Bechtol¹⁵ reported on one patient who had transfer of the sternal portion of the pectoralis major to the inferior border of the scapula with the addition of a tubular fascial graft. Post¹⁹ reported on eight patients who had a similar transfer; however, the fascia lata graft was fashioned into a spiral configuration, which Post believed was a factor in the excellent results. Post did not define the criteria that he used to evaluate his results. Most recently, Connor et al.² reported the results after transfer of the pectoralis major in eleven patients. On the basis of the patients' satisfaction with the outcome, residual pain, function, motion, and strength, seven patients had an excellent result, three had a satisfactory result, and one had an unsatisfactory result.

Our findings are similar to those reported by Post¹⁹ and by Connor et al.² in that most patients had an improved range of motion of the shoulder, better functional use of the upper extremity, and less or no pain after transfer of the pectoralis major tendon. We believe, as Post did, that the method that we used to prepare the fascial graft may account for our good results. The two failures occurred in the initial stage of the study, when we used fascial strips instead of rectangular fascial grafts. Fascial strip grafts tend to stretch, as was noted during revision of the two procedures that failed. Therefore, we modified our technique in the latter eight patients. On the basis of our results, we recommend a rectangular fascial graft when performing this transfer. Connor et al. recommended obtaining direct contact between the pectoralis major tendon and the scapula with the fascial graft in order to minimize the potential for stretching of the graft. Although we share their concern, it is not possible to obtain this type of fixation with a two-incision approach because the pectoralis tendon cannot traverse the distance to the vertebral border of the scapula. Furthermore, we have not seen clinical evidence of stretching or failure of the graft when a rectangular fascial graft was fashioned into a tubular configuration.

Connor et al.² also noted failure of one procedure secondary to overly intensive rehabilitation, which in their study included unsupervised use of a rowing machine two months after the operation. Iceton and Harris¹² reported failure of a reconstruction three months postoperatively, after the patient loaded several hundred bales of hay on the same day. Proper selection of the patients is of the utmost importance and may ultimately affect the outcome. Transfer of the pectoralis major is not recommended for patients who wish to return to strenuous labor or contact sports, although exceptions can be made on an individual basis. We agree with Post¹⁹ that patients should avoid tasks that require repetitive lifting of twenty pounds (9.1 kilograms) or more postoperatively.

Several questions must be considered in the planning of a transfer of the pectoralis major tendon to treat paralysis of the serratus anterior. These questions pertain to the use of a one or two-incision technique, the use of fascial strips or a rectangular fascial graft, the use of only the sternal or both the sternal and the clavicular portions of the pectoralis, and the site on the scapula to which the graft should be fixed. It has been our experience that fascial strips tend to fail, whereas we have not had any failures of rectangular grafts sutured in a tubular configuration. Insertion of the graft along the vertebral border of the scapula more closely reconstructs the normal attachment of the serratus anterior. The two-incision technique makes it possible to reproduce the anatomical path of the serratus anterior, and the two relatively small incisions are more cosmetically acceptable than one long incision. Post¹⁹ and Connor et al.² reported excellent results with use of only the sternal portion of the pectoralis major. We noted similar results in our patients with use of the entire pectoralis major. We believe that this technique offers greater muscle bulk for the transfer and eliminates a tenodesis effect if part of the tendon is left attached. Connor et al. reported atrophy of the chest wall and breast asymmetry after transfer of the entire pectoralis major; however, neither we nor our patients have noted a major change in cosmetic appearance.

The present report describes an operative technique that is different from that reported by Post¹⁹ and Connor et al.². Although those authors advocated a one-incision approach, we believe that the two-incision approach is safer and more closely reconstructs the anatomy and function of the serratus anterior. Transfer of the pectoralis major tendon with the addition of a fascial graft offers good or excellent results for patients who have symptomatic scapular winging secondary to palsy of the long thoracic nerve.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Massachusetts General Hospital Professional Office Building, 275 Cambridge Street, Suite 403, Boston, Massachusetts 02114. E-mail address for Dr. Perlmutter: gperlmutter@partners.org.

Massachusetts General Hospital, White 10, Boston, Massachusetts 02114.

	References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Chaves, J. P.: Pectoralis minor transplant for paralysis of the serratus anterior. J. Bone and Joint Surg., 33-B(2): 228-230, 1951.

2. Connor, P. M.; Yamaguchi, K.; Manifold, S. G.; Pollock, R. G.; Flatow, E. L.; and Bigliani, L. U.: Split pectoralis major transfer for serratus anterior palsy. Clin. Orthop., 341: 134-142, 1997.

3. Constant, C. R., and Murley, A. H. G.: A clinical method of functional assessment of the shoulder. Clin. Orthop., 214: 160-164, 1987.[Medline]

4. Dickson, F. D.: Fascial transplants in paralytic and other conditions. J. Bone and Joint Surg., 19: 405-412, April 1937.[Free Full Text]

5. Dillin, L.; Hoaglund, F. T.; and Scheck, M.: Brachial neuritis. J. Bone and Joint Surg., 67-A: 878-880, July 1985.[Abstract/Free Full Text]

6. Durman, D. C.: An operation for paralysis of the serratus anterior. J. Bone and Joint Surg., 27: 380-382, July 1945.[Free Full Text]

7. Fery, A., and Sommelet, J.: La paralysie du grand dentele: resultat du traitement de 12 cas dont 9 operes et revue generale de la litterature. Rev. chir. orthop., 73: 277-288, 1987.

8. Fery, A.: Results of treatment of anterior serratus paralysis. In Surgery of the Shoulder, pp. 325-329. Edited by M. Post, B. F. Morrey, and R. T. Hawkins. St. Louis, Mosby-Year Book, 1990.

9. Foo, C. L., and Swann, M.: Isolated paralysis of the serratus anterior. A report of 20 cases. J. Bone and Joint Surg., 65-B(5): 552-556, 1983.[Free Full Text]

10. Gregg, J. R.; Labosky, D.; Harty, M.; Lotke, P.; Ecker, M.; DiStefano, V.; and Das, M.: Serratus anterior paralysis in young athletes. J. Bone and Joint Surg., 61-A: 825-832, Sept. 1979.[Abstract/Free Full Text]

11. Herzmark, M. H.: Traumatic paralysis of the serratus anterior relieved by transplantation of the rhomboidei. J. Bone and Joint Surg., 33-A: 235-238, Jan. 1951.[Free Full Text]

12. Iceton, J., and Harris, W. R.: Treatment of winged scapula by pectoralis major transfer. J. Bone and Joint Surg., 69-B(1): 108-110, 1987.

13. Johnson, J. T. H., and Kendall, H. O.: Isolated paralysis of the serratus anterior muscle. J. Bone and Joint Surg., 37-A: 567-574, June 1955.[Free Full Text]

14. Magee, K. R., and DeJong, R. N.: Paralytic brachial neuritis. Discussion of clinical features with review of 23 cases. J. Am. Med. Assn., 174: 1258-1262, 1960.

15. Marmor, L., and Bechtol, C. O.: Paralysis of the serratus anterior due to electric shock relieved by transplantation of the pectoralis major muscle. A case report. J. Bone and Joint Surg., 45-A: 156-160, Jan. 1963.[Abstract/Free Full Text]

16. Misamore, G. W., and Lehman, D. E.: Parsonage-Turner syndrome (acute brachial neuritis). J. Bone and Joint Surg., 78-A: 1405-1408, Sept. 1996.[Abstract/Free Full Text]

17. Ober, F. R.: Transplantation to improve the function of the shoulder joint and extensor function of the elbow joint. In Lectures on Reconstruction Surgery of the Extremities, edited by the American Academy of Orthopaedic Surgeons. Vol. 2, pp. 274-276. Ann Arbor, J. W. Edwards, 1944.

18. Parsonage, M. J., and Turner, J. W. A.: Neuralgic amyotrophy. The shoulder-girdle syndrome. Lancet, 1: 973-978, 1948.[Medline]

19. Post, M.: Pectoralis major transfer for winging of the scapula. J. Shoulder and Elbow Surg., 4: 1-9, 1995.[Medline]

20. Seddon, H. J. [editor]: Peripheral Nerve Injuries. Medical Research Council Special Report Series. No. 282, pp. 82-85. London, Her Majesty's Stationery Office, 1954.

21. Steindler, A.: The Traumatic Deformities and Disabilities of the Upper Extremity, pp. 162-163. Springfield, Illinois, Charles C Thomas, 1946.

22. Tsairis, P.; Dyck, P. J.; and Mulder, D. W.: Natural history of brachial plexus neuropathy. Report on 99 patients. Arch. Neurol., 27: 109-117, 1972.[Abstract/Free Full Text]

23. Tubby, A. H.: A case illustrating the operative treatment of paralysis of the serratus magnus by muscle grafting. British Med. J., 2: 1159-1160, 1904.

24. Vastamaki, M., and Kauppila, L. I.: Etiologic factors in isolated paralysis of the serratus anterior muscle. A report of 197 cases. J. Shoulder and Elbow Surg., 2: 240-243, 1993.

25. Whitman, A.: Congenital elevation of scapula and paralysis of serratus magnus muscle. J. Am. Med. Assn., 9: 1332-1334, 1932.

26. Wood, V. E., and Frykman, G. K.: Winging of the scapula as a complication of first rib resection: a report of six cases. Clin. Orthop., 149: 160-163, 1980.

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