■ trauma update

Scapulothoracic Dissociation
William F. Lavelle, MD; Richard Uhl, MD

ment critical to the orthopedic series, car accidents accounted

A scapulothoracic dissociation is often associated with surgeon staffing a level I trau-
severe neurological and vascular injuries, which may ma center.
be unrecognized at the time of presentation and may be
potentially life threatening. COMMON MECHANISMS OF
INJURY
Although various injury ac-
for almost as many scapulotho-
racic dissociations as motorcy-
cle accidents.11 Together these 2
injury mechanisms account for
nearly 80% of scapulothoracic
dissociations.5,11,12 Falling from

S tability of the scapula

comes from the scapulo-
thoracic articulation aided by
Two factors may account for
what seems to be an increased
prevalence of these injuries in
counts have been described,
a massive traction force ap-
plied to the upper extrem-
a height uses a similar mecha-
nism of injury when during the
fall the patient attempts to catch
support from the clavicle strut. the modern trauma setting. The ity is the common cause of himself by grabbing onto an
In the case of a simple clavicle first factor is the ever-increas- scapulothoracic dissociation. object.
fracture or acromioclavicu- ing popularity of motorcycles It has been reported elsewhere Many patients with scapu-
lar joint separation, an intact and recreational activities that that approximately half of the lothoracic dissociation have a
scapulothoracic articulation place patients at risk for such scapulothoracic dissociations multitude of associated inju-
alone is sufficient to support a devastating injury.2 The sec- described in the literature in- ries, including a high incidence
the scapula. Disruption of the ond is the technical improve- volve a motorcyclist.4 One of head injuries, that make an
clavicle strut and the scapulo- ments in our trauma system, particular series found that exact injury mechanism diffi-
thoracic articulation leads to which have allowed patients 60% of patients with scapu- cult to obtain.
scapular instability. with such devastating injuries lothoracic dissociation were
Complete scapulothoracic to survive.3 motorcycle drivers.5 The most INJURY PATTERNS AND
dissociation with vascular dis- Despite the apparent in- logical mechanism involves a CLASSIFICATION
ruption and brachial plexus crease, scapulothoracic disso- motorcycle driver attempting to All types of scapulotho-
injury is an infrequent but ciation remains a rare injury. hold onto the handlebars while racic dissociations involve a
devastating injury. Oreck et al1 The potentially life-threaten- being forcibly thrown.5-8 Inju- complete loss of the integrity
first described this injury with ing nature of the injury makes ries to all-terrain vehicle riders of the scapulothoracic articu-
a 3-patient case series in 1984. proper identification and treat- would likely occur in a similar lation. An additional musculo-
manner and may become more skeletal injury to the shoulder
Dr Lavelle is from the Department of Orthopedics, SUNY Upstate Medi-
cal University, East Syracuse, and Dr Uhl is from the Division of Orthopedic commonly encountered due to is nearly requisite for scapulo-
Surgery, Albany Medical College, Albany, New York. their increasing popularity.2,9,10 thoracic dissociation. An an-
Drs Lavelle and Uhl have no relevant financial relationships to disclose. Other mechanisms have been teriorly based shoulder injury
Correspondence should be addressed to: Richard Uhl, MD, Division of
described, including automobile such as an acromioclavicular
Orthopedic Surgery, Albany Medical College, 1367 Washington Ave, Ste 200,
Albany, NY 12206 (uhlr@mail.amc.edu). accidents and pedestrian versus joint separation, sternoclavic-
doi: 10.3928/01477447-20100429-23 automobile accidents. In one ular joint separation, or most

JUNE 2010 | Volume 33 • Number 6 417

■ trauma update

commonly a clavicle fracture
is seen (Figures 1, 2). In fact,
a clavicle fracture accompa-
nied 80% of the 25 injuries
reviewed by Zelle et al.12
The violent forces that
disrupt the scapulothoracic
articulation often disrupt the
neurovascular structures. With
the rare exception of children,
whose tissue elasticity may
protect them from a severe
neurological or vascular inju-
ry,13,14 scapular displacement
is normally accompanied by
a significant soft tissue injury.
Complete or partial avulsions
of the brachial plexus that
leave the patient severely de-
bilitated may be seen. In the
acute setting, vascular injuries
maintain precedence, as these
are the components of the in-
jury that are life threatening.
Damschen et al11 proposed
a simple classification system
based on the presence or ab-
sence of either a vascular or
neurological injury. A type
1 injury involves an isolated
musculoskeletal injury (Figure
1A), a type 2 injury involves a
musculoskeletal injury with ei-
ther a vascular injury or a neu-
rological injury (Figure 2A),
and a type 3 injury includes a
patient with a musculoskeletal
injury and both a vascular and
a neurological injury.11 De-
spite the fact that type 2 and 3
injuries would intuitively rep-
resent more devastating and
disabling injuries, functional
outcome data do not to corre-
late with Damschen’s classi-
fication system.12 Zelle et al12
found that the completeness of
the brachial plexus injury was
most predictive of patient’s
functional outcome. The au-
thors found that although a
vascular injury was more life
threatening, the patient’s neu-
rological injury was the most
life altering as determined by
long-term SF-36 scores. The
authors proposed adding a
fourth type of scapulothoracic
injury to include all patients
with a complete brachial plex-
us avulsion.12
PHYSICAL EXAMINATION
FINDINGS
Neurological Findings
Based on the combination
of motor and sensory deficits,
a general location of the injury
may be determined as either at
the spinal roots, within the bra-
chial plexus, or in a peripheral
nerve. A Horner’s syndrome or
paralysis of the serratus ante-
rior, rhomboids, supraspinatus
or diaphragm are suggestive
of a preganglionic lesion.15-17
Some authors recommend early
amputation for patients with a
complete preganglionic neuro-
logical injury in the upper ex-
tremity.12,13,18
Vascular Findings
On physical examination,
the injured limb should be
compared to the contralateral
extremity. The peripheral va-
soconstriction caused by hypo-
volemia and shock may make a
reliable examination difficult.
The arm should be inspected
for mottling and examined for
a temperature difference be-
tween the contralateral, and
presumably uninjured, extrem-
ity. Pulses should be palpated
at the wrist (radial and ulnar),
elbow (antecubital), and upper
arm (brachial and axillary).
Perhaps the most common mis-
take is to attribute a pulseless
extremity from scapulothoracic
dissociation to a more distal
musculoskeletal injury as these
patients often have concomitant
upper extremity trauma.13

ANCILLARY TESTING
Chest Radiograph
On chest radiographs, the
presence of a large soft tissue
1A 1B 1C

2A 2B 2C 2D
Figure 1: A 48-year-old woman was injured when thrown from a motorcycle. She was neurovascularly intact (Type 1 scapulothoracic dissociation). Upright chest radio-
graph showing a clavicle fracture, glenoid fracture, and multiple rib fractures (A). Upright chest radiograph taken 3 days after Figure 1A showing further collapse of the
thoracic cage and inferior displacement of the scapula. The patient began having brachial plexus symptoms (pain, numbness) as the collapse progressed (B). The patient
underwent plating of the clavicle, which helped support the scapula. Four months after the injury, the patient returned to work (C). Figure 2: A 23-year-old man involved in
a motorcycle accident sustained a Type 2 scapulothoracic dissociation with post-ganglionic injury to the brachial plexus. Right shoulder radiograph showing a complete AC
separation. The scapula is completely dissociated from the thoracic cage (A). The distance from the medial border of the scapula to the spinous process is measured. The
larger value either A or B is divided by the smaller value. This patient’s ratio was calculated to be 1.6, which is abnormally wide (B). The scapula and acromioclavicular joint
were reduced and a tibial plateau locking plate was contoured to fit the clavicle and acromion to hold the reduction. The plate was left in place for 3 months, at which time
the patient underwent brachial plexus exploration and plate removal (C). Following plate removal, the position of the acromioclavicular joint and the scapula are maintained.
Note the surgical clips following brachial plexus exploration and repair. The patient ultimately gained some incomplete return of upper extremity function (D).

418 ORTHOPEDICS | ORTHOSuperSite.com


density along the border of the
scapula may represent a hema-
toma and should raise suspicion
for a scapulothoracic dissocia-
tion and an associated vascular
injury. The radiograph may
demonstrate lateral displace-
ment of the scapula along with
any of the other accompanying
musculoskeletal injury patterns
such as an acromioclavicular
joint separation, sternoclavicu-
lar joint separation, or clavicle
fracture (Figure 2A).1
Specific radiographic crite-
ria for the diagnosis of a scapu-
lothoracic dissociation have
been described by Kelbel et al.8
On a nonrotated chest radio-
graph of 50 uninjured patients,
the authors measured the dis-
tance from the medial borders
of both scapulas to the spinous
process (Figure 2B). These 2
distances were then divided to
obtain their ratio, which aver-
aged 1.07. Kelbel et al8 recom-
mended this method and value
as a reproducible measurement
to establish the presence of an
injury as shown in Figure 2B.
For the patient with a scapulo-
thoracic dissociation, Zelle et
al12 reported an average scapula
index of 1.29.
Chest radiographs were also
found to be a valuable tool in
assessing scapular stability. Se-
rial upright chest radiographs
obtained to assess for scapu-
lar droop have been found to
be a significant problem for
patients, which is not always
identified on an initial imaging
series (Figures 1A, 1B).18
Computed Tomography/
Magnetic Resonance Imaging
On the computed tomogra-
phy (CT) scan, a chest wall or
JUNE 2010 | Volume 33 • Number 6
paraspinous hematoma may be
identified. An excessively large
hematoma may be suggestive
of a serious vascular injury.19
Separation of the scapula from
the chest wall may be identi-
fied on axial images.
In the post-injury setting,
CT may be even more valu-
able. A cervical myelography
may show the appearance of
a pseudomeningocele, which
is indicative of a spinal root
avulsion. The presence of ⭓3
pseudomeningoceles is felt to
be diagnostic of an irreparable
neurological injury. In the
case of an incomplete brachial
plexus injury, magnetic reso-
nance imaging (MRI) may of-
fer more detailed information
regarding the injury.20
IMMEDIATE POST-INJURY
TREATMENT
When a patient with
scapulothoracic dissocia-
tion presents to the emer-
gency department, standard
Advanced Trauma Life Sup-
port protocols should be fol-
lowed, including a thorough
and organized primary and
secondary survey. After the
establishment of 2 large bore
intravenous lines, the patient
should be adequately resus-
citated with crystalloid and
blood as needed. Observance
of proper Advanced Trauma
Life Support protocol may be
paramount to patient survival.
Immediate Surgical Treatment
The decision of whether to
revascularize the upper extrem-
ity or to perform an immediate
above-elbow amputation is
often difficult and should in-
volve the collaboration of the
patient’s treating physicians.
Surgeons should be mindful
of the risks of preserving an
injured arm that has been isch-
emic in light of the functional
disability imposed by the loss
of an upper extremity.
An urgent surgical explora-
tion is mandatory for patients
with an active hemorrhage, an
expanding hematoma, or se-
vere hand ischemia. If vascular
exploration is warranted, the
trunks of the brachial plexus
should be inspected. If a com-
plete disruption is found, a
primary amputation should be
considered, as the possibility
of a useful limb is so small that
it may not merit subjecting the
patient to the risks of main-
taining an extremity that has
been ischemic for an extended
or unknown period of time.
These risks are substantial and
include myoglobinuria, hyper-
kalemia, vascular thrombosis,
infection, and sepsis. In addi-
tion, many patients and their
families refuse secondary am-
putation despite possessing a
numb and nonfunctional upper
extremity.12,18,21
Patients with a partial bra-
chial plexus injury have been
found to have some potential
for a functional recovery.12
Direct repair of nerve inju-
ries may be considered in this
instance provided the patient
is stable. In such cases, ur-
gent revascularization of the
ischemic upper extremity is
recommended. Some authors
have recommended follow-
ing the patient’s fluid balance
carefully and considering an
amputation if the fluid bal-
ance is ⬎3 L positive, al-
though this recommendation
■ trauma update
is based primarily on litera-
ture that evaluated threatened
lower extremities.18
Shoulder Stabilizing
Procedures
Debate exists in the litera-
ture as to the indications for
shoulder stabilizing proce-
dures. As is often discussed
with “floating shoulder” type
injuries, the shoulder is com-
prised of a complex combina-
tion of articulations known as
the superior shoulder suspen-
sory complex. The superior
shoulder suspensory complex
may be thought of as a ring
consisting of the middle and
distal clavicle, coracoclavicu-
lar and acromioclavicular liga-
ments, acromion, coracoid pro-
cess, and glenoid.22,23 Injuries
that disrupt 2 components of
the ring are defined as unstable
potentially requiring stabili-
zation.22,23 With the scapula
dissociated from the chest, an
associated musculoskeletal
injury such as an acromiocla-
vicular joint separation, ster-
noclavicular joint separation,
or a clavicle fracture would
make for an unstable shoulder.
In light of this fact, some
authors recommend that for a
patient with an arterial injury,
the orthopedic injury should
be stabilized before a vascular
repair is attempted. Similar to
lower extremity trauma, a sta-
ble limb is required so as not to
disrupt a vascular repair once it
has been completed. Addition-
ally, the shoulder should be sta-
bilized to determine the appro-
priate length of an interposition
graft.18 In this situation, open
reduction and internal fixation
of the clavicle, acromioclavicu-
419
■ trauma update
lar, or sternoclavicular joints is
recommended.
In the extremity that does
not require a vascular repair, a
conservative approach has been
advocated by some authors
such as Damschen et al who
recommends external bracing
and shoulder support.11,13 As
these patients often have an
extensive amount of soft tissue
injury, a stabilization proce-
dure performed through a zone
of injury bears a significant
measure of risk to the patient.
Stabilization procedures may
be considered for significant
scapular droop or as a part of
a definitive reconstructive pro-
cedure once the zone of injury
has improved as a part of the
late post-injury reconstruction
(Figures 1, 2).
LATE POST-INJURY
TREATMENT
In the post-injury setting,
it is important to delineate the
extent of the neurological inju-
ry. A full neurological exami-
nation should be repeated and
a suspected injury level again
identified. If there is a suspi-
cion of a root level injury based
on physical examination, a CT
myelogram is recommended
to evaluate for the presence
of a pseudomeningocele. If
⭓3 pseudomeningoceles are
present on CT myelogram,
irreparable damage has been
done and nerve repair is not a
recommended option.18
An upper extremity electro-
myography (EMG) is another
useful aide in delineating the
location of the neurological
injury. This study should be
completed at 3 weeks as Wal-
lerian degeneration will have
420
occurred and the EMG of the
affected area will demonstrate
evidence of denervation. A
combination of limb EMG and
paraspinal EMG is necessary
as this will allow a pregangli-
onic injury to be differentiated
from a postganglionic injury.15
Patients with a complete neuro-
logical injury by EMG should
be followed clinically as it is
our experience that some pa-
tients may develop some func-
tional recovery.
If nerve reconstruction is
to be attempted, it should be
performed no later than 3 to
6 months from injury to avoid
muscle atrophy and fibrosis
(Figure 2D). Once the muscle
has atrophied and become fi-
brotic, even with successful
reinnervation, the result would
not be clinically useful.4,24
If a diagnosis of pregan-
glionic lesion is made, nerve
repair techniques should be
abandoned and other recon-
structive options considered.
Upper extremity reconstruc-
tive priorities in the setting
of trauma are similar to those
used for birth-related brachial
plexus palsies. The first priori-
ties of reconstruction include
elbow flexion and shoulder
abduction/stabilization. One
treatment option that may be
considered is neurotization.
This is where an uninjured
nerve is transferred from its na-
tive muscle to another, higher
priority muscle that is injured.
In this process, the nerve from
the donor muscle is either di-
rectly grafted to the remnant of
the injured nerve or connected
via a nerve graft.4 This tech-
nique is typically only useful
for avulsions that are isolated
to the upper cervical roots as
more extensive injuries leave
patients without substantial
donor nerves.25
Muscle and tendon trans-
fers represent another avenue
for reconstruction. Unfortu-
nately unlike peripheral nerve
injuries, common donor mus-
cles are often left injured mak-
ing transfer options limited.
Although muscle transfers for
birth palsies have been well
described, no similar series
exists in the literature for trau-
matic brachial plexus injuries
in the adult.13
Shoulder stability may be
an issue for these patients,
therefore arthrodesis remains
a viable option. Patients may
note symptomatic scapular
instability and pain while at-
tempting to rehabilitate the af-
fected arm. A scapulohumeral
arthrodesis has been found
to yield satisfactory clinical
results for properly selected
patients.26 Although attempts
are often made to stabilize
the associated acromiocla-
vicular joint separation, ster-
noclavicular joint separation
or clavicle fracture as these
are much simpler injuries to
treat, persistent and symptom-
atic scapulothoracic instability
has been described and may
lead to significant shoulder
pain and additional functional
limitation. Neurological injury
of associated scapulothoracic
muscles such as serratus ante-
rior, trapezius, and rhomboids
may rarely necessitate a proce-
dure such as a scapulopexy.27
CONCLUSION
Scapulothoracic dissocia-
tion, although a rare injury,
ORTHOPEDICS | ORTHOSuperSite.com
may be life threatening. Prior-
ity should be placed on resus-
citative measures, as these pa-
tients have sustained significant
trauma. As threatening isch-
emia is rare, careful observa-
tion is recommended for the
nonthreatened limb. For the
ischemic limb, inspection of
the neurological injury is rec-
ommended as complete plexus
injuries bear a poor functional
prognosis. In these instances,
amputation should be consid-
ered. Late reconstruction of
neurological injuries may be
complex, with extensive injury
limiting options of nerve re-
pair, nerve transfer, and tendon
transfer.
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sports medicine update
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