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Background: Existing kinematic studies of the shoulder girdle focus on humerothoracic movements. Isolated scapulothoracic movements are also performed during daily activities and rehabilitation but kinematic values are lacking. Methods: A kinematic analysis was performed in 14 cadaveric shoulders during protraction, retraction, and shrug. An optical navigation system was used to analyze sternoclavicular, scapulothoracic, and acromioclavicular motions. Results: In the sternoclavicular joint, shrug and retraction caused a posterior clavicular rotation of 5° (standard deviation [SD] 6°) and 3° (SD 2°), while protraction induced an anterior rotation of 3° (SD 2°). Shrug caused a large clavicular elevation of 25° (SD 5°). Shrug and retraction caused an increase in retraction of 17° (SD 5°) and 9° (SD 2°). Protraction induced an increase of 10° (SD 2°) toward protraction. In the scapulothoracic joint, shrug induced an increase of 3° (SD 2°) in anterior scapular tilt, and a lateral rotation of 26° (SD 4°). Retraction caused a lateral rotation of 4° (SD 3°). Protraction caused an increase of 7° (SD 2°) in the scapular protraction position, while shrug and retraction demonstrated a decrease of 9° (SD 2°) and 6° (SD 5°). In the acromioclavicular joint, posterior tilting of the scapula compared to the clavicle increased 23° (SD 6°) during shrug, while during protraction an increase of only 4° (SD 3°) was seen. During shrug, relative lateral rotation increased 13° (SD 4°). The protraction movement decreased the relative protraction position with 3° (SD 2°). Conclusion: This study provided normative kinematic values of scapulothoracic movements in the shoulder girdle.

Scapulothoracic dissociation, particularly in combination with open fractures of the shoulder girdle, can be associated with significant soft tissue injury and present challenges with coverage and fixation. A single case of an open scapulothoracic dissociation was reviewed. Case presentation, clinical course and initial outcomes are discussed. A 22-year-old patient presented with an open left segmental clavicle fracture, sternoclavicular dislocation and scapulothoracic dissociation after being ejected in a motor vehicle collision. The shoulder girdle was initially stabilized with trans-clavicular trans-manubrial plating followed by staged pedicled rotational rectus abdominis flap. Follow-up at 1 month revealed well healed wounds and 90 degrees of forward flexion. Patients with open fractures and scapulothoracic dissociation can present multiple challenges when considering fixation and soft tissue coverage. A viable option in these patients is a pedicled rotational rectus abdominis flap when more typical coverage options are precluded from associated injuries.

Background Although fracture of the coracoid process (CF) used to be considered rare, it is now more commonly encountered due to increased awareness and advances in imaging methods. This review aimed to analyze reported cases of CF to determine its mechanism and appropriate treatment. Methods PubMed and Scopus were searched using the terms "scapula fracture" and "coracoid fracture." The inclusion criteria were English full-text articles concerning CF that described patient characteristics with appropriate images. The exclusion criteria included cases without appropriate images and those with physeal injury or nonunion. Citation tracking was conducted to find additional articles and notable full-text articles in other languages. Fractures were mainly classified using Ogawa's classification. Results Ninety-seven studies were identified, including 197 patients (131 men, 33 women; average age 37.0±16.9 years). CF was classified as type I in 77%, type II in 19%, and avulsion fracture at the angle in 5%. Concurrent shoulder girdle injuries included acromioclavicular injury in 33%, clavicular fracture in 17%, acromion or lateral scapular spine fracture in 15%, and anterior shoulder instability in 11%. Among patients with type I CF, 69% had multiple disruptions of the superior shoulder suspensory complex. Conservative treatment was applied in 71% of isolated type I CF, while surgical treatment was applied in 76% of type I CF with multiple disruptions. Although the evaluation methods varied, 60% of patients were followed up for more than 6 months, and the outcomes were generally satisfactory for both conservative and surgical treatments. Conclusion CF occurred commonly in the age group with higher social activity. The most common fracture type was type I. The possible mechanism of CF is violent traction of the attached muscles, except for avulsion fracture at the angle. Type I CF with multiple disruptions of the superior shoulder suspensory complex requires surgical treatment, whereas conservative care is recommended for isolated type I and type II CFs.

The Biceps Brachia is an anterior arm muscle consisting of two heads that bridge the shoulder girdle to the forearm. The distal biceps tendon from both heads may converge or remain anatomically separate before attachment to the radial tuberosity. The incidence of distal biceps rupture is 1.2/100,000 per year and is mostly seen in middle-aged men. The rupture of the biceps tendon is a relatively less common lesion making this case unique. Physiotherapy rehabilitation post-surgery is found to be effective; it includes management of pain, increase range of motion exercises, strengthening exercises, muscle energy technique, cardiovascular fitness, all these together helps to improve patient outcomes. A case of the 40-year-old female is presented in this case report who underwent traumatic glass-cut injury in proximal forearm resulting in distal bicep-tendon repair with ulnar artery injury and ulnar nerve neuropathy. After surgical reconstruction patient presented with pain in the shoulder, elbow, and wrist, reduced range of motion, strength, and grip strength leading to difficulty in performing activities of daily living. Surgical history, clinical findings, outcomes, and rehabilitation are mentioned in this report. We report that there is a significant improvement in stability, range of motion, muscle strength, relief from pain, and improvement in the patient's functional level and outcomes.

Background Push-ups (PU) are a common closed chain exercise used to enhance shoulder girdle stability, with variations that alter the difficulty or target specific muscles. To appropriately select and prescribe PU exercises, an understanding of muscle activity during variations of the PU is needed. The purpose of this scoping review was to identify common PU variations and describe their muscle activation levels. Methods Databases searched included PubMed, CINAHL, Scopus, and SPORTDiscus for articles published between January 2000 and November 2019. Results Three hundred three articles were screened for eligibility with 30 articles included in the analysis. Six PU types and five muscles met the criteria for analysis. Weighted mean electromyography (EMG) amplitude was calculated for each muscle across PU types and for each PU type as a measure of global muscle activity. Triceps and pectoralis major had the highest EMG amplitude during unstable, suspension, incline with hands on a ball and the standard PU. Serratus anterior had the highest EMG amplitude during PU plus and incline PU. The greatest global EMG amplitude occurred during unstable surface PU. Discussion These results provide clinicians with a framework for prescribing PU to target specific muscles and scale exercise difficulty to facilitate rehabilitation outcomes.

Background Approximately 9% of shoulder girdle injuries involve the acromioclavicular joint (ACJ). There is no clear gold standard or consensus on surgical management of these injuries, in part perpetuated by our incomplete understanding of native ACJ biomechanics. We have therefore conducted a biomechanical study to assess the stabilizing structures of the ACJ in superior-inferior (SI) translation and anterior-posterior (AP) translation. Methods Twenty fresh frozen cadaveric specimens were prepared and mounted onto a robotic arm. The intact native joint was tested in SI translation and AP translation under a 50-N displacing force. Each specimen was retested after sectioning of its stabilizing structures in the following order: investing fascia, ACJ capsular ligaments, trapezoid ligament, and conoid ligament. Their contributions to resisting ACJ displacements were calculated. Results In the intact native ACJ, mean anterior displacement of the clavicle was 7.9 ± 4.3 mm, mean posterior displacement was 7.2 ± 2.6 mm, mean superior displacement was 5.8 ± 3.0 mm, and mean inferior displacement was 3.6 ± 2.6 mm. The conoid ligament was the primary stabilizer of superior displacement (45.6%). The ACJ capsular ligament was the primary stabilizer of inferior displacement (33.8%). The capsular ligament and conoid ligament contributed equally to anterior stability, with rates of 23% and 25.2%, respectively. The capsular ligament was the primary contributor to posterior stability (38.4%). Conclusion The conoid ligament is the primary stabilizer of superior displacement of the clavicle at the ACJ and contributes significantly to AP stability. Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries.

Background: Frozen shoulder is a condition in which movement of the shoulder becomes restricted.It can be described as either primary (idiopathic) whereby the aetiology is unknown, or secondary,when it can be attributed to another cause. It is commonly a self-limiting condition, of approximately1 to 3 years' duration, though incomplete resolution can occur. The aetiology of shoulder pain isdiverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicularjoint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source ofshoulder pain is the rotator cuff, accounting for over two-thirds of cases. Material and methods:This was a prospective study with 50 patients coming to our OPD. Patients of all stages wereincluded and randomized into two groups. Group 1: Single Site Injection (SSI) group receivedsteroid injection through posterior approach and Group 2: Novel three-site ( NTS )group receivedthe same dose of steroid in diluted doses at three sites (posterior capsule, subacromial andsubcoracoid). The second sitting was repeated after 3 weeks. Both groups had received the samephysiotherapy. The patients were evaluated by the CONSTANT score at initial, 3 weeks, 6 weeks and6 months. Results: Patients of Group 2 (NTS group) had significant pain relief and earlyimprovement in activities of daily living (p < 0.005) as compared to Group 1 (SSI Group). Also,although there was an improvement in shoulder movements in both the groups but in Group 2 (NTS)patients, early near-normal scores were attained and sustained even after 6 months. About 40% inGroup 1 (SSI) could not attain near-normal levels and had relapses. Conclusion: The Novel three-site approach of steroid injections in frozen shoulder provides early recovery, better pain relief andbetter improvement in shoulder function with fewer relapses.

OBJECTIVE We sought to determine if white-light three-dimensional (3D) body scanning can identify clinically relevant shoulder girdle deformity after displaced diaphyseal clavicle fracture (DCF). METHODS Adult patients with DCF (OTA/AO 15A) were prospectively enrolled. Four subcutaneous osseous landmarks were used to measure shoulder girdle morphology of the injured and uninjured shoulder. Measurements were made both manually with a tape measure and digitally with a white-light 3D scanner. Bilateral radiographs were obtained, and clavicle length was recorded. Quick-Disabilities of the Arm, Shoulder, and Hand surveys were administered at injury and at 6 and 12 weeks. RESULTS Twenty-two patients were included in the study. At the initial visit, all patients had significant differences in deformity measurements between injured and uninjured shoulders as measured by 3D scanning. There was no difference between shoulders measured using manual measurements. At 6 and 12 weeks, shoulder asymmetry was significantly less in patients treated with surgery compared with nonoperative patients as measured by the 3D scanner alone. Clavicle shortening measured on 3D scanning had weak and moderate positive correlations to radiographs (R = 0.27) and manual measurements (R = 0.53), respectively. Patients treated with surgery had significant functional improvements by 6 weeks, and a similar improvement was not seen until 12 weeks in nonsurgical patients. CONCLUSION White-light 3D scanning was able to identify and monitor clinically relevant shoulder girdle deformity after DCF. This tool may become a useful adjunct to clinical examination and radiographic assessment, when determining clinically relevant deformity thresholds. In the future, quantifying and understanding shoulder deformity may inform clinical decision making in these patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clavicle fracture is a common traumatic injury around shoulder girdle due to their subcutaneous position. It is caused by either low-energy or high-energy impact. Fractures of the clavicle have been traditionally treated non-operatively. Although many methods of closed reduction have been described, it is recognized that reduction is practically impossible to maintain and a certain amount of deformity and disability is expected in adults. 30 patients with mid-shaft clavicle fracture were systematically randomized (alternate patient) into either operative treatment with plate fixation or non-operative treatment with clavicle brace and sling. All fractures were classified using Robinson’s classification for clavicle fractures and only Type 2A2 and 2B1 were considered for the study. Patients were followed up at 3wks, 6wks, 3rd month & 6th month. Functional outcomes were assessed according to the Constant and Murley Scoring and radiologically. Maximum number (90%) of patients had Robinson’s Type 2B1 fracture. The mean duration of hospital stay for patients in Group A(operative) and Group B(non operative) was 3.67 ± 0.90 days and 1.73 ± 0.46 days respectively. In Group A, the mean duration of trauma to surgery was 3.13 ± 2.64 days. While the mean operative time was 104.87 ± 13.52 minutes. The duration of union was significantly lesser in Group A as compared to Group B according to Chi-Square test (p0.05). Primary open reduction and internal fixation with pre-contoured clavicle plate for displaced, middle third clavicle fractures provide a more rigid fixation and allows early mobilization whereas conservative treatment require longer periods of immobilization till fracture union. Functional outcomes are better with surgical management of middle third clavicle fractures with pre-contoured locking compression plate. The successful use of locking compression plate for middle third fractures of clavicle requires careful assessment of fracture pattern, patient selection, meticulous operative technique, appropriate choice of fixation, judicious internal fixation, careful post-operative monitoring and aggressive early institution rehabilitation. So, there is need to individualize the treatment as per the need and functional demand of the patient to give the optimum outcome.

The Acromioclavicular joint represents the link between the clavicle and scapula, which is responsible for synchronized dynamics of the shoulder girdle. Traumatic injuries to acromioclavicular joint (AC joint) are commonly sustained by contact-sports athletes in high impact collisions or falls. Rockwood classified these injuries into types I through VI. Type I to type III injuries are treated conservatively and type IV -VI injuries require surgical management. Injuries of grade III - V require reconstruction of AC and CC ligaments. We present a surgical technique involving harvesting of semintendinosus autograft from hamstrings and using it to anatomically reconstruct the conoid and trapezoid portions of the coraco-clavicular ligament and the superior acromio-clavicular ligament/capsule. This technique is beneficial because it provides both horizontal and vertical stability. The purpose of our study was to find out the functional outcome of the procedure performed in mid-term follow-up. In our study the result was good functional outcome at 5 year follow up and subsequent followups provided proper placement of clavicular and acromian tunnels at the time of surgery.

Acromioclavicular (AC) injuries are common, especially in the young and active population. AC joint dislocations account for 8% of all joint dislocations and are even more common in contact sports. These injuries are graded as type I through type VI on the basis of the Rockwood classification method. Types I and II are generally treated without surgery whereas types IV, V, and VI are best treated operatively. Type III dislocations remain controversial in terms of treatment, and many surgeons recommend nonoperative treatment first and operative treatment in case of continued symptoms such as pain, instability, or shoulder girdle dysfunction. The goal of operative treatment is to restore AC joint stability, which involves addressing both the coracoclavicular and coracoacromial ligaments to achieve a desirable patient outcome. The objective of this Technical Note is to describe our technique for management of a failed acromioclavicular stabilization, treated with a coracoclavicular and AC joint capsular reconstruction using tibialis anterior and semitendinosus allografts., Technique Video Video 1 A step-by-step video illustration of the surgical technique of the treatment of failed type-V acromioclavicular (AC) separation caused by coracoid fracture via revision of acromioclavicular-coracoclavicular reconstruction and coracoid fixation. The procedure begins by extending the incision scar from the prior procedure. Next, the prior cortical button from the superior clavicle is removed, and the suture from the inferior clavicle is retrieved. Once the coracoid is exposed, the distal aspect presents as mobile and is resected. Preparation for a 4.75 mm SwiveLock is performed by first drilling and then tapping to later attach the conjoined tendon posterior and superior to the anatomic placement of coracoid. The remaining coracoid base is exposed and used to place a 3 mm cannulated guide pin from posterior to anterior at an angle of 45°. A passing suture is passed through the guide pin tunnel. Two tunnels are drilled in the clavicle. The first clavicular tunnel is drilled in the posterior one third of the clavicle, approximately 35 mm from the AC joint. The second clavicular tunnel is drilled on the anterior one third on the clavicle 25 mm to the distal end and is used for reconstruction. Passing sutures are passed through both tunnels. Another tunnel is drilled at the acromion midline, approximately 14 mm lateral to the AC joint, followed by a passing suture for later graft passage. The TightRope suture for the dog-bone button construct is passed superiorly to inferiorly, first through the coracoid tunnel in the clavicle and the grommet seated. The TightRope is then passed through the base of the coracoid, which is then tightened to the base of the coracoid to secure the clavicle in anatomic position. A 4.75 Peak SwiveLock is placed into the previously drilled hole at the superior glenoid neck and loaded with FiberTape sutures. The conjoined tendon is secured by whipstitching the single limb of the sliding suture within the SwiveLock anchor, then tying the previously placed FiberTape sutures to the tension limb after securing it to the base of the remaining coracoid and superior glenoid neck. Once the two ends of the graft are secured with FiberTape, the posterior graft limb is passed deep into the anterior limb and passed inferior to superior through the lateral clavicle tunnel. This limb is then passed from inferior to superior through the acromion tunnel, and a second tenodesis screw is placed in the acromion to secure the graft. The two free graft limbs are again tensioned over the superior clavicle and sutured together with FiberTape. The excess graft limbs are cut. The final construct creates a soft-tissue hook place. Range of motion of the arm is checked, and the stability of the reconstruction is confirmed.

BACKGROUND: Abnormal movement patterns due to compensatory mechanisms have been reported in patients with rotator cuff tears. The long head of the biceps tendon may especially be overactive and a source of pain and could induce abnormal muscle activation in these patients. It is still unknown why some patients with a rotator cuff tear develop complaints and others do not.QUESTIONS/PURPOSES: (1) Which shoulder muscles show a different activation pattern on electromyography (EMG) while performing the Functional Impairment Test-Hand and Neck/Shoulder/Arm (FIT-HaNSA) in patients with a symptomatic rotator cuff tear compared with age-matched controls with an intact rotator cuff tear? (2) Which shoulder muscles are coactivated on EMG while performing the FIT-HaNSA?METHODS: This comparative study included two groups of people aged 50 years and older: a group of patients with chronic symptomatic rotator cuff tears (confirmed by MRI or ultrasound with the exclusion of Patte stage 3 and massive rotator cuff tears) and a control group of volunteers without shoulder conditions. Starting January 2019, 12 patients with a chronic rotator cuff tear were consecutively recruited at the outpatient orthopaedic clinic. Eleven age-matched controls (randomly recruited by posters in the hospital) were included after assuring the absence of shoulder complaints and an intact rotator cuff on ultrasound imaging. The upper limb was examined using the FIT-HaNSA (score: 0 [worst] to 300 seconds [best]), shoulder-specific instruments, health-related quality of life, and EMG recordings of 10 shoulder girdle muscles while performing a tailored FIT-HaNSA.RESULTS: EMG (normalized root mean square amplitudes) revealed hyperactivity of the posterior deltoid and biceps brachii muscles during the upward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 111% ± 6% versus 102% ± 10%, mean difference -9 [95% confidence interval -17 to -1]; p = 0.03; biceps brachii: 118% ± 7% versus 111% ± 6%, mean difference -7 [95% CI -13 to 0]; p = 0.04), and there was decreased activity during the downward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 89% ± 6% versus 98% ± 10%, mean difference 9 [95% CI 1 to 17]; p = 0.03; biceps brachii: 82% ± 7% versus 89% ± 6%, mean difference 7 [95% CI 0 to 14]; p = 0.03). The posterior deltoid functioned less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than in the control group.CONCLUSION: Patients with a symptomatic rotator cuff tear show compensatory movement patterns based on abnormal activity of the biceps brachii and posterior deltoid muscles when compared with age-matched controls. The posterior deltoid functions less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than the control group.CLINICAL RELEVANCE: This study supports the potential benefit of addressing the long head biceps tendon in the treatment of patients with a symptomatic rotator cuff tear. Moreover, clinicians might use these findings for conservative treatment; the posterior deltoid can be specifically trained to help compensate for the deficient rotator cuff.

Introduction One of the most common injuries in children is clavicle fractures. They account for up to 14 % of all pediatric bone injuries. Aim Comparative evaluation of the effectiveness of surgical and conservative methods of treating closed clavicle fractures in children. Materials and methods Between 2011 and 2018, 1,800 children with clavicle fractures referred to the traumatology and orthopedic department at the Children's Clinical Hospital No. 9 in Yekaterinburg.Most of them were treated conservatively, and 94 (5.2 %) children were hospitalized for surgical treatment. Depending on age and type of displacement, children received different conservative treatments, such as Deso dressing in children under two years old, figure-eight-bandage in children over two years of age. Surgical treatment was open reduction of fragments and fixation with either a Kirschner wire or a titanium elastic nail (TEN); titanium plates were used in several cases. For a comparative assessment of the results of the treatment methods for clavicle fractures, two groups of patients were formed. Results Shortening of consolidated clavicle was not observed in children of the main group treated surgically. In several cases, the elongation of the clavicle was revealed by no more than 1 cm. Patients in the comparison group showed shortening of the broken clavicle in three cases, no more than 1.3 cm. Conclusion After surgical treatment, the length of the shoulder girdle was fully restored; insignificant shortening after conservative treatment did not cause functional disorders.

Complex interactions between dynamic and static stabilizers of the shoulder girdle are critical for a biomechanically complex system, allowing for sufficient range of motion in multiple planes. This study assessed the biomechanical consequences of non-retracted rotator cuff tears (RCT), isolated and massive RCT, and irreparable, retracted posterosuperior RCT on the glenohumeral joint using a validated, dynamic shoulder testing system. Eight fresh-frozen cadaveric shoulders were tested using a dynamic shoulder simulator. Each shoulder was tested in the following conditions: (1) intact state; (2) isolated non-retracted supraspinatus tendon (SSP) defect; (3) isolated non-retracted subscapularis tendon (SSC) defect; (4) isolated non-retracted infraspinatus tendon (ISP) defect; (5) massive non-retracted RCT involving all three tendons; (6) irreparable, retracted posterosuperior RCT. The SSP, SSC, and ISP simulated defects showed a significant increase in total deltoid force, respectively (p = 0.012; p = 0.007; p = 0.001). Compared with the intact state, the massive RCT showed a significant decrease in glenohumeral abduction angle (p 0.001, respectively) compared with the intact state. In a dynamic biomechanical shoulder model, isolated non-retracted RCT, located lateral to the rotator cable, can be sufficiently compensated by the remaining intact cuff. However, in irreparable, massively retracted posterosuperior RCT located medial to the rotator cable, devasting effects on the glenohumeral joint can be expected and surgery should be recommended for these patients.

Clavicle fracture is one of the most common bony injuries. They account for 2.6% to 4% of adult fractures and 35% of injuries to the shoulder girdle. Clavicular fractures have traditionally been treated non-operatively. Surgical treatment of acute midshaft fractures was not favored due to relatively frequent and serious complications. However, the prevalence of non-union or malunion in displaced midshaft clavicular fractures after conservative treatment is higher than previously presumed. Twenty-four patients with displaced clavicle fractures were treated with locking compression plate between October 2018 to September 2020 at Kamineni Institute of Medical Sciences, Narketpally. The duration of radiological union ranged from 12-16 weeks with the majority having union at 12 weeks (66.7%). The remaining (33.4%) had union at 16 weeks. Delayed union and nonunion cases were not observed in our study. The functional outcome assessment according to Constant Murley Scoring system showed excellent functional outcome in 75% and good functional outcome in 25% of the patients.

Introduction: A thorough knowledge of the vital structures adds to the safety in approaching the cervicothoracic spine junction. The best described method to reach the spine is via viscero-neurovascular space. We present our experience of 10 cases operated at our institute using the modified transclavicular transmanubrial approach to the cervicothoracic spine pathology.As we gained experience we have used various corridors to the operating field and used a new space to approach the lower cervicothoracic junction spine. Methods: Between February 2011 to August 2015, 10 patients with disease in upper thoracic vertebral body were admitted and evaluated clinically and radiologically. Neurological status in all cases was graded according to Frankel grading system.Patients were followed up with Histopathological reports and treated accordingly. Results: All patients(except metastasis) improved by 1 or 2 grade in post op period. Metastasis patients remained in same grade. Conclusion: Anterior approach with its modifications are the better suited biomechanically for exploring the pathology of cervicothoracic spine,its decompression and stabilization. Also it preserves the stability of shoulder girdle with good neurological and cosmetic outcome.

In the nonoperative treatment of degenerative rotator cuff (RC) tears, exercise therapy is advocated. Exercises focusing on strengthening the anterior deltoid (AD) and the scapular muscles are proposed to compensate for RC dysfunction. However, the amount of electromyographic (EMG) activity in these muscles during these exercises remains unclear. Moreover, it is unknown whether muscle activity levels during these exercises alter with increasing age. Therefore, the purpose of this study was to evaluate EMG activity in the deltoid and scapular muscles during 2 series of commonly used shoulder rehabilitation exercises and assess possible age-related changes in muscle activity.Fifty-five healthy participants (aged 18-60 years) participated in this study. Surface EMG activity was measured in 8 shoulder girdle muscles during a progression of a closed chain elevation program (bench and wall slides) and during a progression of previously published AD exercises. In addition, muscle activity was compared between 3 age categories (18-32 years, 33-46 years, and 47-60 years).The proposed progressions exhibited increasing activity from10% of maximal voluntary isometric contraction to20% of maximal voluntary isometric contraction for the AD for both exercise programs and for the middle deltoid, upper trapezius, and middle trapezius during the closed chain elevation exercises. Activity levels in the other muscles remained20% throughout the progression. Age-related analysis revealed increased activity in the AD, infraspinatus, and middle trapezius and decreased lower trapezius activity during the bench and wall slides. No age-related changes were noted for the AD exercises.These findings may assist the clinician in prescribing appropriate progressive exercise programs for patients with symptomatic RC tears.

Lipoma is slow growing tumors and often occurs under the skin on the neck, shoulders,arms, back, abdomen and thighs. However, occasionally lipoma may be present in deep locationor originate within muscle.Lipoma affected only 1% of population, and commonly found in adults and is higher in manthan in women. The most common benign mesenchymal tumors composed of fat cell of adulttype, diffused or encapsulated type. Surgical removal is indicated when causing trouble assite, size, appearance and presence of pain. The study was carried on 35 male patients presentedby lipoma around shoulder girdle operated in Kobry El-Kobba Military Medical Campus.The patients were divided into four groups, G1:25 patients with primary subcutaneous lipoma,G2: 8 patient with subscapular lipoma, G3: 1 patient with giant submascular left shoulderlipoma, and G4: 1 patient with giant subscapular lipoma “diagnosed before operation”including complete surgical excision was done under general anesthesia in all the patientswithout any recurrence.

Background Facioscapulohumeral muscular dystrophy (FSHD) is a rare condition affecting 1/20,000 persons and the third most common muscular dystrophy condition, with an autosomal dominant pattern of inheritance characterized by progressive muscular weakness primarily involving the face, shoulder girdle, and upper arm. The condition is associated with atrophic musculature of the trunk and core leading to difficulties with gait, posture, and function. FSHD leaves as many as 20% of patients wheelchair-bound and most commonly presents with low back, neck, and shoulder pain. Case Description We present the case of a patient with FSHD who underwent multiple spinal fusion surgeries without relief in her back pain. Imaging studies serve to highlight the extent of paraspinal muscle atrophy and provides the basis for a discussion on the preoperative factors that may predict patients most likely to benefit from surgery. We then provide a brief review of the literature on the role of paraspinal muscle atrophy in back pain. Conclusions This case adds to our understanding of the surgical management of patients with FSHD and patients with atrophic core musculature as a whole.

Sternoclavicular joint (SCJ) instability is a rare condition and results from either a traumatic high energy impact, such as a motor vehicle crash or contact sports injury, or non-traumatically as a result of structural pathology. The infrequency of this injury has contributed to its diagnosis being missed as well as the paucity of literature on treatment and outcomes. Patients with SCJ instability often report diminished range of motion as well as shoulder girdle pain. The presentation of instability in the sternoclavicular joint can vary in severity and anterior or posterior directionality. Variation in severity of the instability changes the course of treatment regarding either operative or non-operative interventions to stabilize the SCJ. In general, anterior instability of the SCJ (the medial clavicle is displaced anterior to the sternum) is less urgent and generally manageable by symptom alleviation and rehabilitation, although some anterior instability cases require surgical intervention. In the case of posterior SCJ instability (the medial clavicle is displaced posterior to the sternum), patients require prompt joint reduction as they are at the greater risk of life-threatening injury due to the location of critical structures of the mediastinum posterior to the SCJ. Computed tomography visualization is useful to confirm dislocation or subluxation direction to better formulate a proper treatment plan. The purpose of this review is to report the clinical presentation and management of SCJ instability including pertinent symptoms, the diagnostic approaches to evaluating SCJ instability, as well as operative and non-operative management of the joint instability.

Periprothetische Frakturen des Schultergurtels werden aufgrund der deutlich gestiegenen Implantationszahl von Schulterprothesen und des demographischen Wandels zunehmend Teil des klinischen Alltags. Diagnostisch sind neben dem Status der Rotatorenmanschette und dem einliegenden Implantat insbesondere der Infektausschluss und der Sitz der Prothese (stabil oder gelockert) fur die Therapie ausschlaggebend. Technische Neuerungen wie das Dual-Energy-Computertomogramm bieten hier verbesserte Planungsmoglichkeiten. Das Unified Classification System beschreibt die Frakturlokalisation, Qualitat des Knochens und Stabilitat der Prothese. Wahrend die konservative Therapie Patienten mit schweren Vorerkrankungen und geringer Dislokation vorbehalten ist, sind bei festem Prothesensitz die Fixation mittels Cerclagen und winkelstabilen Platten moglich. Moderne Implantatsysteme mit polyaxialer Winkelstabilitat, Flugelplatten oder „attachment plates“ bieten verbesserte Verankerungsmoglichkeiten. Bei gelockertem Prothesenschaft ist die Implantation einer Revisionsendoprothese notwendig. Aktuell beschreiben nur wenige Studien mit geringer Fallzahl klinisch-radiologische Ergebnisse, sodass gesteigerte Forschungsanstrengungen zur Verbesserung der Behandlungsqualitat und Vergleichbarkeit der Therapieoptionen unabdingbar sind.

Background The ball impact position during spiking in volleyball may influence the pattern of activation of shoulder girdle muscles and, therefore, could be a significant risk factor for shoulder injury. Methods Activation of 10 muscles in the dominant shoulder was evaluated using surface electromyography (EMG) in 11 male volleyball players, during spiking in a static standing position, with the goal being to precisely control the specified ball impact positions, without a run-up or ball setting. The following 4 ball impact positions were evaluated: standard, posterior, medial, and lateral. The EMG amplitude, normalized to the maximal voluntary isometric contraction of the respective muscles, was compared for each phase of the spiking movement between the standard position and the other 3 different impact positions, using the Dunnett test. Results The following between-position differences were noted for the deltoid muscle: increased activation of the anterior deltoid during the acceleration phase for the posterior position (P = .041), increase in the posterior deltoid during the acceleration phase for the lateral position (P = .04), and increase in the middle deltoid during the deceleration phase for the lateral position (P = .005). Conclusion A posterior or lateral shift in the position of ball impact may cause an increase in the activity of the deltoid muscle that would cause a decrease in the centripetal force of the humeral head through the acceleration and deceleration phases. As such, neuromuscular exercises, combined with strengthening of the rotator cuff muscle, might reduce the risk of shoulder injury during performance of the volleyball spiking movement.

Until now, classifications of coracoid fractures have been based on plain radiographs, without use of 3D CT reconstructions. Therefore, the aim of the present study has been to describe the pathoanatomy of these fractures and their associated injuries to the shoulder girdle, on the basis of 3D CT reconstructions. The cohort comprised 39 patients, who each sustained a coracoid fracture investigated with 3D CT reconstructions. The patients were assessed in terms of age, gender, pathoanatomy of the coracoid fracture, fractures of other parts of the scapula, and associated injuries to the shoulder girdle. We identified 24 fractures of the base, one fracture of the beak body, eight fractures of the apex, and six comminuted fractures of the coracoid process. A total of 22 associated injuries were found (7 fractures of the acromion, 5 fractures of the anterior glenoid rim, 3 fractures of the superior glenoid, 1 fracture of the inferior glenoid, 4 fractures of the surgical neck, 2 fractures of the scapular body) and 18 other associated injuries to the shoulder girdle (8 AC dislocations, 5 proximal humeral fractures, and 5 clavicular fractures). On the basis of 3D CT reconstructions, four basic coracoid fracture patterns were identified. The authors´ findings and literature review have shown that a considerable number of coracoid fractures are combined with injuries to other parts of scapula and shoulder girdle. These associated injuries must be taken into account and targeted when taking the patient’s history, and during clinical and primarily radiological examinations.

The Tikhoff-Linberg procedure is a limb salvage technique for tumours of the shoulder girdle which preserves function of the hand and elbow; however, shoulder function is limited. A humeral cap endoprosthesis (Stryker Orthopedics, Mahwah, NJ, USA) was developed within the Modular Replacement System (MRS) to act as a functional spacer for these defects; however, the outcomes of this implant have not been described. Thirty-three (17 male, 16 female) patients underwent a Tikhoff-Linberg procedure at our institution. Of these, 17 (11 females, 6 males) were reconstructed with a MRS humerus endoprosthesis. Outcomes and complications were compared between patients who were reconstructed (n = 17) and those who were not (n = 16). Complications occurred in 14 (42%) patients, with more complications in patients who were reconstructed (n = 11, 65% vs. n = 3, 19%, p = 0.01). Endoprosthetic complications included stress shielding of the bone/prosthesis interface (n = 7, 41%) and subluxation/instability (n = 5, 29%), leading to a revision surgery in two (12%). Post-operatively, the mean Musculoskeletal Tumor Society Score (MSTS93) was 67 ± 11%, with no difference in the mean MSTS93 between patients who were reconstructed and those who were not (67 ± 10% vs. 68 ± 12%, p = 0.77). Reconstruction with a MRS humerus cap endoprosthesis resulted in a high rate of complications following a Tikhoff-Linberg procedure. Stress shielding and subluxation were common, and as such, the use of this prosthesis is limited to cases where a standard implant is not a feasible option.

Back ground and objectives: Clavicle fracture accounts for approximately 2.6% of all the skeletal fractures. These fractures are often associated with shoulder girdle injuries in approximately 44% of cases. Non operative treatment has been a mainstay of a modality of treatment, and irrespective of the type of fracture and amount of comminution, all these fractures were treated non-operatively. Different surgical methods for clavicle midshaft fractures have been described and these are locking compression plate fixation, intramedullary K-wires, Steinmann pin fixation, and intramedullary nailing with TENS. Therefore in this study we have compared the functional outcome of displaced clavicle fractures treated by non-surgical management with that of surgical management by TENS and by open reduction and internal fixation with clavicular locking compression plate. Methods: 60 patients with clavicle fractures presenting to the Orthopaedic Department of R L Jalappa hospital from Nov. 2017 to April 2019 are included in the study after obtaining informed consent. Result: Among 60 patients with clavicle fractures, majority of the injury occurred in male patients- 45 cases (75%), whereas a total of 15 cases (25%) were seen in females. The functional outcome at the end of 6 months in 30 conservatively managed cases showed, 4 cases (13.3%) with excellent outcome; 6 cases (20%) had good outcome. 16 cases (53.3%) had fair and 4 cases (13.3%) had poor outcome. While in surgically managed 30 cases, the functional outcome at the end of 6months showed a total of 23(76.6%) cases with excellent outcome, 4 cases (13.3%) had good outcome 2 cases (6.6%) had a fair, and 1 case (3.33%) had poor outcome. At the end of 6 months, functional outcome of both the groups were compared by applying chi square test, the p value was

Introduction. Despite the developments, up to now, such questions as the effectiveness of surgical treatment of Sprengel's deformity in children older than 7 years; elimination of the cosmetic defect caused by scapular hypoplasia and shoulder girdle shortening; and prevention of neurological disorders caused by the brachial plexus compression remain debatable.Objective. Effectiveness evaluation of surgical treatment of Sprengel's deformity in patients of various age groups, and the improvement of the results of surgical correction of high scapula.Materials and methods. Treatment data of 14 patients with high scapula were analyzed. To compare the effectiveness evaluation of surgical treatment, patients were divided into 2 groups: I group - 6 children (42.8 %) aged 4 to 8 years; II group - 8 children (57.2 %) aged 9 to 16 years. During examination, the active and passive shoulder abduction alongside with its rotation was measured in degrees. Shoulder girdles length and the size of transverse and longitudinal scapula bodies were measured in the radiographs of both shoulders. Diameters of the articular surface and the head of the shoulder were determined.Results. Analysis of the clinical manifestations of the disease showed that diagnosis in children under 2 years of age was noted only in 2 (14.3 %) cases with a bone form of the disease. Deformity in other patients was regarded as a manifestation of scoliosis, an anomaly in the development of the cervical spine according to the Clinnel-Feil type, the presence of cervical ribs, and a benign bone tumor. Restriction of shoulder abduction was a symptom that drew parents’ attention. All patients underwent surgery. Analysis of the results of surgical treatment of two groups of patients showed that the scapula position along its lower corner corresponded to the opposite side in the first group of patients. There was symmetry in the position of the spine of the scapula. All patients of the first group had shortening of the shoulder girdle due to the decrease of scapula lateral size, which ranged from 2.5 to 3 cm, depending on the age of the patient. Further observation over the next 2 years showed that the difference in the scapula transverse size decreased to 1.2-1.5 cm in 5 (35.7 %) cases. Scapula transverse size before surgery was reduced from 3.1 up to 4.5 cm. in patients of the second group, depending on the form of Sprengel's deformity. 6 months after the operation, scapula position in its lower corner was equal to the indices of a healthy half of the body. Therefore, a comparative analysis of the anatomical data during the follow-up period after surgery up to 2 years showed that patients of the first age group had a tendency to improve indicators of scapular size and shoulder length. Analysis of the shoulder joint function in the form of shoulder abduction showed that its average increase was 700 in patients of the first group, and only 500 in patients of the second group.Conclusions. Surgical treatment of high scapula gives a positive result in children older than 7-8 years in the form of cosmetic defect elimination and some improvement in the range of shoulder joint motion. Functional indicators in children of a younger age group are better, however, lagging in scapula growth and shortening of the shoulder girdle is possible. Sharp shortening of the shoulder girdle while pulling shoulders back can be corrected by lengthening the spine of the scapula with the help of osteotomy method and replacing the defect with a bone allograft.

Background Osseous tumors of the shoulder girdle occur most frequently in the proximal humerus, scapula and clavicle. Prior studies have determined that tumors occurring in the scapula have a higher risk of malignancy, but few have looked exclusively at tumors of this site to describe incidence, clinical features and potential predictors of malignancy. As imaging technologies for diagnosis have improved, it is important to re-evaluate if patterns of incidence have changed and if new imaging findings could potentially be predictors of malignancy. Methods This retrospective analysis identified 173 patients from a pediatric and an adult hospital between 1990 and 2015. All patients with tumors of the scapula either of bony origin or with bony invasion were included. Diagnosis, tumor location, and patient demographics were collected. Bivariate and logistic regression analyses were performed to identify potential predictors of malignancy. Results Chondrosarcoma and osteochondroma were the most common malignant and benign tumors, respectively. Benign tumors were more prevalent in the pediatric population. Tumors occurred most frequently in the body of the scapula. Risk for malignancy increased with age (OR 1.09, 95% CI 1.05–1.12), tumors invading multiple sites (OR 10.85, 95% CI 2.37–49.72) and tumors that were lucent (OR 7.02, 95% CI 1.14–43.21) or had a mixed radiographic appearance (OR 11.47, 95% CI 1.36–99.65). Conclusions Including neoplasia in the differential diagnosis for shoulder complaints is important because the scapula is a site of increased risk of malignancy. Patterns of incidence and prevalence have not changed in the last years with the use of more advance techniques of imaging studies. Older age, lucent or mixed imaging, and tumors that span multiple sites of the scapula were found to be predictors of malignancy. Additional cross-sectional anatomy studies may be warranted for further evaluation in patients presenting with these characteristics given the higher concern for malignant disease. Level of evidence Level IV, Prognostic Study.

Highlights • The incidence of combined proximal humerus fracture and acromioclavicular joint injury is rare. • High energy trauma can injure more than one structure. • In shoulder joint injury, the surgeon can avoid missing a related injury by investigating the patient in the upright position., Introduction Both the proximal humerus fracture and the acromioclavicular (AC) joint injury are commonly found in shoulder girdle injuries but there are no reports of them presenting together. The mechanism of the AC joint injury is similar to that of the proximal humerus fracture, a lateral impact to the shoulder girdle, but the arm positions are different, as the AC injury usually involves an adducted arm while the proximal humerus fracture normally occurs with the arm in a neutral position. Herein we report, to our knowledge, the first case of a combined proximal humerus fracture and AC joint injury. Case presentation A 40-year-old Thai male presented with right shoulder pain after a motorcycling accident. He was diagnosed as a proximal humerus fracture (Neer 4-part fracture). Open reduction and internal fixation with a Philos plate (Synthes®) in the supine position were then performed. However, an AC joint injury (Rockwood type III) was then noticed on the post-operative X-ray taken in the upright position. We had missed the AC joint injury because all pre-operative imaging had been done only in the supine position. Conclusion The combination of these two fracture types is uncommon and has not been previously reported. Our report suggests that in cases of a proximal humerus fracture resulting from a high-energy mechanism, the surgeon should obtain an X-ray or perform fluoroscopy with the patient in the upright or semi-upright position before surgery to avoid missing an AC joint injury.

Highlights • Posterior sternoclavicular joint fracture-dislocations are a rare and often-missed injury in trauma. • Posterior displacement at the SCJ is a true emergency and can be associated with compression of vital structures and thoracic outlet syndrome. • Closed or open reduction of these injuries is generally advised but is associated with considerable risk. • Conservative management can be successful in the presence of physeal injury but has never been described in the setting of thoracic outlet syndrome., Introduction Posterior sternoclavicular joint fracture-dislocations are a rare and often missed diagnosis. They represent

Sternoclavicular joint (SCJ) dislocation is a rare but serious orthopedic injury. Posterior dislocations are more concerning due to the SCJ's proximity to visceral structures such as the trachea, esophagus, subclavian vessels, and brachial plexus. Due to the potential long-term sequelae of missed diagnosis, clinical suspicion should be high when a patient presents with a compression-type injury to the shoulder girdle and pain or deformity to the SCJ. Here we present a case of a 15-year-old soccer player who presented to the emergency department (ED) after a fall onto his right shoulder with additional compound injuries. A posterior SCJ dislocation diagnosis was suspected and confirmed after a computed tomography scan. A successful closed reduction was done in the ED after consultation with cardiothoracic and orthopedic surgery. This case adds to the body of literature describing diagnosis and management of posterior SCJ dislocations.

Background: Fractures of the clavicle record for practically 50% of all injuries in the shoulder girdle. In recent years, the treatment paradigm for clavicle fractures has shifted from nonoperative treatment toward operative treatment, especially in fractures with significant displacement or shortening. Case Report: A 16 years old female presented to the emergency room with an injury on her right shoulder after a motorcycle accident. The radiograph showed a displaced midshaft clavicle fracture, classified as Robinson 2B1. Operative measures were performed using intramedullary K-Wire. Discussion: There is no universally agreed gold standard for clavicle fracture fixation. The majority of midshaft clavicle fractures with a displaced fragment can be successfully repaired without surgery. On the other hand, conservative therapy of Robinson type 2B clavicle fracture has been linked to a higher rate of nonunion and a decrease in strength and endurance of the shoulder. In this patient, on the two-week follow-up after wire removal surgery, the patient regained full shoulder range of motion without any limitation on activities of daily living with a minimal post-operative scar. Conclusion: We recommend that intramedullary fixation using K-wires is a useful technique in displaced midshaft clavicle fracture as it is effective, has a good cosmetic outcome, and is well-suited for the BPJS era as it had the low-cost burden.

Case A 21-year-old woman with a history of multiple failed surgical and conservative management for recurrent involuntary shoulder instability presented with 1-year history of shoulder pain. Physical examination demonstrated intractable static anterior glenohumeral instability, deficient capsular tissue, with reducible scapular winging secondary to long thoracic nerve palsy. Allograft capsular reconstruction and open split pectoralis major tendon transfer were performed to salvage shoulder motion and stabilize her shoulder girdle. Conclusion This report presents a novel repair option for intractable shoulder instability and scapular winging. Surgeons should recognize potential causes of shoulder instability and familiarize themselves with multiple stabilization techniques as potential salvage options before glenohumeral fusion.

Septic arthritis of the smaller acromioclavicular joint is uncommon, with only a few reports and case series available in the literature. The aim of this outcomes analysis was to determine the prevalence of shoulder girdle septic arthritis within the authors' institution, with a particular focus on describing the authors' experience with acromioclavicular joint septic arthritis. A retrospective outcomes analysis was conducted of patients admitted to a single tertiary referral center from 2008 to 2018 with acromioclavicular joint septic arthritis. Demographic and clinical data were recorded for each patient; the modified Frailty Index score was calculated for each patient. Nine patients were identified as having acromioclavicular joint septic arthritis, making up 12% of shoulder girdle septic arthritis. Diabetes mellitus was the most prevalent comorbidity, present in 4 (44.4%) patients. Staphylococcus aureus was responsible in 55.6% and Streptococcus species in 44.4%. Seven patients were treated surgically. Mean (SD) length of antibiotic therapy was 6.2 (2.7) weeks. Mean (SD) length of stay was 6 (2.83) days (range, 4–8 days) for patients who received antibiotic therapy only and 12.7 (7.52) days for those who proceeded for operative management. Mean modified Frailty Index score was 1.1. Septic arthritis of the acromioclavicular joint is an uncommon infection that occurs both in patients with impaired immunity and in those with intact immune systems. Tailored antimicrobial therapy in conjunction with surgical intervention, when indicated, appears to result in successful suppression or eradication of infection in the majority of cases. [ Orthopedics . 2021;44(4):e493–e497.]

Design Presentation of clinical cases and literature analysis. Material and methods Clinical observation of patients with congenital cervical spine and shoulder girdle anomalies operated on with neuromonitoring was performed. Operative treatment of Sprengel’s deformity was produced with the use of neuroimaging. Results Surgical treatment resulted in good clinical outcomes without neurological adverse events and good aesthetic and radiological appearance at the descended scapula. Discussion Consideration for intraoperative neuromonitoring should be given to prevent neurological complications at lowering the elevated scapula. Conclusion Review of outcomes showed efficacious application of the most valid methods used to descend the scapula with neuromonitoring. This was supported by clinical and radiological findings of the extent of cranial transposition after appropriate correction and absence of neurological adverse events early postsurgery and at a long-term follow-up. No recurrence of scapular dislocation was observed at a long-term follow-up.

Scapular fractures are relatively uncommon fractures, which often are a result of high-energy trauma. The majority of fractures of the scapula can be successfully treated without operation and require a short period of immobilization before physiotherapy to regain function. The indications for surgery are based on the general principles of trauma surgery; to reduce significant intra-articular fractures and restore the necessary alignment of extra-articular fractures. There is an absence of compelling studies that define the threshold for surgical intervention, making the treatment of these fractures difficult. This is further complicated by the complexity of the structures which interact with the scapula to allow the shoulder girdle to function. In this article, the anatomy and fracture patterns which affect the scapula and treatment options, will be discussed.

Objective . To assess risk factors for the imbalance of the shoulder girdle and to identify reproducible X-ray criteria for persistent shoulder imbalance after correction of idiopathic scoliosis. Material and Methods . A total of 94 patients with idiopathic scoliosis were included in the retrospective study. All patients underwent primary posterior correction of the deformity using pedicle screw instrumentation. Radiography of the spine throughout its length was performed before surgery, in the early postoperative and in the long-term (at least 12 months after surgery) periods. The shoulder imbalance was considered clinically significant with radiographic shoulder height difference more than 2 cm. Results . A significant decrease in the magnitude of all curves after surgery and in the long-term period was noted. The magnitude of the proximal curve decreased from 25.38° ± 15.89° to 14.51° ± 8.17° (p < 0.0001) and to 14.29° ± 8.25° (p = 0.24); the main thoracic curve from 59.33° ± 20.76° to 20.096° ± 9.89° (p < 0.0001) and to 20.87° ± 9.48° (p = 0.19); and thoracolumbar curve from 47,20° ± 15,99° to 15.69° ± 8.66° (p < 0.0001) and to 16.98° ± 7.6° (p = 0.01), respectively. The shoulder imbalance was recorded in 27 patients (28.72 %) after surgery and in 13 (13.83 %) – in the long-term period. In these patients, various Lenke types of deformity were presented. A correlation of the distal adding-on phenomenon with self-correction of the shoulder balance is revealed (r = 0.56; p < 0.005). Persistent shoulder imbalance correlated with presence of a structural proximal thoracic curve (p = 0.041642), residual proximal curve magnitude after surgery (r = 0.22; p = 0.03), and presence of a symptom of double rib hump on radiographs after surgery (r = 0.75; p ≤ 0.005). Conclusion . The most characteristic pattern of persistent shoulder imbalance is the presence of asymmetry in the proximal and main regions of the chest. This sign can be detected by intraoperative lateral radiography of the spine, which will allow the surgeon to take measures to eliminate this phenomenon and reduce the probability of persistent shoulder imbalance development.

Background Improved knowledge of normal shoulder girdle proprioception should benefit the treatment and rehabilitation of shoulder disorders. Whereas many of the available methods for assessing joint position sense (JPS) are costly and complex, Balke et al. have described a simple test. The primary objective of this study was to use this test to identify factors that influence shoulder-girdle JPS evaluation in healthy individuals. The secondary objective was to determine reference values based on the values obtained and on the factors associated with their variability. Hypothesis Age and dominant limb influence the results of shoulder girdle JPS evaluation, creating a need for reference values that take these factors in account. Patients and methods A single-centre prospective study of healthy volunteers was performed between September 2012 and January 2013. In each volunteer, shoulder repositioning accuracy was assessed bilaterally as described by Balke et al. A line was drawn on the floor parallel to and 1 metre away from a wall. A target on the wall showed marks corresponding to three angles of arm elevation: 55°, 90°, and 125°. The volunteer was asked to raise the arm to the three positions, in abduction and in flexion, while memorising the joint positions, then to replicate the same positions with the eyes closed. The absolute differences between the replicated positions and the reference positions, designated angle deviations, were measured in degrees. Age, sex, and dominant upper limb were recorded. Results The 88 shoulders of 44 healthy volunteers were studied. No significant difference was found between males and females (p > 0.05). The only significant difference between sides was better replication by the dominant arm of flexion at 55° (p = 0.03). By univariate analysis, age was the only factor significantly associated with repositioning errors (p = 0.003); neither dominant limb nor sex were significant (p = 0.29 and p = 0.59, respectively). In flexion, the angle deviation increased significantly with movement amplitude. The measurements were used to create a chart of expected angle deviations in healthy individuals according to age and to plane and amplitude of movement. Discussion The test described by Balke et al. is simple and feasible in everyday practice. Age, dominance, and plane of movement should be considered when evaluating abnormal shoulders. Further studies in larger numbers of individuals are needed to better define normal angle deviations related to these factors. Level of evidence IV.

Background Shoulder impingement syndrome is considered to be associated with an altered muscular activity, which is related to strategy changes in the movement plan. The present study aimed to investigate the differences in timing and intensity of activity of shoulder girdle muscles while performing a forehand topspin loop between elite table tennis players with and without shoulder impingement syndrome. The timing and activity amplitude of these shoulder girdle muscles have not been evaluated in other studies in table tennis elite athletes. Methods Activation timing and activity levels of the upper trapezius, lower trapezius, and serratus anterior, anterior deltoid, supraspinatus, and biceps brachii muscles were measured in 30 table tennis players (Premier League tournament level or higher) with shoulder impingement syndrome and compared with 30 same-level healthy players while performing the forehand topspin loop. Results The results indicated that the activity levels of the serratus anterior (P = .007) and supraspinatus (P = .001) muscles significantly decreased; however, the activity level of the upper trapezius significantly increased in the impingement compared with the healthy group (P = .009). The serratus anterior (P = .001) was activated significantly later, but the upper trapezius (P = .004) was activated significantly earlier in the impingement group. Conclusion Results of the present study support the theory that the activation and sequence of recruiting of the shoulder muscles are altered in people with impingement symptoms, suggesting that impingement syndrome may be associated with disturbed timing and activity level of shoulder girdle muscles.

Objective Different classification systems for surgical tumor resections in the proximal humerus and scapula have been described, but none are specific or have been recently revised. The purpose of this article is to report modified surgical techniques and a new classification system for resections in the humerus and scapula. Methods Thirty-two patients with shoulder girdle bone tumors were operated upon. Two separate new classifications were assigned to resections in the humerus (types I–IV) and scapula (types I–III). An annotation is added to signify deltoid preservation (A) or sacrifice (B). Modified surgical techniques were devised. Results For extra-articular resections of the proximal humerus, we show that sacrificing the acromion and coracoid process is not required. Preservation of these structures can improve cosmetic shoulder outcome. For tumors with no large medial component, we show that there is no need to detach the muscle attachment from the coracoid process allowing earlier elbow extension postoperatively. After a mean follow-up period of 46 months, only two patients developed local recurrence. Postoperative infection was seen in two and stem loosening in one patient. The average MSTS functional score for all patients was 83%. Conclusion Our modified surgical techniques saved structures which were unnecessarily resected with no advantage in surgical series. We reserved the integrity of more muscular tissues and attachments leading to less restriction during the rehabilitation process. This new classification system is realistic, easy to implement, and applicable to all patients.

Purpose of the study. Evaluation of the results of surgical treatment of desmoid fibroids (DF) using reconstructive plastic surgery and determination of possible prognostic factors of relapses.Patients and methods. The results of surgical treatment of 40 patients with desmoid fibroids of extra abdominal local­ization were analyzed. In 45% of patients, the tumor was located in soft tissues of the shoulder girdle and upper limb, in 35% — on the trunk, in 20% — in soft tissues of the lower limb and in 7% of patients on the neck. The tumor size varied from 2 to 20 cm, the median was 8 ± 4.38 cm. Surgical treatment for newly diagnosed DF was performed in 22 (55%) patients, and for recurrent tumors — in 18 (45%) patients.Results. According to the planned histological study, negative resection boundaries were established in 24/40 patients (63%). In the remaining 16 cases (37%) positive resection margins were obtained: R1 in 14 patients and R2 in 2 patients. Adjuvant treatment is recommended for 14 patients with resection R1/R2. The duration of follow — up after treatment ranged from 6 to 107 months, median‑16.5 months. During follow-up, relapses were diagnosed in 14 patients (35%). No deaths have been reported.Conclusion. Surgical treatment of DF of extraabdominal localization is accompanied by a sufficiently high frequency of relapses. According to the results of the study, an unfavorable factor in the development of relapses is the location of the tumor in soft tissues of the shoulder girdle and upper limb.

Background: Clavicle fractures account for approximately 2–4% of all adult fractures and about half of all fractures in the shoulder girdle. Conservative management poften leads to cosmetic deformities, complications such as axillary pressure sores, upper extremity edema and venous congestion, brachial plexus palsy, worsening of deformity and increased risk for non-union. There are two commonly performed surgical techniques used to repair displaced midshaft clavicle fractures, open reduction and plate fixation and intramedullary nailing. The present study was conducted to evaluate the end results of Mid shaft clavicle fractures treated in Tertiary Care Centre by various surgical modalities and to evaluate the effectiveness of the different modalities of the treatment and their complications.Materials and Methods: The present study was a Randomized, Prospective study carried out from October 2016 to March 2018 among patients admitted with midshaft clavicle fractures operated with intramedullary nailing and Open reduction and internal fixation with plating, patients were selected which were operated during the study duration at Orthopaedics Department in Krishna Hospital and Medical Research Centre attached to Krishna Institute of Medical Sciences Deemed University, Karad, Satara.Results: It was observed that majority of patients in Group P (56%) had excellent outcome followed by good outcome (44%) according to DASH Score. In group I, 15 (60%) patients had good outcome followed by fair outcome (36%).However Group I showed poor outcome (4%). The difference among outcome in both groups showed no statistical significance. (P>0.05).Conclusion: Plate fixation for severely displaced comminuted midshaft clavicle fractures provides excellent results in terms of rigid fixation, rotational stability and maintenance of anatomical length. Intramedullary nailing of simple midshaft clavicle fractures provides a similar result in terms of quick return to activities with a very good cosmetic outcome.

Introduction Idiopathic brachial plexus neuritis or neuralgic amyotrophy is a rare neurological condition whose true etiology currently remains unknown. Epidemiologically, the incidence of this condition is exceptionally rare with only 1.6 cases for every 100,000 people (Turner and Parsonage, 1987). Symptoms present an initial acute and sudden pain to the shoulder girdle and upper arm which is followed by a sense of profound weakness and numbness to the upper arm (Parsonage and Turner, 1948). Localized neuropathy within the arm-pit region may also be presented. The pain often exacerbates upon movement of the shoulder. Due to the anatomic location affected and the nature of the clinical symptoms presented, accurate diagnosis of brachial plexus neuritis poses a challenging diagnostic task for physicians due to remarkably similar symptoms expressed by differential diagnoses. Presentation of case Here, we report the case of a 55-year-old woman who underwent surgery entailing cervical laminectomy with instrumented fusion. She presented with postoperative symptoms of severe pain in the left arm with significant weakness within 24 h after surgery. A diagnosis of brachial plexus neuritis was made based on the symptoms presented and upon review of imaging scans. Discussion After a six-month follow-up visit, the patient recovered from the brachial neuritis but has residual numbness in the hand. The presentation of this case serves to transmit three fundamental purposes. First, this case serves to establish an intriguing possible association of the post-surgical period of cervical laminectomy with acute brachial neuritis and signifies the importance post-operative linkage with brachial neuritis in general. Second, this case also highlights the importance of close clinical monitoring of patients with unique symptoms within the postoperative follow-up period to ensure successful improvement and accurate diagnosis. Conclusion As an underdiagnosed and relatively obscure condition, this case serves as an imperative reference for physicians to illuminate differential diagnosis of similar symptomatic conditions and also to promote knowledge of brachial plexus neuritis which can lead to an early and precise diagnosis.