Review Question - QID 211727

The patient is presenting with a scapulothoracic dissociation which often results in an ipsilateral brachial plexus injury. This commonly leads to the development of a flail upper extremity.

Scapulothoracic dissociation is the result of a lateral traction injury to the upper extremity. It often occurs with ipsilateral scapula fractures, clavicle fractures, AC dislocation, subclavian artery injuries, and ipsilateral brachial plexus injuries. Flail extremity can occur in up to 52% of cases due to the neurotmesis injury of the brachial plexus. Definitive treatment of a flail extremity includes slinging, tendon transfers, or forequarter amputation.

Althausen et al. reviewed the diagnosis and treatment of scapulothoracic dissociation. They reported vascular and neurologic injuries are found in up to 88% and 94% of cases, respectively. Up to 51% of patients from the included literature had a flail extremity with early amputation performed in 21% of cases.

Ebraheim et al. retrospectively reported on 15 patients treated for scapulothoracic dissociation. Three of the treated patients died, two from exsanguination, with most patients requiring repair of the damaged artery and a brachial plexus exploration. All twelve surviving patients were left with flail upper extremities from the brachial plexopathy.

Figure A is an AP chest radiograph depicting a right clavicle fracture with significant distraction between the fracture fragments. There is lateral- excursion of the right scapula compared to the contralateral side, consistent with scapulothoracic dissociation.

Incorrect answers
Answers 1: Malunion can commonly occur in the setting of a clavicle fracture that is treated nonoperatively. However, clavicle fractures associated with scapulothoracic dissociation should be treated with internal fixation to minimize a neurogenic nonunion. Additionally, malunion is not unique to clavicle fractures.
Answer 2: The presence of a scapulothoracic dissociation is often associated with a lung injury, but does not necessarily require intubation.
Answer 3: Abdominal injuries are common in the high-energy traumatized patient, but is not specific to a scapulothoracic dissociation. Ipsilateral pulmonary injuries are common with this injury pattern.
Answer 4: Cervical spine injuries occur frequently with motor vehicle accidents, but is not specific to a scapulothoracic dissociation. Ipsilateral rib fractures often occur in this setting.