Session VI - Upper Extremity

Traumatic Scapulothoracic Dissociation: Long-Term Results and a New Classification System

Boris A. Zelle, MD^1,2; Hans-Christoph Pape, MD²; Birten Ceylan, MD²; Christian Krettek, MD, FRACS²;

¹University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA;

²Hannover Medical School, Department of Trauma Surgery, Hannover, Germany

Purpose: Traumatic scapulothoracic dissociation (TSD) is an infrequent injury with a potentially devastating outcome. The injury pattern includes a closed complete traumatic forequarter amputation that is often accompanied by neurovascular injuries. The aim of this study was to evaluate the long-term functional outcome after TSD and to find variables that are predictive of the outcome.

Methods: During the past 24 years, we have treated 25 patients (21 male and 4 female) with this lesion. The average age was 32.5 ± 13.5 years, and the average Injury Severity Score (ISS) was 21.5 ± 11.1. Sixteen patients had vascular injuries (64%). Osseous injuries included a displaced clavicle fracture in 20 patients (80%), dislocation of the acromioclavicular joint in 4 patients (16%) and a dislocation of the sternoclavicular joint in 1 patient (4%). Nine patients had a complete avulsion of the brachial plexus (36%); 10 patients had an incomplete neurologic deficit (40%). The outcome was evaluated by using the SF-36. In nonamputated patients, the shoulder function was evaluated by using the Subjective Shoulder Rating System (SSRS). The initial lateral displacement of the scapula was assessed with anteroposterior radiographs of the chest. The degree of scapular lateralization was quantified with the scapula index.

Results: The average follow-up was 12.6 ± 6.3 years. Three patients died from their associated injuries; six patients required an above-the-elbow amputation. One amputated and two nonamputated patients were lost to follow-up. The physical and mental component summary scores and the sum scales on role physical, general health, and mental health of the SF-36 were significantly lower in patients with a complete brachial plexus avulsion (P < 0.05). The sum scales of the SF-36 on physical function, bodily pain, social function, and role emotional trended toward lower values in patients with a complete brachial plexus avulsion (P > 0.05). In nonamputated patients, the SSRS score was significantly lower in patients with complete brachial plexus avulsion (P = 0.046). The SF-36 scales and the SSRS scores of the patients with a vascular injury did not significantly differ from the results of the patients without a vascular injury (P > 0.05).

The sum scales of the SF-36 and the SSRS did not correlate with the initial scapula index or the ISS (P > 0.05).

Conclusions: The results of this study revealed that the long-term outcome after TSD mainly depends on the degree of neurologic injury. Therefore, we suggest a new classification system with complete brachial plexus avulsion as the most severe type of injury.

Proposed classification system for the injury severity of Traumatic Scapulothoracic Dissociation

Type	Clinical Findings
Type 1	Musculoskeletal injury alone
Type 2A	Musculoskeletal injury with vascular disruption
Type 2B	Musculoskeletal injury with incomplete neurologic impairment of the upper extremity
Type 3	Musculoskeletal injury with incomplete neurologic impairment of the upper extremity and vascular injury
Type 4	Musculoskeletal injury with complete brachial plexus avulsion