The initial management of scapulothoracic dissociation: A challenging task for the vascular surgeon

Abstract

The medical records of nine patients who had sustained a STD secondary to a blunt trauma during the last decade (1990±2000) were reviewed in the University of Crete Vascular Surgery Unit. Patients with penetrating or open trauma, and those with musculoskeletal or vascular or neurologic injury alone, were excluded from the study. The diagnosis of STD was made initially from the patients' history and the clinical presentation. All patients ± males with a median age of 30 years (range from 21 to 54 years) ± were victims of decelerating, high speed motorcycle or automobile accidents (Table 1) and presented with a pulseless and severely ischaemic upper limb, absence of motor and sensory function below the shoulder or arm, and a shoulder girdle or chest wall swelling or haematoma and ecchymoses with intact skin. On subsequent plain X-rays or CTs all patients were found to have disruption of the acromioclavicular or sternoclavicular joints and/or clavicular fracture (Table 1). Surgical exploration in three patients and an urgent arteriogram or CT scan in the remaining patients demonstrated the vascular injury in the thoracic outlet region. Innominate artery or aorta rupture was not found in our patient population. Active bleeding from the damaged subclavian arteries was recognised in five patients and from several perforator arteries and veins of the chest wall in all patients. Concomitant injuries of the trunks of the brachial plexus were identified in all patients. In all patients, head injury, hypovolaemic shock and upper extremity fractures or ischaemic neuropathy made detailed preoparative assessment of the neurological status of the upper extremity ipsilaterally to the injured shoulder girdle unreliable, if not impossible. The specific injuries of neurovascular structures identified during the operative intervention are outlined in Table 1. Additionally, all patients experienced multiple other moderate or severe local and remote injuries. After initial stabilisation of the patients' vital signs and general condition all patients were operated upon urgently. The surgical exploration was performed via a supraclavicular incision in five patients, a combined supraclavicular incision and sternotomy in three patients (Table 1: cases 1, 4 and 8), and a combined supraclavicular incision and left thoracotomy in one patient (Table 1: case 5). After controlling the actively bleeding sites and detailed investigation and identification of the injured trunks of the brachial plexus and other structures, our effort was directed to reestablishing arterial flow to the ischaemic arm. Arterial reconstruction was performed in eight patients, using the autologous great saphenous vein as an interposition arterial graft connecting the proximal Please address all correspondence to: N. Katsamouris, Vascular Surgical Unit, University of Crete Medical School, University Hospital of Heraklion, Crete, Greece. Tel.: ‡30 81 392 379 or ‡30 932 277 357; Fax: ‡30 81 542 063; E-mail: asterios@med.uoc.gr Eur J Vasc Endovasc Surg 24, 547±549 (2002) doi:doi:10.1053/ejvs.2002.1722, available online at http://www.idealibrary.com on