Scapular prolapse into the intrathoracic cavity in a lung transplant patient

A 76-year-old woman had an uncomplicated right lung transplantation at our hospital in October, 2013, for idiopathic pulmonary fi brosis, with standard right posterolateral thoracotomy between the fi fth and sixth ribs with part resection of the right sixth rib. Her immediate postoperative course was uneventful. In June, 2014, 8 months after the operation, she felt a snap as she reached for her telephone with her right arm while lying in bed just after waking. The snap was followed by right shoulder pain which radiated down her back and she was unable to lift her arm overhead. Chest radiograph showed a new opacity overlying the right lung (fi gure), which was thought to represent pneumonia, although she had no fever, cough, or shortness of breath. She was transferred to our hospital for further management. On examination she had a subtle depression of the right scapular contour compared with the left, and pain on more than 30° of forward fl exion and 30° abduction of the right shoulder. Chest CT showed abnormal position of the right scapula with the inferior angle of the scapula protruding into the right intrathoracic cavity through her thoracotomy defect (fi gure). After consultation with thoracic surgery colleagues, we gave mild sedation and close reduced the right scapula with axial traction along the medial border of her scapula while passively forward fl exing her right shoulder. Repeat radiographs showed reduction of the scapula without evidence of complications (appendix). The patient had an immobilisation sling fi tted and was instructed not to move her arm for 2 weeks. She then had a course of physical treatment to strengthen the periscapular musculature. At last follow-up in August, 2014, she had full range of motion of her right shoulder without pain. Scapular prolapse is a rare complication after thoracotomy. Several contributing factors have been described, including abnormal shoulder movement, debilitation, radiochemotherapy, weakness and malformation of the shoulder, and use of steroids. In this case, the intercostal gap created by thoracotomy and part right sixth rib resection, in addition to steroids given for her lung transplant, probably contributed to the prolapse. Presentation varies from acute pain and malformation to chronic pain and shoulder weakness. Eguchi and colleagues described a case of life-threatening haemorrhagic shock after scapular prolapse that occurred 80 days after thoracotomy and extended chest wall resection for treatment of lung cancer. The diagnosis of scapular prolapse in our patient was readily apparent on chest CT and, in retrospect, on the basis of clinical history and physical examination. However, the team’s primary concern was to rule out a consolidative process in the transplanted lung, and the condition was not immediately recognised because non-specifi c chronic shoulder pain, malformation, and weakness are common after thoracotomy. In such cases, a high level of suspicion is crucial. An important clue on chest radiograph is abnormal soft tissue density, consisting of subcutaneous tissue and musculature and possibly oedema and haematoma surrounding the scapular tip, which is angulated in position (fi gure). Chest CT with multiplanar reformations can confi rm the diagnosis and identify possible associated complications such as widening of thoracotomy defect, rib fracture, pulmonary contusion, pneumothorax, and haemothorax. Closed reduction of the scapular prolapse with immobilisation and restricted overhead activity for 2 weeks followed by periscapular strengthening of the aff ected limb is the fi rst-line treatment and might suffi ce to prevent further dislocations. If the scapular prolapse is unstable, either on initial reduction or as a result of redislocation, an open reduction with repair of the chest wall defect might be needed.