Case Report 1476 www.thelancet.com Vol 384 October 18, 2014 Scapular prolapse into the intrathoracic cavity in a lung transplant patient Thanissara Chansakul, Arvind von Keudell, Peter Rohloff, Laura Janneck, Nirma Bustamante, Michael J Weaver, Urvi Fulwadhva A 76-year-old woman had an uncomplicated right lung transplantation at our hospital in October, 2013, for idiopathic pulmonary fibrosis, with standard right posterolateral thoracotomy between the fifth 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 (figure), 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 flexion 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 (figure). 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 flexing her right shoulder. Repeat radiographs showed reduction of the scapula without evidence of complications (appendix). The patient had an immobilisation sling fitted 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. 1–6 Several contributing factors have been described, including abnormal shoulder movement, debilitation, radiochemotherapy, weakness and malformation of the shoulder, and use of steroids. 1,3 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 1 described a case of life-threatening haem- orrhagic 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-specific 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 (figure). Chest CT with multiplanar reformations can confirm 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 affected limb is the first-line treatment and might suffice to prevent further dislocations. 3 If the scapular prolapse is unstable, either on initial reduction or as a result of re- dislocation, an open reduction with repair of the chest wall defect might be needed. 4,6 Contributors All authors cared for the patient and contributed to the report. References 1 Eguchi T, Kondo R, Shiina T, Yoshida K. An intrathoracic scapular prolapse with hemorrhagic shock after a thoracotomy. Interact Cardiovasc Thorac Surg 2011; 12: 326–27. 2 Gilkeson RC. Intrathoracic scapula: an unusual complication of thoracotomy. AJR Am J Roentgenol 1998; 171: 1706–07. 3 Gould SW, Radecki PD, Gembala-Parsons RB, Caroline DF. Intrathoracic scapular prolapse after thoracotomy. Can Assoc Radiol J 1994; 45: 145–47. 4 Lee RS, Dooley JF. Intrathoracic dislocation of the inferior pole of the scapula following thoracotomy. Acta Chir Belg 2012; 112: 450–52. 5 Murray JG, McAdams HP, Erasmus JJ, Patz EF Jr, Tapson V. Complications of lung transplantation: radiologic findings. AJR Am J Roentgenol 1996; 166: 1405–11. 6 Palissery V, Veenith T, Siddaiah N, Brennan L. Internal dislocation of scapula following thoracotomy for lung transplantation—a case report. Int Arch Med 2009; 2: 10. Lancet 2014; 384: 1476 Department of Radiology (T Chansakul MD, U Fulwadhva MD), Department of Orthopedic Surgery (A von Keudell MD, M J Weaver MD), Department of Hospital Medicine (P Rohloff MD), and Department of Emergency Medicine (L Janneck MD, N Bustamante MD), Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA Correspondence to: Dr Arvind von Keudell, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston 02114, MA, USA avonkeudell@mgh.harvard.edu Figure: Scapular prolapse (A) Chest radiograph showing abnormally angulated inferior angle of the right scapula (red arrow), abnormal opacity surrounding the scapula tip (green arrows), and widening of the fifth intercostal space (blue double-headed arrow). (B) non-contrast-enhanced multidetector CT images shows herniation of the right scapular tip (red arrow) into the intrathoracic space via a thoracotomy defect. Soft tissue density surrounding the herniated scapula (green arrows) shows subcutaneous tissue and musculature of the chest wall combined with chest wall oedema and haematoma. A B See Online for appendix