Scapulothoracic Dissociation: Evaluation and Management
Scapulothoracic dissociation is a rare, potentially limb- and life-threatening injury of the shoulder girdle. The injury is characterized by lateral displacement of the scapula resulting from traumatic disruption of the scapulothoracic articulation. The typical physical examination findings consist of substantial swelling of the shoulder girdle, along with weakness, numbness, and pulselessness in the ipsilateral upper extremity. Radiographic evaluation includes measurement of the scapular index on a nonrotated chest radiograph and assessment for either a distracted clavicle fracture or a disrupted acromioclavicular or sternoclavicular joint. Although vascular injury occurs in most patients, emergent surgery is performed only in patients with either limb-threatening ischemia or active arterial hemorrhage. Management of neurologic injury can be delayed if necessary. The location and severity of neurologic injury determine whether observation, nerve grafting, nerve transfer, or above-elbow amputation is performed. Skeletal stabilization procedures include plate fixation of clavicle fractures and reduction of distracted acromioclavicular or sternoclavicular joints. The extent of neurologic injury determines clinical outcomes. Medical Outcomes Study 36-Item Short Form scores are significantly lower in patients with complete brachial plexus avulsion injury than in patients with postganglionic injury.