Young man involved in a high-speed motorcycle collision with diminished left

upper extremity pulses

What are the pertinent imaging findings? What is your leading diagnosis?
How do you explain the clinical findings?
(Click for a larger image.)

Case Details
Radiologic Findings - AP portable trauma bay chest radiograph (Fig. 1A) with accompanying
edge-enhanced image (Fig. 1B) demonstrates a widened mediastinum with poor definition of
the transverse aorta, aorticopulmonary window and right tracheobronchial angle consistent
with hemomediastinum in this setting. Left perihilar and upper lobe air space disease is
present consistent with a pulmonary contusion. The left diaphragm and left heart border is
crisp reflective of an ipsilateral pneumothorax. Note the significant left chest wall trauma
characterized by acute fractures of the 1st through 8th ribs; comminuted scapular fracture;
displaced left mid-shaft clavicular fracture; and the marked separation of the left scapula
from the chest wall. The scapulothoracic ratio (i.e., thoracic spinous process-medial scapular
border distance) is 1.8. Selected contrast-enhanced chest CT axial (Fig. 2A-2D) (mediastinal
windows); coronal (Fig. 3A-3C) (bone windows); and 3-D volume rendered images (Fig. 4AC) demonstrate these injuries to better advantage. Compare the relationship of the left and
right scapula to the thoracic cage on the 3-D images (Fig. 4A-4C).
Answer
Diagnosis: Left Scapulothoracic dissociation

Differential Diagnosis
None
Discussion
Scapulothoracic dissociation is a rare but serious devastating closed forequarter amputation
of the upper extremity resulting from a direct blow to or severe traction on the shoulder
girdle. 50-60% of patients with scapulothoracic dissociation are motorcyclists. The postulated
mechanism of injury involves attempting to hold onto the handlebars while being forcibly
thrown. Injuries to all-terrain vehicle riders occur in a similar manner and are becoming
more common. Clinically, there is near complete disruption of the forequarter from the torso.
Clinical Findings
Massive soft-tissue swelling, and partial or complete tears of the deltoid, pectoralis minor,
rhomboids, levator scapulae, trapezius, and latissimus dorsi muscles are usually present.
Concomitant injury to the ipsilateral brachial plexus, subclavian artery and or subclavian vein
invariably occurs. The axillary artery is not infrequently injured. The neurological deficit is
most often the result of complete avulsion of the brachial plexus but incomplete neurapraxia
is possible. There is also a high prevalence of other often severe thoracic and chest wall
injuries.
Imaging Findings
Chest Radiography

Radiographic hallmark: lateral displacement of the scapula

o Scapulothoracic ratio (abnormal:normal, 1.40 on a well-centered frontal
exam) (i.e., thoracic spinous process-medial scapular border distance)
o Concomitant fracture of ipsilateral clavicle with lateral displacement of distal
fragment, acrominoclavicular separation, and sternoclavicular fracture

MDCT / MRI

Depicts conventional radiographic findings to better advantage

Separation of the scapula from the chest wall
An excessively large hematoma may be suggestive of a serious vascular injury
Chest wall or paraspinous hematoma may be identified
Pseudomeningocele; indicative of spinal root avulsion
MRI offers more detailed information regarding brachial plexus injury

Treatment

Urgent surgical exploration mandatory for patients with active hemorrhage,

expanding hematoma, or severe hand ischemia
Complete disruption of brachial plexus; primary amputation should be considered
Partial brachial plexus injury; some potential for functional recovery
o Direct repair of nerve injuries may be considered if patient is stable
o Urgent revascularization of the ischemic upper extremity

Prognosis

Early recognition and aggressive treatment crucial; outcome is not dependent on

management of the arterial injury, but rather on the severity of the neurological deficit
Severe long-term disability may result from ischemia and brachial plexus damage
Complications may ultimately require shoulder arthrodesis and amputation

Selected Readings
1. Lee GK, Suh KJ, Choi JA, Oh HY. A Case of Scapulothoracic Dissociation with
Brachial Plexus Injury: Magnetic Resonance Imaging Findings. Acta Radiol 2007;
48(9): 1020-1023.
2. Witz M, Korzets Z, Lehmann J. Traumatic Scapulothoracic Dissociation. J
Cardiovasc Surg (Torino) 2000; 41(6): 927-929.
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