THE ‘OTHER’ STD; THE UNFORESEEN CALAMITY

Abstract

Introduction 

Scapulothoracic dissociation (STD) is a rare but potentially catastrophic upper extremity injury caused by high-energy traction injuries. Originally described in 1984 as a laterally displaced scapula with ipsilateral acromioclavicular joint separation, subclavian vessel and brachial plexus disruption, with intact overlying skin. We reported a case of polytrauma with challenging diagnosis and management of STD in Emergency Department.

Case Report

A case of 14-year-old boy was brought to emergency department following a motorcycle skidded. Upon arrival, he was agitated, tachycardic and, hypertensive with GCS of 14. On examination, there was a deformity over left thigh and forearm, as well as abrasion wound over left shoulder. Initial primary survey was clear. Subsequently, his condition deteriorates and required airway protection. Post intubation, he was hypotensive with tachycardia. However, serial E-FAST was negative. The patient was resuscitated as per ATLS protocol and MTP was activated after his haemoglobin level dropped by 2g/dL. During resuscitation, noted progressive swelling over the left shoulder, with no pulse palpable over the left brachial and radial artery. Urgent CT thorax and CT Angiography were ordered and revealed a left sternoclavicular dislocation with neck of scapula fracture, scapula thoracic dissociation with left subclavian artery and vein injury, and anterior mediasternum haematoma. He also suffered a severe traumatic brain injury and multiple long bone fractures. Eventually, patient was scheduled for emergency forequarter amputation with Video Assisted Thoracotomy (VAT), however few hours post-injury he succumbed to his illness despite multidisciplinary effort. 

Discussion & Conclusion

STD have an increased chances of being overlooked in the acute setting, particularly in the presence of polytrauma. It is challenging to recognize neurovascular involvement in STD cases in patients with hemodynamically unstable polytrauma, as in this case. Early recognition of injuries and a multidisciplinary approach were key determinants in the patient’s better prognosis.