Following radical mastectomy in a patient with carcinoma breast, winged scapula is due to injury to the:

On examination following surgical removal of a firm nodular cancer swelling in the right breast and exploration of the right axilla, a patient is found to have a winged scapula. This occurred due to injury to the:

A. Subscapular muscle
B. Coracoid process of scapula
C. Long thoracic nerve
D. Circumflex scapular artery


Answer is C: Long Thoracic Nerve.

In the normal individual, the pull of the serratus anterior muscle keeps the medial border against the thoracic wall. However, when there is injury to the long thoracic nerve which supplies the serratus anterior muscle, there is winging of scapula, which is excessive prominence of the medial border of the scapula.

Actions of the serratus anterior muscle are:

1. It pulls the scapula forwards around the chest wall to protect the upper limb, as in pushing and punching actions
2. It rotates the scapula so that the glenoid cavity is turned upwards, which allows abduction of the arm above 90 degree.

In paralysis of the serratus anterior muscle, when movements like pushing, punching and raising arm above 90 degree is attempted, winging of scapula occurs.

• Long Thoracic nerve is also known as “Nerve of Bell”.
• Serratus anterior muscle arises by eight digitations from the upper eight ribs.