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Average 4.1 of 53 Ratings
A 25-year-old is involved in a motor vehicle accident and sustains an isolated upper extremity injury. A representative radiograph is shown in Figure A. What physical exam findings are most predictive of functional outcomes?
Presence of open fractures
Asymmetry of pulses
Ecchymosis of the upper shoulder girdle
Swelling of the shoulder
Neurologic compromise of the extremity
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Based on the radiograph and mechanism of injury, this patient has sustained a scapulothoracic dissociation. In the context of this injury, neurologic status of the extremity is the exam finding most predictive of functional outcome.
Scapulothoracic dissociation is a traumatic injury to the scapulothoracic articulation that results from lateral traction to the shoulder girdle. It is often associated with significant chest wall, heart and lung trauma. A hallmark physical exam finding is decreased or absent pulses in the affected extremity. Because of the significant traction placed on the brachial plexus, functional outcome is dependent on the extent of neurologic injury. In patients with a complete brachial plexopathy, forequarter amputation should be considered.
Clements et al. review the diagnosis and management of scapulothoracic dissociation. They indicate that this entity is defined by subclavian or axillary vascular disruption, lateralization of the scapula, separation of the clavicular articulations, and nerve root or brachial plexus injury. For patients with flail extremities, an above elbow amputation is recommended
Figure A shows an AP radiograph of a patient with scapulothoracic dissociation. Note the significant lateral displacement of the scapula and scapular body comminution
Illustration A shows a coronal 3D reconstruction of a CT scan of the chest. Note the significant lateral displacement of the scapula relative to the chest wall. There is greater than 1 cm displacement relative to the vertebral spinous processes. A video is provided that reviews diagnosis and management of scapulothoracic dissociation.
Answers 1, 2, 3, 4: While these may all be seen in the setting of this injury, neurological status of the extremity is the most predictive of functional outcomes.
Clements RH, Reisser JR.
J Trauma. 1996 Jan;40(1):146-9. PMID: 8576982 (Link to Abstract)
Clements, JTACS 1996
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Average 4.0 of 12 Ratings
A 30-year-old male sustains a right shoulder injury with initial radiographs shown in Figures A and B. What single piece of additional information would best assist in determining this patient's functional outcome?
Lower extremity injury
Contralateral upper extremity injury
Proximal humerus fracture
Figures A and B show a scapulothoracic dissociation, with significant lateralization of the scapula and widening of the acromioclavicular joint to over 4 cm (Figure A). This can be thought of as an internal disarticulation of the scapulothoracic association and acromioclavicular joints.
The referenced article by Riess et al revealed that functional outcomes are worse with brachial plexus injuries and concomitant scapulothoracic dissociation than with isolated brachial plexus injuries. In fact, at 2 year follow-up, only 57% of the dissociation patients could carry anything over 5 lb with the injured side.
The other referenced article by Zelle et al found that complete brachial plexus injuries portended the worst outcome for scapulothoracic dissociation injuries.
Riess KP, Cogbill TH, Patel NY, Lambert PJ, Mathiason MA
J Trauma. 2007 Nov;63(5):1021-5. PMID: 17993946 (Link to Abstract)
Riess, JOT 2007
Zelle BA, Pape HC, Gerich TG, Garapati R, Ceylan B, Krettek C
J Bone Joint Surg Am. 2004 Jan;86-A(1):2-8. PMID: 14711938 (Link to Abstract)
Zelle, JBJS 2004
Average 3.0 of 25 Ratings
A patient presenting with scapulothoracic dissocation and ipsilateral extremity neurologic injury is most likely to have which of the following outcomes?
Return of 3/5 motor strength in distal extremity
Full return of extremity sensory function only
Scapulothoracic dissociation is a high-energy injury resulting from massive traction injury to the shoulder girdle with disruption of the scapulothoracic articulation. The most common long term result from this injury is complete loss of motor and sensory function of the extremity (flail limb), with death in the acute or semi-acute period also common.
The referenced study by Althausen et al found that outcomes from this injury were: a flail extremity in 52%, early amputation in 21%, and death in 10%.
The other referenced study by Ebraheim et al found that 12/15 patients had a complete brachial plexus injury and that none recovered any function (the other 3 patients died in the acute period).
Althausen PL, Lee MA, Finkemeier CG
Clin. Orthop. Relat. Res.. 2003 Nov;(416):237-44. PMID: 14646766 (Link to Abstract)
Althausen, CORR 2003
Ebraheim NA, An HS, Jackson WT, Pearlstein SR, Burgess A, Tscherne H, Hass N, Kellam J, Wipperman BU.
J Bone Joint Surg Am. 1988 Mar;70(3):428-32. PMID: 3346268 (Link to Abstract)
Ebraheim, JBJS 1988
Average 3.0 of 32 Ratings
Education video discussing the condition and treatment of scapulothoracic dissoc...