Peter Alexander Cole

Background: Malunions and nonunions of scapular neck and body fractures can cause considerable pain and disability. This study reports outcomes regarding functional measures, range of motion, and strength before and after reconstruction. Methods: This retrospective case series at a Level-1 trauma center between 2003 and 2024 identified 50 consecutive patients (mean age, 50.3 years; 82% male; 80% White) with symptomatic malunion or nonunion of a scapular neck and/or body fracture who were referred to a single surgeon. Medial-lateral displacement and angular deformity were corrected through surgical reconstruction and malunion osteotomy. The Disabilities of the Arm, Shoulder and Hand (DASH) score, range of motion, strength, and postoperative procedures requiring a return to the operating room were recorded. Results: Fifty patients were included in the study; 5 patients were lost to follow-up before 12 months, leaving 45 patients (40 with malunion and 5 with nonunion) with >1-year outcomes. Eleven patients underwent reconstruction between 6 weeks and 3 months after injury because of the severity of the injury, their symptoms, and/or the necessity of an osteotomy. The median time from injury to reconstruction was 10 months (interquartile range [IQR] width, 16 months), and the median follow-up was 28.9 months (IQR width, 23.2 months). All patients achieved radiographic evidence of union. No intraoperative complications occurred. There was a mean 30.7-point improvement between the preoperative and final postoperative DASH scores (p < 0.001). The mean postoperative DASH score was 14.1 in patients who underwent reconstruction between 6 weeks and 3 months and was 23.2 in those who underwent reconstruction after 3 months. Forward flexion and abduction demonstrated significant increases in both range of motion and strength from preoperatively to postoperatively. External rotation range of motion and strength showed no significant increases. Subsequent procedures were performed in 12 patients: 8 patients underwent symptomatic implant removal (1 also underwent concurrent manipulation under anesthesia), 1 patient underwent open reduction and internal fixation for a new fracture, 2 patients underwent implant revision (1 also underwent concurrent manipulation under anesthesia), and 1 patient underwent manipulation under anesthesia for shoulder contracture. Conclusions: Extra-articular scapular malunions and nonunions can be associated with considerable pain and disability. Deformity correction improved range of motion and strength and reduced disability in this cohort. A principled reconstruction can be successful in addressing the sequelae of displaced scapular fractures. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Case: An 80-year-old man with osteoporosis sustained a complex, comminuted medial clavicle (MC) fracture that failed nonoperatively. A novel reconstruction involved MC resection, midclavicle distraction osteoplasty (DO) with iliac crest bone graft, and sternoclavicular (SC) joint reconstruction using a semitendinosus tendon allograft. By 1 year, the patient achieved successful healing and functional recovery. Conclusion: Patients with excessive MC bone loss may require a clavicular lengthening to approximate the MC to the manubrium. Restoring clavicular length through a DO in conjunction with a SC joint reconstruction using a tendon allograft is a salvage maneuver which can yield a successful outcome.

Case: A 63-year-old man sustained multiple bilateral rib fractures, left scapula, and clavicle displaced fractures after being gored by a bull. He underwent surgical stabilization of the ribs, and the shoulder injuries were managed nonoperatively. Three months later, the patient presented with scapula and clavicle malunions and disabling shoulder ankylosis, which were addressed in a single reconstruction. Six-year follow-up manifested in nearly asymptomatic, normal function. Conclusion: Single-staged reconstruction of all indicated fractures in forequarter lateral implosion injuries is recommended.

Case: A 50-year-old man underwent reconstruction of 4 left and 3 right rib nonunions using approximately 30 cc of left iliac crest bone graft (ICBG). At 6 weeks, left flank discomfort and swelling developed. CT scan at 8 months revealed hernia at ICBG harvest site. The patient underwent robotic hernia repair 14 months postoperatively. At 20 months, he had returned to work, no recurrence of symptoms, and pain resolution. Conclusion: Major complication of iliac crest bone harvest, abdominal hernia, may result by supra-iliac repair attrition or insufficient abdominal wall reattachment to the bony crest, underscoring importance of surgical site closure.

The term forequarter lateral implosion injury describes any constellation of injuries involving the shoulder girdle and chest that comes from a lateral to medial force driving the shoulder toward midline. The scapula, clavicle, proximal humerus bones, as well as the glenohumeral, acromioclavicular (AC), and manubrioclavicular joints (MCJs) make up what is often referred to as the shoulder girdle. The reality is that the proper function of the shoulder girdle depends on a stable and anatomic chest wall, as the ribs and scapula in particular function as a unit with the clavicular attachment to the axial skeleton. Patients with scapula and clavicle fractures have rib fractures in a high percentage of cases, depending on the degree of force. Lateral implosion injuries are most commonly the result of high energy trauma, and computed tomography (CT) is preferred for assessment of rib fractures and intrathoracic pathology. While many isolated rib or shoulder girdle fractures can be treated nonoperatively, the lateral implosion injury represents a subset of patients often with multiple operative indications due to the displacement of the fractures or luxations of joints. Operative indications for the scapula, clavicle, AC joint, MCJ, and ribs are reviewed in this paper. The purpose of this review is to generate interdisciplinary communication between thoracic, general and orthopaedic trauma surgeons. It is written primarily for the Trauma and Thoracic Surgeon community to communicate appropriate indications in orthopaedics for the shoulder girdle. An interdisciplinary approach to managing these conditions is paramount for optimal care of the patient. There are many opportunities for combining procedures under anesthesia or staging operations, depending on prioritization or even planning surgical incisions for combined injuries.

OBJECTIVES: To discover postoperative symptom differences between nerve-sparing and nerve-sacrificing techniques during ORIF of clavicle fractures. METHODS: Design: Prospective, partially blinded randomized controlled trial. Setting: Single academic level I trauma center. Patient Selection Criteria: Patients with closed, isolated, displaced, midshaft clavicle fractures (OTA/AO 15-2A, -2B, -2C) underwent ORIF and were consented and randomized to a “nerve-sacrificing” or “nerve-sparing” group. Outcome Measures and Comparisons: Semmes-Weinstein monofilament used to test for sensation changes around the supraclavicular area, single assessment numerical evaluation scores, and symptom severity level providing patient self-reported changes, and patient morbidity questionnaires were issued at follow-up. One trained research fellow measured and mapped area of anesthesia. Outcomes between “nerve-sacrificing” and “nerve-sparing” groups were compared. RESULTS: In total, 21 patients (median age 41.5 years, 28.6% women) were randomized to “nerve-sacrificed” and 16 patients (median age 45.6 years, 18.8% women) to the “nerve-spared” group. There were no statistical differences in age or sex ratio (P = 0.304 and 0.702, respectively). Longitudinal models including an interaction between group and time showed cohort differences being driven by 12 weeks (49.3 (95% CLM 7.68–90.92)) and 24 weeks (23.92 (95% CLM 1.70–46.14)). Although point estimates for the spare group were still lower at 2 and 52 weeks, they were not significantly different between groups. Single assessment numerical evaluation scores and symptom severity level data showed improvements in both cohorts over time; however, there were no statistically significant differences between the groups (P = 0.176 and 0.155, respectively). CONCLUSIONS: Sparing the supraclavicular nerve during open reduction and internal fixation of clavicle fractures significantly decreased chest-wall area of anesthesia at 12 and 24 weeks postoperatively. However, nerve sparing did not provide clinically significant differences in other symptoms compared with sacrificing the nerve. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Case: A 66-year-old woman, former bodybuilder with right sternoclavicular (SC) arthritis managed with a 4-cm proximal clavicle (PC) resection, that led to scapulothoracic abnormal mobility (STAM), severe loss of shoulder function, and pain. A novel reconstruction involving a humeral allograft with a semitendinosus allograft for SC stabilization was performed. A 3-year follow-up is presented with satisfactory outcome. Conclusion: PC overresection in the management of SC joint pathology without ligament reconstruction may lead to severe STAM. Restoring clavicular length with a cortical allograft combined with a tendon reconstruction of the SC joint can yield a successful outcome.