Winged scapula after surgery for right upper-lobe lung adenocarcinoma

What happened, in summary

A 69-year-old man was diagnosed by bronchoscopy with adenocarcinoma in the right upper lobe of the lung. He was scheduled for right upper lobectomy and mediastinal lymph-node dissection. The procedure began using video-assisted thoracic surgery, but injury to the azygos arch during lymph-node dissection caused bleeding and required conversion to an open thoracotomy. The bleeding was controlled and the lung operation was completed.

His immediate postoperative recovery was otherwise satisfactory, and he left the hospital on day 18. Because he feared that using his right arm could damage the surgical area, he avoided moving it after discharge. Two months later, another person noticed that his right shoulder blade protruded abnormally. He also had difficulty lifting his arm.

Examination showed a winged scapula caused by weakness of the serratus anterior muscle, consistent with injury to the long thoracic nerve. Shoulder abduction was limited to 130 degrees and forward flexion to 110 degrees. Clinicians considered the nerve likely to have been overstretched during the urgent thoracotomy rather than completely severed.

Occupational therapy began immediately after diagnosis and continued once or twice weekly for six months. His program included progressive bench-press exercises and pushing against a wall to strengthen the affected muscle. Shoulder movement began improving within two weeks. By six months, abduction had reached 180 degrees and forward flexion 170 degrees. Mild scapular prominence and some permanent limitation remained, but he reported no major problem in daily life and continued part-time work as a golf caddie.

His recovery centered on regaining shoulder function after a rare postoperative nerve complication while returning to independent daily life and part-time work.