Congenital unilateral absence of the clavicle and scapula with preserved humerus: incidental finding in empyema thoracis

Abstract

Introduction: Congenital musculoskeletal anomalies are among the commonest birth defects described in the literature, with many patterns recognised and others probably unrecorded. Partial absence of the shoulder girdle or isolated clavicular aplasia are documented; complete absence of the scapula is rare and usually described with absence of the limb. We report an adult with empyema thoracis in whom complete absence of the left pectoral girdle was found incidentally.

Case report: An adult man presented with eight months of recurrent discharge from the left chest. The illness began after a closed chest injury from a fall, managed initially with an intercostal drain for eight days at a peripheral hospital. Four weeks later he developed recurrent drainage and sought further care. He had no known comorbidities. On examination he was haemodynamically stable, respiratory rate 22 breaths per minute, with an actively discharging sinus at the left fifth intercostal space (mid-axillary line) and two healed drain sites. Chest expansion and air entry were reduced over the left mid and lower zones, with dullness to percussion. The right upper limb was normal. On the left, the shoulder outline was normal; the arm rested at about 30° abduction and active abduction reached about 70°. Elbow, forearm and hand were normal. Chest radiographs showed empyema thoracis and complete absence of the left clavicle and scapula with a normally positioned humerus. MRI was requested but the patient underwent decortication elsewhere and died a few days post-operatively. Consent for publication was obtained from the next of kin.

Discussion: Complete absence of the left pectoral girdle was found incidentally during assessment for empyema thoracis. With an intact humerus and no history of resection or major trauma, the features support a congenital origin and remind clinicians to check for musculoskeletal anomalies when chest imaging is atypical.