Scapulothoracic dissociation

Last revised by Tom Foster on 25 Feb 2023

Scapulothoracic dissociation is a rare potentially life and limb-threatening condition with high mortality characterized by disruption of the scapulothoracic articulation 1-3.

Scapulothoracic dissociation is associated with the following 2:

A combination of clinical criteria and typical imaging findings can establish the diagnosis 1.

This condition is usually seen in high-energy trauma. A common finding is an asymmetric swelling of the affected shoulder 1.

The examination should follow the advanced trauma life support (ATLS) principles and assessment of the injured limb and neurological status 4.

Scapulothoracic dissociation is a spectrum of musculoskeletal, vascular and neurological abnormalities that include the following 1:

Concomitant subclavian or axillary vascular injury and brachial plexus injury might be present 1,2.

The most common cause of scapulothoracic dissociation seems to be a massive blunt force affecting the shoulder girdle and upper extremity while the latter remains fixed in the following settings 2,3:

  • motorcycles, bicycles or all-terrain vehicle accident

  • fall from height

  • industrial machine accident

Anteroposterior chest radiographs can be helpful in the diagnosis of this condition. A difference greater than 1 cm of lateral scapular displacement in the injured side to that of the non-injured is diagnostic for scapulothoracic dissociation. It is measured from the medial border of the scapula to the spinous process of the thoracic vertebrae.

CT is the modality of choice in severe trauma. It might reveal an ipsilateral chest wall or paraspinous hematoma, separation of the scapula from the chest on axial images, clavicular fractures as well as acromioclavicular and sternoclavicular joint injuries. It might also identify and depict vascular injury especially if conducted as a CT angiogram 1,3.

CT myelography can be used to diagnose any preganglionic nerve injury and identify pseudomeningoceles 3.

Useful for identification of any brachial plexus injuries and any peripheral nerve lesions 1-3.

Scapulothoracic dissociation has a high mortality rate of approximately 11% 1, 2. Management requires a multidisciplinary approach often involving endovascular intervention for any active arterial hemorrhage orthopedic stabilization of fractures and possibly neurosurgical intervention for the treatment of plexus injuries, the latter can be delayed if necessary 5.  

Scapulothoracic dissociation was originally described by the orthopedic surgeons Steven L Oreck, Andrew R Burgess and Alan M Levine in 1984 1,5.

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