Closed Forequarter Amputation | High-Energy Trauma | Neurovascular Emergency
- Scapulothoracic dissociation = traumatic disruption of the scapulothoracic articulation
- Lateral scapular displacement on a non-rotated film - a scapular index around 1.29 or more is the commonly quoted diagnostic value
- Brachial plexus avulsion in 94% - often complete (C5-T1) with poor prognosis
- Subclavian/axillary injury in 88% - may be occult, requires angiography
- Flail extremity in 52%, early amputation in 21%, death in 10% (Damschen series, n=58)
- Type III with complete plexus avulsion (later Type IV) can produce a flail limb; discuss forequarter / above-elbow amputation
- “Called 'closed forequarter amputation' - internal degloving of shoulder girdle
- “High-energy mechanism: MVA, motorcycle, industrial traction injuries
- “CXR shows lateral scapular displacement - measure scapular index
- “Flail limb with absent pulses = emergent angiography + vascular surgery consult
Overview and Epidemiology
Scapulothoracic dissociation is the traumatic separation of the scapula from the thoracic wall. The scapulothoracic articulation is completely disrupted, through an AC joint separation, an SC joint disruption or a clavicle fracture, and so is the soft-tissue envelope around it. It is often called a closed forequarter amputation, and it runs as a spectrum from isolated musculoskeletal injury to exactly that.
A true orthopaedic emergency. In the landmark Damschen review (n=58), mortality was 10%, early amputation 21%, and a flail extremity resulted in 52%. The soft-tissue disruption is massive and the haemorrhage occult.
Who. The injury is rare, and its true incidence is unknown because it is frequently underdiagnosed. Young males predominate, the typical high-energy trauma demographic; the mean age in Zelle's series was about 32 years. Neurological injury accompanies it in 94% and vascular injury in 88% (Damschen).
Mechanism. High-energy lateral traction on the upper limb. The common mechanisms:
- Motorcycle accidents - the arm is caught and the body continues
- Motor vehicle accidents - ejection with traction on the arm
- Industrial accidents - entrapment in machinery
- Agricultural accidents - power take-off (PTO) injuries
Pathophysiology and Anatomy
The only bony strut. The scapula is attached to the axial skeleton by the clavicle alone, through the AC and SC joints; every other attachment is muscular. A dissociation therefore needs disruption of that bony connection and of the extensive muscular envelope, the neurovascular structures and the soft tissues as well.
- Normal Function
- Bone bridge to axial skeleton
- Injury Pattern
- Fracture or dislocation
- Normal Function
- Scapular retraction/elevation
- Injury Pattern
- Complete rupture
- Normal Function
- Upper limb perfusion
- Injury Pattern
- Tear, avulsion, intimal injury
- Normal Function
- Venous return
- Injury Pattern
- May cause massive haemorrhage
- Normal Function
- Motor and sensory function
- Injury Pattern
- Avulsion (preganglionic) or rupture
- Normal Function
- Soft tissue envelope
- Injury Pattern
- Internal degloving (Morel-Lavallée)
Avulsion or rupture. Where the plexus fails decides whether it can be mended. An avulsion (preganglionic) tears the root from the spinal cord; it is not repairable and the prognosis is poor. A rupture (postganglionic) tears the nerve beyond the ganglion; it is potentially repairable and the prognosis is better. A complete C5-T1 plexus injury is the most common pattern in scapulothoracic dissociation.
The clues that point to avulsion:
- Horner syndrome (ptosis, miosis, anhidrosis) - T1 root avulsion; its presence suggests complete plexus avulsion and a poor prognosis for limb function
- Rhomboid and serratus paralysis - the dorsal scapular and long thoracic nerves
- A preserved SNAP despite anaesthesia
- A positive myelogram
The vessels. Assume a vascular injury until it is proven otherwise. The patterns:
- Complete transection - obvious, and requires repair
- Intimal tear - occult; it may thrombose hours later
- Pseudoaneurysm - delayed presentation
Classification Systems
Damschen's classification is the most commonly cited. It sorts the injury by which system is injured, not by how ischaemic the limb is: Type IIA is vascular, Type IIB is neurologic and Type III is both. Type I, musculoskeletal injury alone, is rare in true scapulothoracic dissociation, given how often the nerves and vessels are injured.
Type IV. A fourth type, complete brachial plexus avulsion, was added after the 1997 description and should never be presented as part of the original paper.
- Description
- Musculoskeletal injury only
- Neurovascular Status
- Intact
- Management
- Conservative/fixation
- Description
- Musculoskeletal + vascular
- Neurovascular Status
- Perfusion threatened, plexus intact
- Management
- Urgent vascular repair
- Description
- Musculoskeletal + neurologic
- Neurovascular Status
- Perfused, plexus injured
- Management
- Document deficit, plexus workup
- Description
- Musculoskeletal + vascular AND neurologic
- Neurovascular Status
- Threatened limb with plexus injury
- Management
- Revascularise; salvage vs amputation
Applying Damschen. Three questions place the injury:
- Is there any neurovascular injury? (Type I vs II/III)
- Is the injury vascular or neurologic? (IIA vs IIB)
- Are both systems injured? (Type III) - and is the plexus lesion complete? (Type IV, a later addition)
Clinical Assessment
These patients are polytrauma until proven otherwise. Complete the ATLS primary and secondary surveys before the focused limb assessment: haemorrhagic shock from occult vascular injury is common.
History. Establish the time from injury, because ischaemia time is critical, and ask about associated chest, spine and other limb injuries. Record hand dominance, which bears on the functional prognosis, and occupation, manual or sedentary.
Inspection. The shoulder girdle is massively swollen and the whole shoulder displaced laterally, with bruising, abrasions or degloving of the skin. The limb may hang flaccid. Open wounds are rare; this is usually a closed injury.
Examination. After the primary survey, examine the vessels, then the nerves, then the skeleton:
- Vascular - radial, ulnar and brachial pulses, capillary refill, hand temperature and colour; Doppler if the pulses are absent
- Neurological - each root of the plexus, and Horner syndrome
- Musculoskeletal - the clavicle for fracture, AC joint stability, the SC joint, scapular position and associated limb injuries
- Motor Function
- Shoulder abduction (deltoid)
- Sensory
- Lateral arm
- Reflex
- Biceps
- Motor Function
- Wrist extension (ECRL/ECRB)
- Sensory
- Lateral forearm, thumb
- Reflex
- Brachioradialis
- Motor Function
- Elbow extension (triceps)
- Sensory
- Middle finger
- Reflex
- Triceps
- Motor Function
- Finger flexion (FDP)
- Sensory
- Medial forearm
- Reflex
- -
- Motor Function
- Finger abduction (interossei)
- Sensory
- Medial arm
- Reflex
- -
The differential. Other injuries produce a swollen, weak or pulseless shoulder girdle, and each carries its own trap:
- Distinguishing Features
- Lateral scapular displacement (index about 1.29 or more), combined neuro + vascular deficit, intact skin
- Pitfall to Avoid
- The closed skin envelope can mask the severity - look for the radiographic sign
- Distinguishing Features
- Neurological deficit WITHOUT scapular lateralisation or major vessel injury
- Pitfall to Avoid
- Do not assume an isolated plexus lesion - always exclude vascular injury and STD
- Distinguishing Features
- Pulseless limb, normal scapular position, neurology may be intact
- Pitfall to Avoid
- STD is suggested when vascular injury coexists with plexus deficit and scapular displacement
- Distinguishing Features
- Double disruption of the superior shoulder suspensory complex; scapula NOT lateralised
- Pitfall to Avoid
- STD is a more proximal, neurovascular catastrophe - not the same entity
- Distinguishing Features
- Mediastinal compression symptoms; localised SC deformity
- Pitfall to Avoid
- Posterior SC dislocation can itself threaten great vessels - image with CT angiography
- Distinguishing Features
- Open soft-tissue disruption / external degloving
- Pitfall to Avoid
- STD is the CLOSED equivalent - intact skin distinguishes it
Investigations
- Key Findings
- Lateral scapular displacement, fractures, haemothorax
- Utility
- Initial screening - measure scapular index
- Key Findings
- Vascular injury, intimal flap, occlusion
- Utility
- Gold standard for vascular assessment
- Key Findings
- Definitive vascular imaging, allows intervention
- Utility
- If CTA equivocal or intervention planned
- Key Findings
- Nerve root avulsion (pseudomeningoceles)
- Utility
- Delayed - for surgical planning
- Key Findings
- Distinguish avulsion vs rupture
- Utility
- Delayed (3 weeks) - preserved SNAP = avulsion
The scapular index. Measure from the midline (the spinous processes) to the medial border of the scapula on each side, on the chest radiograph or CT scout, and divide the injured side by the normal side. The ratio is only meaningful on a genuinely non-rotated film, and one marginally above 1.0 reflects little more than asymmetry or film rotation. About 1.29 or more is the commonly quoted diagnostic value.
Where 1.29 comes from. It is the mean scapula index (1.29 plus or minus 0.19) in Zelle's 25 confirmed cases, not a cut-off derived from any accuracy study. A cohort mean cannot function as a diagnostic threshold, because by definition about half the confirmed cases fell below it, and no sensitivity, specificity or ROC analysis for the scapular index has ever been published.
Treat a high index as strong supporting evidence and a normal index as worthless for exclusion. In a high-energy patient with a flail, pulseless or insensate limb, the diagnosis is clinical and the index must never be used to rule it out.
It does not predict outcome. In the same series the index showed no correlation with SF-36 or shoulder scores. It is a diagnostic measurement, not a prognostic one: the prognosis is set by the brachial plexus, not by how far the scapula moved.
CT angiography. The findings that matter:
- Vessel occlusion - complete cutoff
- Intimal flap - linear filling defect
- Pseudoaneurysm - contained rupture
- Active extravasation - contrast blush
- Vessel displacement - with haematoma
Nerve conduction studies. Performed at 3 weeks or later, when the SNAP separates avulsion from rupture. A preserved SNAP means avulsion: the dorsal root ganglion is intact, and its sensory fibres are still connected to it though disconnected from the cord. An absent SNAP means rupture, the entire nerve disrupted, sensory fibres included.
Management
Life before limb. ATLS resuscitation takes absolute priority. Once the patient is stable, the vascular emergency is dealt with before definitive orthopaedic management.
Emergency Management Algorithm
Airway, Breathing, Circulation, Disability, Exposure. Large-bore IV access. Blood products if shocked. Address life-threatening injuries (tension pneumothorax, haemothorax).
Pulse check. If absent or diminished: emergent CTA or direct to angiography. Vascular surgery consult. Document ischaemia time.
Complete brachial plexus examination. Document motor (0-5 scale) and sensory function for each root. Look for Horner syndrome.
CXR (scapular index), CT chest/shoulder, CTA (vascular injury). MRI delayed for nerve root assessment.
Surgical Technique
The surgery is multidisciplinary and coordinated. Vascular surgery takes priority, and the orthopaedic and reconstructive procedures are staged around it.
Indications. Emergent vascular surgery is indicated for:
- Subclavian artery disruption
- Axillary artery injury
- Active haemorrhage
- Limb ischaemia with a salvageable limb
Exposure. A supraclavicular incision gives proximal control and is extended infraclavicularly or through a deltopectoral approach as needed. Median sternotomy for proximal subclavian access is rarely required.
Reconstruction. Primary repair is rare, because the vessel is usually too damaged. The alternatives are an interposition graft of saphenous vein or of prosthetic PTFE or Dacron, and temporary shunting if staged procedures are needed.
Warm ischaemia time of greater than 6 hours results in a near 100% amputation rate. Document the time of injury and the time of revascularisation.
Do not forget the vein. The subclavian or axillary vein is injured in a large proportion of cases, and venous disruption is a major source of the occult haemorrhagic shock that kills these patients. The bleeding is low-pressure but high-volume, into the disrupted shoulder girdle and chest, and easily underestimated behind intact skin. When you say "88 percent vascular injury", remember that means artery and vein, and control both.
Ligate the vein, repair the artery. In the unstable polytrauma patient a damaged subclavian or axillary vein is usually ligated rather than repaired, which is well tolerated because of collateral venous drainage; the artery is repaired or grafted to save the limb. If a large central vein is open to atmosphere, be alert to venous air embolism: place the patient head-down and pack or occlude the wound.
Complications
- Incidence
- 10% (Damschen)
- Prevention/Management
- ATLS resuscitation, haemorrhage control
- Incidence
- 52% (Damschen)
- Prevention/Management
- May require amputation
- Incidence
- Common
- Prevention/Management
- Pain management, amputation may help
- Incidence
- Risk with revascularisation
- Prevention/Management
- Prophylactic fasciotomy
- Incidence
- High
- Prevention/Management
- Staged procedures, VAC therapy
- Incidence
- With soft tissue trauma
- Prevention/Management
- Indomethacin, radiation
Reperfusion. After revascularising an ischaemic limb, consider prophylactic forearm fasciotomy, especially if the ischaemia time was greater than 6 hours, and monitor for compartment syndrome. Reperfusion can cause myoglobinuria and acute kidney injury, and hydration and urine alkalinisation may be needed.
Postoperative Care and Rehabilitation
Rehabilitation Phases
Haemodynamic monitoring. Wound care. Pain management. Vascular graft surveillance (duplex daily). Limb elevation. Compartment monitoring.
Oedema control. Wound healing. Psychosocial support. Pain team involvement.
Active ROM as nerve function returns. Strengthening as tolerated. Occupational therapy for ADLs. Reassess for nerve reconstruction.
Ongoing therapy. Orthotics/prosthetics if needed. Vocational rehabilitation. Chronic pain management.
After limb salvage. For the first 6 weeks the vascular repair is protected, with gentle passive movement if the fixation is stable. Active movement and gentle strengthening follow from 6 to 12 weeks, progressive strengthening and functional activities from 3 to 6 months, and a return to modified activities after 6 months.
Nerve recovery. Nerves regenerate at approximately 1mm a day (1 inch a month). Injuries at the level of the brachial plexus take 12-18 months to reach their distal targets. Motor recovery precedes sensory, and therapy concentrates on the function that is available. Recovery is never complete after severe injury.
After forequarter amputation. Rehabilitation follows its own course:
- Early - wound care, pain management, psychological support
- 4-6 weeks - prosthetic evaluation if desired
- 6-12 weeks - prosthetic training, if fitted
- Ongoing - phantom limb pain management, psychosocial support
Prosthetic choice. A cosmetic prosthesis is the most common choice; a functional prosthesis is of limited utility at this level, and many patients prefer no prosthesis at all. Patient autonomy in prosthetic decisions is paramount.
Pain. Multimodal analgesia with neuropathic agents (gabapentin, pregabalin) and early involvement of the pain team, with referral to a chronic pain clinic and consideration of a spinal cord stimulator.
Psychosocial support. Early psychological assessment, screening for and treatment of PTSD, peer support programmes, vocational counselling and family support services.
Outcomes and Prognosis
- Functional Outcome
- Good
- Notes
- Full recovery expected if fractures heal
- Functional Outcome
- Variable
- Notes
- Depends on neurological recovery
- Functional Outcome
- Variable
- Notes
- Depends on completeness of plexus injury
- Functional Outcome
- Poor limb function
- Notes
- Amputation often provides better QOL
Prognostic factors. The features that predict a poor result:
- Complete brachial plexus avulsion
- Delayed revascularisation (greater than 6 hours)
- Associated severe injuries
- Complete flail limb
- Preganglionic injury (Horner syndrome)
Those that predict a better one:
- Incomplete plexus injury
- Early revascularisation
- Type I (musculoskeletal only)
- Postganglionic injury (repairable)
- Young patient
Guidelines, Registries & Global Practice
Scapulothoracic dissociation is too rare for dedicated society guidelines, randomised trials, or arthroplasty-style registries. The evidence base is small retrospective series and reviews, and management principles are extrapolated from broader trauma frameworks (ATLS / vascular trauma) and brachial plexus injury practice. There is no country-specific "correct" pathway - the priorities below apply worldwide.
- Relevant Principle
- Life-threatening haemorrhage and airway/breathing take priority
- Application to STD
- Resuscitate and control occult chest-wall/neurovascular bleeding before limb surgery
- Relevant Principle
- Damage-control orthopaedics; staged fixation in the unstable polytrauma patient
- Application to STD
- Temporary stabilisation then delayed definitive clavicle/scapula fixation
- Relevant Principle
- Combined ortho-vascular pathway, time-critical revascularisation, fasciotomy after prolonged ischaemia
- Application to STD
- Joint vascular-orthopaedic team; document ischaemia time; low threshold for fasciotomy
- Relevant Principle
- Early specialist referral; staged neurophysiology before reconstruction
- Application to STD
- EMG/NCS at ~3 weeks, plexus reconstruction typically at 3-6 months in a specialist centre
- Consistently rare across all reported series and likely underdiagnosed worldwide
- Affects predominantly young males after high-energy trauma
- Mechanisms vary by region: motorcycle/MVA in most settings; agricultural PTO and industrial traction injuries more prominent in rural and lower-resource settings
- Pooled outcomes (Damschen, n=58): 94% neuro, 88% vascular, 52% flail, 21% amputation, 10% death
- High-resource: CT angiography on demand, 24/7 vascular and microsurgery, hybrid/endovascular options, specialist brachial plexus reconstruction, advanced prosthetics
- Limited-resource: reliance on clinical examination and plain radiographs, longer transfer and ischaemia times, earlier amputation more common, limited access to nerve reconstruction and prosthetic services
- Universal priorities: early recognition, haemorrhage control, timely revascularisation of the salvageable limb, and honest shared decision-making for the flail limb
Any suspected scapulothoracic dissociation should be transferred to a major trauma centre with:
- Level 1 trauma capability
- Vascular surgery available around the clock
- Microsurgery / plastics capability
- Critical care capacity
- Access to brachial plexus reconstruction expertise (often at a regional specialist centre)
Controversies and Areas of Uncertainty
- Multiple competing schemes exist (Oreck radiographic, Damschen spectrum, Zelle neurology-based)
- No system is prospectively validated
- Zelle (Level II evidence) argues neurological status, not vascular status, should define severity
- For exams, name Damschen as most-cited but acknowledge the limitation
- Some advocate early above-elbow amputation for the confirmed flail limb (Clements; Brucker)
- Others favour limb preservation with delayed, patient-led decision-making
- No comparative trial exists; the choice is shared and value-laden
- Phantom and neuropathic pain occur with either pathway
- About 1.29 or more is the commonly quoted value, but the exact diagnostic cut-off is debated
- Patient rotation on the film readily produces false asymmetry
- Zelle found the index did NOT predict functional outcome - it is diagnostic, not prognostic
- Hybrid/endovascular techniques for subclavian-axillary injury are emerging in case reports
- Evidence is limited to small series; open repair remains the default for unstable patients
- Decisions should involve vascular surgery early
MCQ Practice Points
- Key Point
- About 1.29 or more = positive
- Exam Trap
- A ratio of 1.0 is symmetry, not a threshold
- Key Point
- Damschen I/IIA/IIB/III
- Exam Trap
- Know all 4 types and what distinguishes them
- Key Point
- T1 avulsion (preganglionic)
- Exam Trap
- Indicates poor prognosis - NOT repairable
- Key Point
- Indicates avulsion NOT rupture
- Exam Trap
- Counter-intuitive finding
- Key Point
- ATLS resuscitation
- Exam Trap
- NOT immediate surgery for the limb
Q: A patient with complete brachial plexus injury undergoes nerve conduction studies at 4 weeks. SNAP is preserved. What does this indicate?
A: Preganglionic avulsion injury (NOT repairable). When SNAP is preserved despite clinical sensory loss, it indicates the dorsal root ganglion is intact but disconnected from the spinal cord. The sensory nerve still conducts because the injury is proximal to the ganglion. This is counter-intuitive but a classic exam question.
Q: What chest X-ray finding suggests scapulothoracic dissociation?
A: A scapular index of about 1.29 or more (lateral scapular displacement). Calculate it by comparing the distance from the spinous processes to the medial scapular border on the injured versus uninjured side, on a non-rotated film. A ratio marginally above 1.0 merely reflects asymmetry; the mean in Zelle's confirmed series was 1.29 plus or minus 0.19. It supports the diagnosis but does not predict outcome.
Q: A polytrauma patient has ptosis, miosis, and anhidrosis on one side. Which brachial plexus root avulsion does this suggest?
A: T1 avulsion (preganglionic). Horner syndrome indicates disruption of sympathetic fibers traveling through T1. This is a poor prognostic sign indicating preganglionic injury (not surgically repairable). It suggests high-energy mechanism with severe nerve damage.
Q: A patient presents with suspected scapulothoracic dissociation after a motorcycle accident. What is the first management priority?
A: ATLS resuscitation - Life before Limb. These injuries have approximately 10% mortality in the Damschen series, largely from associated vascular injury and haemorrhagic shock. After stabilization, address vascular emergency (subclavian/axillary artery) before definitive orthopaedic management.
Q: What distinguishes Damschen Type IIA from Type IIB scapulothoracic dissociation?
A: Vascular status and the injured system. Type IIA is musculoskeletal injury plus vascular injury with the plexus intact; Type IIB is musculoskeletal injury plus neurologic injury with perfusion intact; Type III involves both systems. Complete plexus avulsion is the later-added Type IV modifier.
Q: A Type III scapulothoracic dissociation results in a 'flail limb'. What management options should be discussed with the patient?
A: Limb preservation vs forequarter amputation. A flail limb has no motor or sensory function. Many patients ultimately choose amputation because it: eliminates a painful non-functional limb, improves quality of life, reduces infection/wound risks. Patient autonomy is paramount - amputation should be discussed but never mandated.
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 28-year-old motorcyclist is brought to ED after high-speed collision. His left arm is massively swollen and hangs flaccid. There are no pulses in the left upper limb and complete motor/sensory loss. CXR shows lateral displacement of the left scapula. How do you proceed?”
“Describe the scapular index and how you would calculate it on a chest X-ray. What is the diagnostic threshold?”
“A patient with Type III scapulothoracic dissociation and complete plexus avulsion asks about the option of keeping his arm versus amputation. How would you counsel him?”
Key Numbers
- Scapular Index about 1.29 or more = positive; diagnostic, not prognostic
- 94% have brachial plexus injury
- 88% have vascular injury
- 10% mortality rate
- 6 hours ischemia threshold for poor outcomes
Diagnosis
- High-energy traction mechanism (motorcycle, MVA)
- Massive shoulder girdle swelling
- Lateral scapular displacement (scapular index)
- Absent/diminished distal pulses
- Brachial plexus deficit (C5-T1)
Damschen Classification
- Type I: Musculoskeletal injury only
- Type IIA: Vascular injury, plexus intact
- Type IIB: Neurologic injury, perfusion intact
- Type III: Vascular + neurologic injury
- Type IV (later addition): Complete plexus avulsion
Management Priorities
- ATLS resuscitation (Life before Limb)
- CTA for vascular assessment
- Emergent revascularization if ischemic
- Document neuro status before intervention
- Type III: Discuss forequarter amputation
High-Yield Exam Points
- Preserved SNAP = preganglionic avulsion (NOT repairable)
- Horner syndrome = T1 avulsion (poor prognosis)
- Complete plexus avulsion = consider amputation
- Know scapular index calculation method
Evidence Base
Original radiographic description of lateral scapular displacement
- Three cases with radiographic and pathological evidence of complete scapulothoracic disruption without an overlying open wound.
- Established lateral scapular displacement with AC separation as the defining radiographic sign, with associated brachial plexus and subclavian artery/vein injury.
- Coined the recognition that the injury may be missed in the multiply-injured patient, with potentially fatal consequences.
Scapulothoracic dissociation caused by blunt trauma (landmark spectrum/classification series)
- Four institutional cases plus 54 adequately described literature cases (n=58).
- Neurologic injury in 94% and vascular injury in 88%.
- Flail extremity in 52%, early amputation in 21%, and death in 10%.
- Defined a broader spectrum of injury and a rational, severity-based approach to diagnosis and intervention.
Functional outcome following scapulothoracic dissociation
- 25 patients over 24 years; mean ISS 22; mean follow-up 12.6 years.
- Subjective Shoulder Rating System 33.8 (complete plexus avulsion) versus 72.5 (no/incomplete avulsion), p=0.046; SF-36 physical and mental scores also significantly lower with complete avulsion.
- Mean scapula index 1.29; initial index did NOT correlate with functional scores.
- Proposed modifying classification so that complete brachial plexus avulsion defines the most severe injury type.
Newly recognised variant and a new classification with review of treatment options
- Described scapulothoracic dissociation with sternoclavicular separation (a previously unreported radiographic combination) and an isolated, non-polytrauma case.
- Reviewed treatment options including amputation, shoulder arthrodesis, prosthetic fitting and reconstructive tendon transfers.
- Characterised the injury as a closed complete traumatic forequarter amputation with a flail pulseless arm.
Above-elbow amputation recommended for the flail extremity
- Defining constellation: subclavian/axillary vascular disruption, lateral scapular displacement, clavicular articulation separation, and cervical root avulsion or plexus injury.
- Recommended orthopaedic stabilisation, vascular repair and brachial plexus exploration.
- Advocated above-elbow amputation, either primarily or within 24 hours, for the flail extremity.
Level of vascular insult as a prognostic indicator
- 8 institutional cases plus 37 from the literature (n=45).
- Subclavian artery injury was associated more often with COMPLETE brachial plexus involvement; axillary artery injury with PARTIAL plexus injury (p less than 0.05).
- The more proximal the vascular injury, the more severe the neurological damage.
Scapulothoracic dissociation: evaluation and management (review)
- Synthesised the small case-series literature on evaluation, management and functional outcome.
- Emphasised timely diagnosis of neurovascular injury, with early above-elbow amputation for severe neurovascular and soft-tissue compromise.
- Complete brachial plexus avulsions carry limited potential for functional recovery.
Scapulothoracic dissociation: evaluation and management (AAOS review)
- Emergent surgery is reserved for limb-threatening ischaemia or active arterial haemorrhage; neurologic management can be delayed.
- Diagnosis relies on the scapular index on a non-rotated chest radiograph plus a distracted clavicle fracture or AC/SC disruption.
- Outcome is determined by the extent of neurological injury; SF-36 scores are significantly lower with complete plexus avulsion than postganglionic injury.