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SYM13: Update on Shoulder Trauma

Moderator(s): Milan K. Sen, MD

Faculty: Paul Clay Baldwin, III, MD, and Bryan J. Loeffler, MD

Session Handouts

Saturday, October 03, 2020

75TH VIRTUAL ANNUAL MEETING OF THE ASSH

OCTOBER 1-3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: meetings@assh.org

9/3/2020

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SYM13: Update on Shoulder TraumaClavicle Fractures

Chair: Milan K. Sen, MD

Faculty: Paul Clay Baldwin, III, MD and Bryan J. Loeffler, MD

DISCLOSURES

Paul Clay Baldwin, III, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

SYM13: Update on Shoulder Trauma

Paul C. Baldwin III, MD

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Clavicle Fractures - Epidemiology

• 2-10% of all adult fractures

• Middle 1/3 fractures most common (~70-80%)

• Middle 1/3 fractures more common in younger active patients

• Distal 1/3 fractures (~10-20%)

• Distal 1/3 fractures more common in older patients

To Fix or Not to Fix

• 2007 RCT COTS (McKee et al) ORIF vs Closed Treatment

- Improved functional outcomes, faster healing, decreased non-union

with ORIF

• 2020 Meta-analysis (Amer et al)

- 11 studies (497 ORIF, 457 Closed treatment)

- Decreased rate of non-union and symptomatic malunion with ORIF

- No significant difference in outcome scores

- Plate fixation better than IMN fixation

Surgical Indications

• Absolute:

- Open Fractures

- Displacement with Skin Tenting

- Shortening > 2 cm

- Greater than 100% Displacement

- Floating Shoulder Injury Pattern

- Symptomatic Nonunion

- Symptomatic Malunion

• Relative:

- Polytrauma

- Bilateral Clavicle Fractures

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Imaging

• Dedicated Clavicle Radiographs

• Patient is Upright

• AP

• AP with 20-30º Cephalic Tilt

Surgical Technique

• My Preference – Supine (Non-op Arm Tucked) or Beach Chair

Surgical Technique

• My Preference – Supine or Beach Chair

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Fixation Options – Single Plate

• Superior vs. Anterior Plating- Superior pre-contoured plates demonstrate superior biomechanicalstrength compared to anterior pre-contoured plates and superiornon-contoured plates.

• Theoretical decrease in implant irritation with anterior plating- No difference found with complications and second procedures

• Fracture pattern should dictate plate position• Plate size (3.5 mm vs. 2.7 mm)

- Low complications and good results with 2.7 mm DCP whenwhen compared to 2.7 mm reconstruction plates.

Fixation Options – Single Plate

• Anterior Plating

Fixation Options – Single Plate

• Superior Plating (Tight Rope Augment)

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Fixation Options – Dual Plate

• Mini Fragment Plates- Compared to superior plating higher resistance to superior loads- Compared to anterior plating higher resistance to anterior loads- High rate of union- Low rate of implant irritation and need for implant removal

• My Preference:- 2.7 mm reconstruction plate or 2.7 mm DCP plate anteriorly- 2.4 or 2.0 mm reconstruction plate or DCP plate superiorly

Fixation Options – Dual Plates

Thank You!!!

Please Email with Questions/Comments

pcbiiimd@gmail.com

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Fixation Options – Dual Plates

Fixation Options – Dual Plates

Fixation Options – Intramedullary Fixation

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DISCLOSURES

Milan K. Sen, MD

Consulting Fee: Globus Medical, Smith and Nephew, Depuy Synthes, ACell

Sternoclavicular Injuries: Management and Techniques 

Milan K. Sen MD

Associate Professor, Albert Einstein College of Medicine

Chief, Division of Orthopedic Surgery

Director, Orthopedic Trauma

NYC Health+Hospitals/Jacobi, Bronx, NY

American Society or Surgery of the Hand

75th Annual Meeting

October 3rd, 2020

Introduction

• RARE (1% of all traumatic joint dislocations)

• Experience is lacking

• Natural history is uncertain

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Objectives

• Indications for operative management

• Treatment techniques

• Functional outcomes

• Case examples

Posterior vs Anterior

• Anterior dislocations are often treated non‐operatively

• Posterior dislocations are treated operatively

Posterior SC Dislocations

• Mechanisms of injury

• Indirect ‐ shoulder is compressed and rolled forward

• Direct force applied to SC joint or anteromedial clavicle

• Most commonly due to sports injury (53.7%) or MVC (18.5%)

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Posterior SC Dislocations

Symptoms

• Acute• Dyspnea• Hoarseness• Dysphagia• Venous congestion

• Chronic• Post‐traumatic arthritis• Decreased function

Investigations

• X‐rays

• CT Scan

• CT Scan with contrast

• MRI

Posterior SC Dislocations

• Most are operative

• Proximity of important structures:• Subclavian artery and vein

• Brachial plexus

• Vagus nerve

• Recurrent laryngeal nerve

• Trachea and lung

• Larynx

• EsophagusBois AJ, Wirth MA, Rockwood CA Jr. Disorders of the sternoclavicular joint. In: Rockwood CA Jr, Matsen FA, Wirth MA, Lippitt SB, Fehringer EV, Sperling JW, eds. The shoulder, 5th edition. Philadelphia: Saunders Elsevier; 2016. p 453‐ 91. 

Treatment

• Closed reduction should be attempted <72h• Often stable after successful closed reduction

• If unsuccessful, proceed to open reduction:• All posterior dislocations

• Anterior dislocations in a young, active, or high demand patients

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Surgical Technique

Varies in the literature, no gold standard

Do not use Kirschner wires

Do not use Steinmann 

pins

Do not use cerclage wires

Surgical Technique• Supine, radiolucent table that allows for serendipity view intra‐op

• Bump between the shoulder blades

• Anterior approach

• Reduction with pointed tenaculum

Image from Bontempo NA, Mazzocca AD Biomechanics and treatment of acromioclavicular and sternoclavicular joint injuries British Journal of Sports Medicine 2010;44:361‐369.

Do you need a Cardiovascular Surgeon to be present?

Not necessarily.

However….

….prudent to do these cases in the daytime with a CV surgeon in the building

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Stabilization

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Best Technique

• No consensus, no gold standard

• Figure of 8 stabilization• Allo/autograft vs Tape

• Augmentation/Internal Brace?

Tytherleigh‐Strong G, Pecheva M, Titchener A.Orthop J Sports Med. 2018 Jul 10;6(7)

My Preferred Technique

• Don’t resect medial end of the clavicle

• Figure of 8 with Tape

• Augmentation with Tape superior to inferior through medial end of clavicle, brought through the anterior capsule, and tied over anterior capsule repair

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Outcomes

JBJS Rev. 2018 Nov;6(11):e2

J Orthop Trauma 2019;33:e251–e255 

Outcomes

• In general, favorable outcomes were found following surgical stabilization of SC dislocations

• Ligament reconstruction with tendon graft had the fewest recurrent instability cases and complications

• Level 4 and mostly Level 5 evidence

Case #1 43 y/o s/p motorcycle accident

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4 months postop

• SC joint incision healed

• Clinically symmetric clavicles

• NTTP at SC joint

• Lt shoulder ROM    • FF to 120   

• Abd to 90   

• NTTP at shoulder

Case #2: 16 y/o s/p injury at football practice

• c/o pain in chest and LUE

• No respiratory compromise

• NVI in LUE

Courtesy of Andrew Choo MD

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MRI

Axial

Coronal

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2.5 months postop

• No pain

• Symmetric appearance on examination

• Doing pushups

• When can he get back to football?

Case #3: 16 y/o male s/p multiple GSW

Courtesy of Andrew Choo MD

• Taken emergently by Trauma for bilateral neck explorations

• Sternotomy done for exposure

• Initially mid‐clavicular resection done as well

• Still couldn’t see, so medial third clavicle also resected

• Ortho gets call from trauma intraop—what should we do with the clavicle now?

• Told to place back into wound for later reconstruction

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After I&Ds, sternal closure…

ORIF of segmental clavicle osteotomy, SC joint reconstruction with semi‐T allograft

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Unfortunately…

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Not recognized until 3.5 weeks postop

• Taken back for revision fixation, ORIF across SC joint

6 weeks postop

Summary

1. CT scan is the best imaging modality for these injuries

2. Most anterior SC dislocations can be closed reduced or treated nonoperatively

3. Most posterior SC dislocations can be closed reduced• If irreducible or unstable, these require operative management

4. Pts under 25 y/o should also have an MRI• Medial physeal injuries are usually unstable and require surgery

5. No gold standard for repair• Figure of 8 tendon allograft +/‐ augmentation

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Thank you

• Twitter: @MilanSenMD

DISCLOSURES

Bryan J. Loeffler, MD

Consulting Fees: Hanger Clinic, Checkpoint Surgical

Proximal HumerusFractures: 

Non‐op, Repair or Replace?

ASSH VAM ‘20SYM13: Update on Shoulder Trauma

Bryan J. Loeffler, MDOrthoCarolina

Associate Professor, Atrium Health Department of OrthopaedicSurgery

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Anatomy

Rockwood CA, et al. The Shoulder. 4th Edition. Philadelphia: Saunders, 2009.

64%

36%

Hertel et al, JSES 2004

• 100 intracapsular fractures

• Assessed perfusion intraop by drilling head and & by laser Doppler flowmetry

• Medial metaphyseal extension < 8 mm is predictor of ischemia

• Medial hinge disruption > 2 mm also a predictor

• With both factors present, 97% PPV for head ischemia

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• Same group of patients as initial study

• Mean 5 year follow‐up

• Some without ischemia showed signs of collapse and some with ischemia did not

• “We conclude that osteosynthesis with preservation of the humeral head is worth considering when adequate reduction and stable conditions for revascularization can be obtained.”

Indications for Operative Management

• Patient factors– Age– Activity level/occupation– Previous (dys)function or arthritis– Comorbidities– Hand dominance

• Fracture factors– # of parts– Dislocation– Coronal plane alignment– Bone quality

?=

A Simple Algorithm Doesn’t Exist

• Surgical indications are not well defined

• Treatment should be individualized and expectations discussed when determining treatment plan 

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Treatment Options

• CRPP• Suture fixation• External fixation• ORIF• IMN• Hemiarthroplasty• Reverse total shoulder arthroplasty• NON‐OP!

Surgical Treatment

IM Rod

• Expanding indications (esp. in Europe)

• Combined proximal humerus and humeral shaft fx

• Deltoid and rotator cuff split

• Shoulder pain / rotator cuff dysfunction

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ORIF: Treatment by fracture type

• 2 part Fx– Surgical neck fx

• Minimally displaced, stable: non‐op with early ROM

• Significant displacement: ORIF– Isolated GT fx or LT fx: Fix if displaced– Anatomic neck fx

• ORIF if young, arthroplasty for elderly

• 3 and 4 part fx– ORIF if young or adequate bone stock– Non‐op or arthroplasty if elderly and/or poor bone stock

• Suture augmentation– Multiple heavy, non‐absorbable sutures through tendon‐bone junction / around tuberosities

• Screw placement– Prioritize calcar screws

• Structural augmentation PRN– Fibular strut*

– Calcium phosphate

– 2nd plate

Fixation: Key Points

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Fibular Strut Augmentation

• Used to restore medial support

• Replaced intramedullary plate; much easier to use and manipulate

• Indications have expanded

– Varus pattern with medial comminution

– Articular support in valgus pattern

– To improve bone stock / screw fixation

ORIF proximal humerus steps

• LHB is guide, release rotator interval to the base of the coracoid

• Limit unnecessary soft tissue stripping• Heavy non‐absorbable sutures around the 

Greater and Lesser Tuberosities. • Correct varus with 2 mm kwire joysticks from 

superior and small Cobb thru tuberosity split• Reduce the GT, provisional .062 kwire in the 

center of the piece. • Suture the tuberosities together under the 

plate• Place plate with screw guide just lateral to 

bicipital groove• Assess plate height• Drill & fill

64 y/o healthy, active RHD f s/p ground level fall

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ORIF with fibular strut

16 wks postop: 150/40/ L1, no pain

Post‐op Rehabilitation Protocol

• PROM only for 6 weeks

– Pendulum exercises

– Passive forward elevation and external rotation

– Good bone and good fixation: 130/30

• Start AAROM, pulleys at 6 weeks with stable x‐rays

• 8 wks: AROM

• Strengthening at 3 months

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Complications of ORIF

• Loss of reduction – screw cut‐out

• Screw penetration

• Hardware failure

• Nonunion

• Stiffness

• AVN

Konrad et al, JBJS 2010: ORIF with PHLP. 34% complications, 40% due to technical error, intraop screw perforation most common complication, 19% return to OR within 1 year

•Primarily 3 and 4 part fracture (+/‐dislocation)

•Stable internal fixation can not be achieved

–CT helpful

•Head split

•High risk for AVN

•Pre‐existing cuff pathology / DJD

So when arthroplasty?

Which arthroplasty for proximal humerusfractures?

Hemiarthroplasty

Limited personal indications•~55‐65 y/o

•Fracture dislocation w/ > 40% articular impression

•Success most dependent on tuberosity healing

Reverse TSA• > 70 y/o (physiological age)• Tuberosity comminution

– > 70, female, severe fx type associated with poor result when treated with hemi (Goldman et al, JSES 1995)

• Can get a satisfactory result without anatomic tuberosity healing

– Bufquin et al, JBJS 2007: AFE 97 degrees

Laderman et al, 2019: Systematic review of pt’s > 70 y/o• RTSA > HA• better clinical scores • less pain• higher forward elevation• greater patient satisfaction• Lower complications

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• Sutures around tuberosities– Use LHB as guide

• Remove head

• Implant fracture specific prosthesis for tuberosity fixation and bone grafting– Hemi: anatomic is approx. 30 

degrees retroversion– Reverse: 0‐20 degrees 

retroversion

• Determine head size and position (for hemi)– Height: 5.6 cm from top of 

humeral head to upper border of pec major

• Tuberosity reduction and fixation– Tuberosity bone grafting– Tuberosity to prosthesis, 

tuberosity to shaft, tuberosity to tuberosity

Arthroplasty technical considerations

Importance of tuberosity position

• If too high…

– Weakness & impingement

• If too low…

– Overtension rotator cuff, producing pain

• Anatomic position to maximize healing potential

• MUCH more important for HA than Reverse

78 y/o active, independent LHD female s/p fall

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78 y/o active, independent LHD female s/p fall

When arthroplasty? Elderly, 4 part / head split, comminuted tuberosities, high risk AVN, not fixable

4 months: 130 AFE (150 PFE) / 40 (no lag) / L4, painless

Summary

• Operative indications individualized

– Consider all patient and fracture related variables

• Younger patients: fix (well) whenever possible

• HHR: limited indications

• Reverse: older patients, poor bone quality, pre‐existing shoulder issues

– Reverse provides implant longevity & durable clinical results –even in pt’s < 60 y/o (Ernstbrunner, JBJS 2017)

– Reverse seems to work as well even if in revision setting  (Ernstbrunner, JBJS 2017)

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OrthoCarolina Hand CenterThank you!

DISCLOSURES

Milan K. Sen, MD

Consulting Fee: Globus Medical, Smith and Nephew, Depuy Synthes, ACell

Operative Treatment of Scapula Fractures

Milan K. Sen MD

Associate Professor, Albert Einstein College of Medicine

Chief, Division of Orthopedic Surgery

Director, Orthopedic Trauma

NYC Health+Hospitals/Jacobi, Bronx, NY

American Society or Surgery of the Hand

75th Annual Meeting

October 3rd, 2020

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Scapula Fractures

• What we think we know about scapula fractures

• When should we operate?

• Surgical exposure

• Case examples

Scapula Fractures

• High energy trauma

• Associated injuries in 90% of patients

• 0.5% ‐ 1% of all fractures• 3‐5% of shoulder fractures

Classification

OTA Classification Committee, J Orthop Trauma 2012 

1/4 have associated clavicle fractures

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Imaging

• Xrays are not sufficient

• Better intraobserver agreement with CT scan

• 13% of body fractures were actually fossa fractures on CT scan

• Many fractures were only seen on CT scan• Process fractures: coracoid and acromion

• Body fractures

• Fossa fractures

Imaging

• Recommendations:

• CT scan with reformats• ~50% agreement on plain xrays, 70% with CT scan added.

• 3D reconstruction with subtraction of the humerus if you suspect a fracture

• Most fractures involving the glenoid (80%) were treated operatively

• Most fractures involving only the body (99%) or only the neck (83%) were treated nonoperatively

• 77% ‐ 86% good to excellent results

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Scapula Fractures

When to operate?

• Intra‐articular displacement

• >4 mm step off? 

• 25% glenoid involvement

• Extra‐articular displacement

• 10 – 20 mm, 25 ‐ 45 degrees?

• Glenopolar angle <22 degrees

• Fractures contributing to instability

• Fractures interfering with rotator cuff function

• Shoulder suspensory complex

• Double disruption or more

Shoulder Suspensory Complex

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• Compared 12 pts treated non‐operatively to 7 pts treated operatively

• Strength• ROM• ASES Shoulder Scale• DASH• SF‐36

• Forward flexion higher in operative group• Weakness in IR and ER in operative group

• Differences were no longer significant when normalized for hand dominance

Shoulder Suspensory Complex

Floating shoulder: ipsilateral fractures of the clavicle and glenoid neck, AND disruption of the coraco‐acromial and acromioclavicular ligaments

• High energy injuries• MVA and “open cockpit” injuries

• All had concomitant injuries (100%)• 87% rib fractures, 87% nerve injury, 67% head injury

• 12 triple and 3 quadruple disruptions• Treated with ORIF

• Loss of shoulder strength

• Near normal ROM and DASH scores

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Operative Treatment

Positioning

•Lateral• Gives access to anterior structures 

• Imaging more difficult

• Requires more manipulation of the arm

•Prone• No access to anterior structures

• Better flouro

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Modified Judet Approach

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• Axillary nerve exiting quadrangular space beneath teres minor 

• Posterior circumflex artery exits quadrangular space with axillary nerve beneath inferior border of teres minor.  

Suprascapular nerve passes around base of spine of scapula via spinoglenoid notch 

Deep Dissection:  It is difficult to identify internervous plane between infraspinatus(suprascapular) and teres minor (axillary).  Dissect bluntly with finger to develop plane.  

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Modified Judet

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Key Points

Make sure you have good xray imaging prior to draping the patient

Identify the correct interval• Infraspinatus and Teres Minor

• Infraspinatus is a bi or tri‐pennate muscle • Look for the fat stripe

• Use blunt dissection• Bleeding from branch of circumflex scapular artery

Key Points• Very easy to get between Teres Minor and Teres Major

• Quadrangular Space• Hemorrhage from posterior humeral circumflex artery

• Axillary nerve injury

• Triangular space• Hemorrhage from branch of circumflex scapular artery

• Avoid rigorous retraction of Infraspinatus• Injury to suprascapular nerve

Don�t Miss This

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Don�t Miss This

Scapulothoracic Dissociation

• ATLS

• Vascular exam

• Neurological exam

• Scapular index

Case 1

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Case 2

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Case 3

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Case 4

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9/3/2020

51

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9/3/2020

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Summary: Scapula Fractures

• Surgery for displaced articular, and certain non‐articular fractures

• Reduction and stable fixation is obtainable• Mobilize earlier and easily

• Modified approaches can minimize the soft tissue trauma

• Good outcomes are possible

Thank you

• Twitter: @MilanSenMD

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