Shoulder stabilization following traumatic scapulectomy

Abstract

A 1&year-old boy was driving a power boat at high speed when he was thrown out by the impact of a wave. He was subsequently run over by the driverless boat, sustaining a mutilating injury to the left scapular region caused by the propellor. At operation it was found that the whole of his scapula and associated musculature had been cut up into numerous strips, and after excision of tissue the only remnant of the scapula was a large fragment of the glenoid fossa. The acromioclavicular joint and the lateral end of the clavicle had also been destroyed along with the posterior two4hirds of the deltoid muscle, the rotator cuff muscles and most of the trapezius muscle lateral to the mid-clavicular line. The neurovascular bundle to the arm was uhinjured and the upper limb was essentially undamaged. Th e patient had lost a great deal of blood. The appearance of the wound is shown (Figure la). After wound excision the 'humeral head was buried under muscle and a skin graft applied (Figure Ib) as an interim measure to allow time for the patient's condition to stabilize. After 2 weeks the humeral head, though exposed, was held in place by fibrosis against the lateral aspect of upper ribs. Since the patient had lost nearly all the muscles and ligaments which elevate or suspend the upper limb from the trunk but still had intact pectoralis major and latissimus dorsi muscles, it was feared that with time his upper limb would inexorably be pulled downwards by a combination of gravitational pull and muscular action with consequent stretching of the brachial plexus. Hence, some 4 weeks after the initial injury, the skin graft was excised. The ipsilateral latissimus dorsi muscle, normally a depressor of the humerus, was raised with an overlying skin island and transferred into the defect (Figure 2). The muscle was sutured to the lateral end of the clavicular remnant, thus converting it from a depressor of the arm to an elevator. At 1.5 years after injury the flap and the skin graft are stable, with minimal descent of the humerus. There is a good range of active shoulder flexion and adduction, but little active shoulder extension or true abduction. However, the transferred latissimus dorsi muscle shows active contraction. The radiographic appearance of both shoulders is shown in Figure 3.