Updated: 5/24/2021

Scapulothoracic Dissociation

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  • Introduction
    • A traumatic disruption of the scapulothoracic articulation often associated with
      • severe neurologic injuries
      • vascular injuries
      • orthopaedic injuries
  • Etiology
    • Mechanism
      • usually caused by a lateral traction injury to the shoulder girdle
      • involves significant trauma to heart, chest wall and lungs
    • Associated conditions
      • orthopaedic
        • scapula fractures
        • clavicle fractures
        • AC dislocation/separation
        • sternoclavicular dislocation
        • flail extremity (52%)
          • complete loss of motor and sensory function rendering the extremity non-functional
      • vascular injury
        • subclavian artery most commonly injured
        • axillary artery
      • neurologic injury (up to 90%)
        • ipsilateral brachial plexus injury (often complete)
        • neurologic injuries more common than vascular injuries
  • Anatomy
    • Scapulothoracic joint
      • a sliding joint
      • articulates with ribs 2-7
      • moves into abduction at 2:1 ratio
        • GH joint 120°
        • ST joint 60°
    • Neurovascular anatomy
      • brachial plexus
      • subclavian artery
      • axillary artery
  • Presentation
    • History
      • history of high energy trauma
    • Symptoms
      • pain in involved upper extremity (UE)
      • numbness/tingling in involved UE
    • Physical exam
      • inspection
        • significant swelling in shoulder region
        • bruising around shoulder
      • vascular exam
        • decreased or absent pulses in involved UE
      • neurological exam
        • neurologic deficits in UE
        • neurological status critical part of exam
  • Imaging
    • Radiographs
      • required views
        • AP chest
      • recommended view
        • AP and lateral of shoulder as tolerated
        • appropriate images of suspected fracture sites
      • findings
        • laterally displaced scapula
          • edge of scapula displaced > 1 cm from spinous process as compared to contralateral side
        • widely displaced clavicle fx
        • AC separation
        • sternoclavicular dislocation
    • CT scan
      • recommended views
        • chest CT
          • axial views
      • findings
        • asymmetric distance from spinous process to medial edge of scapular body
    • Angiogram
      • indicated to detect injury to subclavian and axillary artery
  • Treatment
    • Nonoperative
      • immobilization/supportive care
        • indications
          • patients without significant vascular injury who are hemodynamically stable
            • patients may have adequate collateral flow to UE even with injury
    • Operative
      • high lateral thoracotomy with vascular repair
        • indications
          • axillary artery injury in hemodynamically unstable patient
      • median sternotomy with vascular repair
        • indications
          • more proximal arterial injury (i.e., subclavian artery) in a hemodynamically unstable patient
      • ORIF of the clavicle or AC joint
        • indications
          • associated clavicle and AC injuries
      • forequarter amputation
        • indications
          • complete brachial plexus injury
  • Prognosis
    • Mortality rate of 10%
    • Functional outcome is dependent on neurologic injury
      • if return of neurological function is unlikely, early amputation is recommended
Questions (4)
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(SBQ12TR.19) 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?

QID: 3934
FIGURES:
1

Presence of open fractures

1%

(91/6660)

2

Asymmetry of pulses

6%

(390/6660)

3

Ecchymosis of the upper shoulder girdle

1%

(44/6660)

4

Swelling of the shoulder

0%

(28/6660)

5

Neurologic compromise of the extremity

91%

(6076/6660)

L 1 B

Select Answer to see Preferred Response

(OBQ10.20) 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?

QID: 3108
FIGURES:
1

Lower extremity injury

2%

(69/2781)

2

Neurological deficit

83%

(2303/2781)

3

Contralateral upper extremity injury

2%

(58/2781)

4

Proximal humerus fracture

1%

(26/2781)

5

Worker's compensation

11%

(310/2781)

L 2 B

Select Answer to see Preferred Response

(OBQ10.52) A patient presenting with scapulothoracic dissocation and ipsilateral extremity neurologic injury is most likely to have which of the following outcomes?

QID: 3140
1

Glenohumeral arthritis

1%

(41/3130)

2

Return of 3/5 motor strength in distal extremity

7%

(206/3130)

3

Full return of extremity sensory function only

2%

(54/3130)

4

Flail extremity

80%

(2514/3130)

5

Death

10%

(299/3130)

L 2 B

Select Answer to see Preferred Response

Evidence (6)
VIDEOS & PODCASTS (2)
EXPERT COMMENTS (4)
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