PMC8282161_01
Pre-operative radiographs of right shoulder showing Hamada 3 rotator cuff tear arthropathy. A, Grashey (Glenoid AP) view. B, Axillary view.
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She exhausted non-operative management including activity modification, oral anti-inflammatories, physiotherapy and multiple corticosteroid injections (Figure 1).
Post-operative right shoulder x-ray demonstrating reverse total shoulder arthroplasty.
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In October 2013, a RTSA procedure was completed (Biomet Comprehensive Reverse Shoulder prosthesis (Biomet Inc, Warsaw, Indiana, USA) with a 6-mm mini cemented stem, 28-mm glenoid baseplate, 36-mm standard glenosphere (Versa-Dial between position B and C providing a 2 mm inferior offset) and a standard 44-mm humeral tray with a 36-mm polyethylene humeral cup was implanted (Figure 2).
Right clavicle demonstrating a displaced mid-to-distal third shaft fracture AP view at 1 week post fall.
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Repeat radiographs demonstrated an isolated mid-to-distal one-third clavicle shaft fracture without any evidence of prosthetic loosening or change in position of her RTSA implants (Figure 3).
Failure of non-operative management. Right clavicle x-ray demonstrating fracture non-union AP view at 6 months post fall.
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On serial reassessments, the fracture failed to demonstrate healing on standard clinical and radiographic examinations and she subsequently developed a chronic symptomatic non-union of her right clavicle fracture (Figure 4).
Superior scapular tilt with an increase in upward rotation angle of the scapula. A, One week post fall with scapular tilt 16.6 degrees. B, One-month post fall with scapular tilt 24.8 degrees. C, Post clavicle ORIF with scapular tilt 19.3 degrees. Scapular measurements were taken according to Endo et al.

 using a shoulder AP radiograph. Two landmarks were used create the scapular spine line and included 1) the interface between the upper border of the scapular spine and the acromio-clavicular joint and 2) the most medial aspect scapular spine. The angle between the scapular spine line and the horizontal (reference line that is parallel to the floor) represented the upward rotation angle.
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The scapula had a notable increase in superior tilt, as demonstrated with increasing upward rotation angle with scapular measurements taken according to Endo et al.   and shoulder AP radiographs (Figure 5), in addition to scapular notching and exposure of the inferior base plate screw compared to her initial postoperative imaging (Figure 6).
Right shoulder AP x-ray and CT scan coronal views at 5 months following clavicle fracture demonstrating scapular notching + superior scapular tilt.
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The scapula had a notable increase in superior tilt, as demonstrated with increasing upward rotation angle with scapular measurements taken according to Endo et al.   and shoulder AP radiographs (Figure 5), in addition to scapular notching and exposure of the inferior base plate screw compared to her initial postoperative imaging (Figure 6).
Post-operative right clavicle x-rays at 4 months after anatomic reduction and internal fixation. A, AP view. B, Lateral scapular (Y view). C, Axillary view.
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At her 4 month post-operative follow-up, her fracture had healed, both clinically and radiographically (Figure 7).
A, Initial 2 week post-operative RTSA x-ray pre-injury. B, Scapular notching with serial Grashey views in a RTSA after clavicle fracture. C, Six weeks post-operative ORIF. D, Ten months post-operative ORIF with restoration of scapular tilt comparable to pre-injury x-ray.
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There was no further progression of her superior scapular tilt or scapular notching (Figure 8).