A Devastating Shoulder Girdle Injury and an Innovative Approach to Management – A Case Report

Introduction

Scapulothoracic dissociation is a rare but devastating injury characterized by complete disruption of the shoulder girdle’s musculoskeletal attachments from the thoracic wall, often associated with neurovascular compromise and typically resulting from high-energy trauma. Despite the profound internal disruption, the overlying skin is usually intact, hence the description of this entity as an internal or “closed” forequarter amputation.

Clinically, the condition presents with significant swelling in the shoulder region, preserved skin integrity, and varying degrees of neurological and vascular compromise – most notably, weakness, sensory disturbances, and absent pulses in the affected upper limb.

Diagnosis relies heavily on imaging, particularly anteroposterior chest radiographs, where measurement of the scapular index (ratio of distances from the midline to each scapula on an AP chest radiograph) can indicate lateral displacement of the scapula, which must be supplemented with higher imaging.

The Zelle et al.’s modification of Damschen et al.’s classification (Table 1) is a system for categorizing the severity of scapulothoracic dissociation injuries and has some predictive utility in determining the functional recovery of the affected limb.

In this report, we describe a case of scapulothoracic dissociation managed successfully with operative skeletal stabilization of an acromioclavicular joint injury and a scapular spine fracture with innovative, custom-fabricated implants.

Case Report

A 35-year-old male was involved in a high-energy motor vehicle collision involving a truck. He was brought to the emergency department, where initial assessment revealed that he was unconscious and regained consciousness after half an hour. Diffuse swelling was observed around the right shoulder girdle, with no evidence of neurovascular deficit from C5 to T1. Clinical examination further demonstrated paradoxical breathing along with localized traumatic signs. Radiographs (Fig. 1) of the chest and right shoulder, along with computed tomography of the right shoulder (Fig. 2), revealed a laterally displaced right scapula with a fracture-dislocation of the acromion process and associated disruption of the acromioclavicular joint. Additional findings included a flail chest – multiple fractures of the right 2nd to 4th ribs. The scapular index on the right side was measured at 1.30 (Fig. 1). Further assessment demonstrated transverse process fractures from D2 to D9 along with associated muscle avulsion and presence of a hemopneumothorax for which an ICD tube insertion was done. Magnetic resonance imaging (Fig. 1) of the shoulder girdle with brachial plexus assessment showed severe contusion and edema involving the soft tissues, periscapular muscles, and fascial planes, in addition to extensive subcutaneous crepitus. The medial scapulothoracic muscles were not involved. Diffuse edema was seen around the trunks, divisions, and cords of the right brachial plexus with no obvious discontinuity along the nerve fibers involving the cervical and brachial plexus. Computed tomography (CT) arteriogram revealed no filling defects. A CT brain did not reveal any intracranial bleeds.

This injury was thus classified as Zelle et al. ^[1] Type I Right Scapulothoracic Dissociation (Table 1). Although there is no absolute indication for orthopedic intervention in this patient, we felt that there is an increased susceptibility for the patient to have an unstable shoulder girdle in the near future if left untreated.

Discussion

Advances in imaging at tertiary trauma centers have increased recognition of scapulothoracic dissociation ^[2], a condition with potentially fatal outcomes that warrants standardized diagnostic and management protocols. Orthopedic management of scapulothoracic dissociation begins with adherence to Advanced Trauma Life Support protocols, ensuring airway, breathing, and circulation are secured. Priority is then given to vascular injuries, which may necessitate urgent surgical repair. Subsequent steps include stabilization of associated fractures and assessment of brachial plexus integrity. A detailed diagnostic workup (Table 2) for a suspected case of scapulothoracic dissociation has been outlined, encompassing clinical, radiological, and adjunctive investigations to facilitate timely recognition and management.

In cases of non-salvageable limbs with extensive neurovascular compromise, early above-elbow amputation may be indicated. Depending on the extent of neural and musculoskeletal injury, further surgical options may include brachial plexus reconstruction or shoulder arthrodesis to optimize functional outcomes.

Disruption of two or more elements of the superior shoulder suspensory complex (SSSC) generally necessitates fixation ^[3]. Surgical stabilization is typically indicated to safeguard vascular repairs, prevent neurological deficit, and enable rehabilitation ^[4]. Early fixation has been associated with improved outcomes and fewer complications ^[5,6,7]. Although vascular repair remains the priority when limb viability is threatened, some authors advocate initial skeletal stabilization to protect subsequent vascular reconstructions ^[8].

The scapular index ^[9], with values >1.29 considered suggestive, has been described as a diagnostic adjunct but lacks specificity due to influences such as positioning, chest wall asymmetry, or pre-existing deformities. In this case, the index normalized on follow-up imaging, indicating either muscle sprain or atony rather than a complete muscle tear. Thus, the scapular index should be regarded only as a screening tool, with a definitive diagnosis confirmed by advanced imaging such as computed tomography/magnetic resonance imaging.

To date, no study has directly compared the outcomes of surgical fixation of clavicular fractures, acromioclavicular joint disruptions, or associated ipsilateral extremity fractures in patients with scapulothoracic dissociation against those in patients with isolated injuries. Consequently, the necessity of surgical stabilization in this condition remains uncertain. Fixation methods vary, with choices often guided by surgeon preference and available resources; reported techniques include plates, suture anchors, tightrope constructs, and mesh plates ^[10]. In this case, the modified infrapectineal plate (Fig. 5) provided inherent stability due to the anatomy of the implant and by addressing both the spine of the scapula fracture and the acromioclavicular disruption through a single stable construct.

The operative technique employed in this case precludes motion at the acromioclavicular joint, which normally contributes once the arm is elevated beyond 90°. It is important to emphasize that the primary objective of this procedure is to maintain stability between the axial skeleton and the shoulder girdle, rather than to achieve conventional fracture fixation. To further augment stability, a cortical screw was inserted through the plate from the clavicle into the coracoid process. While this construct provides robust stabilization, it inevitably restricts terminal elevation of the shoulder. Consequently, implant removal will be necessary in the near future to allow restoration of the full range of shoulder motion.

Conclusion

Scapulothoracic dissociation is an uncommon, high-energy injury that necessitates a high index of suspicion for prompt diagnosis and timely intervention to optimize limb and life salvage. In the absence of standardized management protocols, thorough diagnostic evaluation and appropriate classification are essential for guiding treatment. Until evidence-based guidelines are established, management must be individualized, often requiring innovative, case-specific strategies.

Clinical Message

Scapulothoracic dissociation is a rare, potentially limb- and lifethreatening injury that may be overlooked when the associated bony injuries are not fully appreciated. This case highlights the importance of recognizing a bifocal SSSC disruption in association with a relatively subtle Type I scapulothoracic dissociation. Restoration of the integrity of the SSSC using stable fixation can help re-establish shoulder girdle alignment and provide a stable platform for functional recovery. Careful assessment of the entire shoulder girdle, including the acromion, acromioclavicular joint, clavicle, scapula, and neurovascular structures, is therefore essential in patients with suspected scapulothoracic dissociation.

References

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About the Authors

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  S K Srinivasa Ram Prakassh

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  Mohamed Sameer

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  Srijay Sashaank