Question

Following surgical removal of a firm nodular cancer swelling in the right breast and exploration of the right axilla, on examination the patient was 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

Hint:

Winged scapula after axillary surgery points to serratus anterior palsy from long thoracic nerve injury.

Answer 1

The Correct Option is C

This question checks whether you can connect a nerve injury during axillary surgery to a specific clinical sign, the winged scapula. Axillary clearance for breast cancer runs close to several nerves, and the long thoracic nerve is the classic one at risk.

1. Subscapular muscle: This muscle sits on the front of the scapula and rotates the arm inward. Damaging it does not push the scapula away from the chest wall, so it does not fit.
2. Coracoid process of scapula: This is just a bony hook on the scapula where some muscles attach. It carries no nerve fibers of its own, so injuring it cannot paralyse a muscle.
3. Long thoracic nerve: This nerve runs down the side of the chest wall on the outer surface of serratus anterior, right through the field of axillary dissection. Cutting it paralyses serratus anterior, and the scapula's medial border springs away from the ribs, giving the winged look.
4. Circumflex scapular artery: This is a vessel that supplies muscles around the scapula through the triangular space. Injury to it causes bleeding or poor blood supply, not a winged scapula.

The structure that fits both the surgical field and the clinical sign is the long thoracic nerve. Its loss stops serratus anterior from anchoring the scapula, so the bone lifts off the chest wall.

Let's summarize:

• Serratus anterior keeps the scapula flat against the ribs and is powered by the long thoracic nerve.
• The long thoracic nerve runs superficially in the axilla, making it easy to injure during lymph node clearance.

So the winged scapula in this patient is caused by injury to the long thoracic nerve.