Scapulothoracic disruptions are severe injuries usually resulting from high-energy trauma. They may involve the scapular body, spine, lateral border, and acromion and are often associated with chest wall or clavicular injuries. These injuries compromise shoulder mechanics and require stable reconstruction to prevent chronic dysfunction. While isolated scapular plating and acromial fixation have been described individually, there is limited documentation of cases managed with both dual-column scapular plating and acromion tension band wiring in the same setting. To the best of our knowledge, this is the only case report presenting such a scenario demonstrating excellent radiographic and functional results following comprehensive surgical intervention.

A 43-year-old right-hand-dominant male was brought to our institute following a high. Initial evaluation revealed extensive scapulothoracic injury with displaced fractures of the left (non-dominant side) scapular body, lateral column, and acromion process (Fig. 1) without any vascular or neurological deficits (Type 1, Zelle et al. ^[1]). Computed tomography scans confirmed significant disruption of the scapular architecture with lateral displacement of more than 2 cm and shortening, as well as fracture of the acromion (Fig. 2).

Informed consent was taken from the patient and his relatives, following which he underwent surgical stabilization. Through the Judet approach, after elevating the infraspinatus muscle from the infraspinous fossa and retracting it laterally, the posterior aspect of the scapula was exposed in its entirety. After securing the suprascapular nerve and artery at the spinoglenoid notch, anatomical reduction of the scapular body and lateral column was achieved and fixed with 3.5 mm reconstruction plates in a dual-column configuration (Fig. 3). The acromion fracture was separately addressed through superior scapular approach. Tension band wiring was done using two 2 mm Kirschner wires and a 1.5 mm stainless steel wire wound in a figure-of-eight fashion to achieve compression and restore the deltoid insertion (Fig. 4).

Post-operative rehabilitation included early passive motion followed by active-assisted range of motion at 4 weeks. At 4 months, the patient demonstrated active shoulder abduction up to 120° (Fig. 5), minimal pain (Visual Analogue Scale 1/10), and radiographic evidence of fracture union (Fig. 6). The University of California, Los Angeles Shoulder Score following a questionnaire was found to be 34/35 and the Constant–Murley score was 95/100, again confirming an excellent outcome ^[2,3].

Scapular plating is commonly indicated in cases of medial/lateral column disruption, >25 mm displacement, or angulation >45° ^[4,5]. Acromial fractures are typically treated conservatively but may require tension band wiring or plating when displaced or impeding shoulder motion [6-8]. To the best of our knowledge, no reports exist describing the combined use of dual-column plating and acromial fixation in the same patient. Goss introduced the concept of the superior shoulder suspensory complex (SSSC) and emphasized the need for restoration of all its components to prevent instability ^[9,10]. This case supports this biomechanical principle by treating both the lateral scapular border and acromion, which are integral to the SSSC [Table 1].

Jain et al. reported good outcomes using tension band wiring in isolated acromion fractures ^[11], while Herrera et al. found dual-column scapular fixation yielded better functional recovery compared to single-plate constructs in complex fractures ^[12].

Qalib et al. reported good outcome in a displaced acromion fracture treated with three cannulated cancellous screws perpendicular to the fracture ^[13]. Hollensteiner et al. concluded that double plating approach with two locking plate constructs bore good results in Levy type III acromion fractures ^[14]. Bauer et al. reported a durable result after double plating of entire scapular spine and acromion with concurrent reverse shoulder arthroplasty in a case of rotator cuff arthropathy with scapular spine fracture ^[15]. Hsiue et al. demonstrated an excellent outcome of dual plating of the acromion along with arthroscopic capsulolabral repair in a patient with an acromion fracture with first-time anterior shoulder dislocation. A 2.7 mm variable angle distal clavicle plate was used along the superior aspect of scapular spine up to the acromion and a 3.5 mm reconstruction plate was placed posteriorly in their report ^[16]. However, concurrent fixation of scapular body, lateral border, and acromion has not been extensively documented, making this case noteworthy in the field of complex trauma. Successful shoulder function depends on the integrity of the scapular body, lateral border, acromion, and surrounding musculature. Disruption of multiple components, as seen in this case, requires an individualized surgical strategy aimed at restoring anatomy and biomechanics. The dual-column scapular plating ensured proper restoration of the scapular contour and glenoid alignment, while acromial fixation maintained deltoid lever arm function. The combination prevented scapular winging and shoulder weakness – common complications in scapulothoracic injuries. Rehabilitation played a critical role in achieving excellent outcomes, considering this was the patient’s non-dominant arm, emphasizing the importance of early mobilization post-stabilization.

This case demonstrates that a comprehensive surgical approach combining scapular dual-column plating and acromion tension band osteosynthesis can lead to excellent radiological union and functional recovery in patients with complex scapulothoracic disruption. Surgeons should consider early and anatomical reconstruction of all disrupted components of the shoulder girdle in high-energy injuries to optimize outcomes.

Timely anatomical fixation using dual-column scapular plating and acromial tension band wiring, combined with structured rehabilitation, can restore shoulder function and stability within a short time in rare scapulothoracic disruptions with associated fractures.