Clavicular Region Research Articles

Differential regional pectoralis major activation indicates functional diversity in healthy females

Pectoralis major activation enables the performance of several upper extremity movements. Its regional activation, however, is not documented in healthy females. This work used high-density surface electromyography to investigate regional pectoralis major activation in twenty-nine healthy young females across two independent experiments in several ramp and hold isometric tasks and force levels. Regional mean root mean square amplitudes (normalized to the task-specific maxima) were quantified for the clavicular, superior, and middle sternocostal regions. Two-way ANOVAs were used to determine if differences in normalized regional activation exist within each task and force level. The middle sternocostal region activated 12–108% more than the clavicular and the superior sternocostal region in extension, adduction with external rotation, and high elevation internal rotation. In high elevation adduction, the middle sternocostal region activated more (7–22%) than the superior sternocostal region. In low elevation, internal rotation (60°), the clavicular and middle sternocostal regions activated more (9–13%) than the superior sternocostal region, while in adduction 60°, the clavicular region activated 9–19% more than the superior sternocostal region. Lastly, in forward and horizontal flexion, all three regions activated similarly irrespective of the force level, except at 25% MVF in forward flexion, where the clavicular region activated 21% more than the superior sternocostal region. This work provides a first comprehensive evaluation of the normalized regional pectoralis major activation in healthy females. The present findings indicate that the performance of isometric tasks in different directions activates different pectoralis major regions in healthy females, suggesting regional specificity to functional actions.

Non-uniform excitation of the pectoralis major muscle during flat and inclined bench press exercises.

Non-physiological sources may lead to equivocal interpretation on the degree of muscle excitation from electromyograms (EMGs) amplitude. This presumably explains the contradictory findings regarding the effect of the bench press inclination on the pectoralis major (PM) activation pattern. To contend with these issues, herein we used high-density surface EMG to investigate whether different PM regions are excited during the flat and 45° inclined bench press exercises. Single-differential EMGs were collected from 15 regions along the PM cranio-caudal axis, while 8 volunteers performed a set of the flat and 45° inclined bench press at 50% and 70% of 1 repetition maximum. The coefficient of variation, the range of motion, and the cycle duration were calculated from the barbell vertical position to assess the within-subject consistency across cycles. The number of channels detecting the largest EMGs amplitude (active channels), their interquartile range, and their barycentre coordinate were assessed to characterize the EMG amplitude distribution within PM. No significant differences in the range of motion (p>0.11), cycle duration (p>0.28), number of active channels (p>0.05), and interquartile range of active channels (p>0.39) were observed between the two bench press inclinations. Conversely, the barycentre shifted toward the PM clavicular region (p<0.001) when the bench press changed from flat to 45°. Our results revealed that greatest EMG amplitudes were concentrated at the PM sternocostal and clavicular heads when exercising in the flat and 45° inclined bench press, respectively. Performing the bench press exercise, with different postures, seem to demand the excitation of different PM regions.

27619 Hemifacial hyperhidrosis as the presenting sign of thoracic disc herniation

A 41-year-old male presented with a one-decade history of episodic hyperhidrosis accompanied by anxiety, palpitations, and shortness of breath. Multispecialty workup was unrevealing. After unsuccessful symptomatic control with alprazolam, propranolol, aluminum chloride, and glycopyrrolate; he was referred to dermatology. Careful attention to his history revealed his episodes began ten years prior, shortly after a traumatic injury playing lacrosse. Directed questioning revealed his excessive sweating was localized to the right upper half of his body. A starch-iodine test of the bilateral head, neck, trunk, and arms demonstrated the excessive sweating was localized to the right forehead, right clavicular region, and right forearm. The history and unilateral nature of the sweating suggested a primary neurologic etiology. He was referred to a neurologist and a thoracic spine MRI was obtained. These images revealed diffuse disc disease with specific impingement on the ventrolateral spinal cord at T3. We hypothesize the T3 impingement represents an irritative lesion that stimulates preganglionic fibers of the right cervical sympathetic trunk. Such a lesion anatomically explains both his unilateral sweating and associated hyperadrenergic symptoms. When considering hyperhidrosis, there is a distinction between primary and secondary forms. This patient’s late-onset and unilateral nature were red flags. Our recognition led to the diagnosis of thoracic disc herniation myelopathy, a potentially disabling, yet reversible, condition.

Shoulder Pain - Dodgeball

HISTORY: 39-year-old right-handed man presented to clinic for right shoulder pain. Symptoms were present for 4-5 months prior and began several days after playing in a dodgeball tournament. There was no trauma or clear inciting event. Pain was localized to the top of the right shoulder and worse with reaching across the body and with overhead activities. The 3-4 weeks prior to presenting to clinic he noticed a lump and swelling over the top of the shoulder and clavicular region that was not painful to touch. His pain was rated overall 3/10 intensity. PHYSICAL EXAM: Full range of motion of the shoulder in abduction, flexion without pain. Negative empty can test, Hawkins and Neers tests on the right. Speeds test negative on the right. Fullness and bony prominence noted at the distal clavicle on the right shoulder. No focal tenderness at the AC joint. Mild discomfort with scarf test on the right. DIFFERENTIAL DIAGNOSIS: 1. Acromioclavicular joint sprain 2. Acromioclavicular joint arthralgia 3. Distal clavicle osteolysis 4. Osteoid osteoma. TESTS AND RESULTS: Ultrasound right shoulder: Cortical irregularity of the distal right clavicle. XR right shoulder: Distal clavicular ill-defined lytic lesion with apparent cortical breakthrough superiorly and possibly inferiorly. MRI right shoulder: Indeterminate 3.6 cm expansile enhancing lesion with fluid. Biopsy right clavicle with USP6 genotype testing: consistent with an aneurysmal bone cyst FINAL/WORKING DIAGNOSIS: Aneurysmal bone cyst in the distal clavicle TREATMENT AND OUTCOMES: 1. Patient referred to orthopedic oncology and underwent biopsy 2. Underwent aspiration of aneurysmal bone cyst with injection of doxycycline 3. 2 months post-operatively continued to have pain and tightness in the shoulder 4. 5 months post-operatively reported resolution in shoulder pain and improved mobility, interval sclerosis noted of aneurysmal bone cyst on imaging

Tiger Trauma

A 40-year-old woman presents to the trauma bay after being mauled by a tiger. She was emergently transported to the local tertiary community hospital for stabilization and treatment. She suffered from 33 different lacerations of multiple puncture wounds across her chest, full thickness lacerations to her left and posterior neck, left posterior scalp, and left arm. Vitals were stable and GCS 15. She was able to move all extremities with some weakness to her LUE and right sided facial droop with ptosis. She was subsequently intubated for distress, potential airway decompensation, and possible carotid artery injury. CT imaging illustrated a stable spinous process fractures at C5 and C6, non-displaced fractures of the left transverse process at C7 and T1, extensive subcutaneous emphysema within the inferior neck, superior right chest, and left clavicular region, as well as, air within the cervical canal and extrinsic to the thecal sac. MRI suggested ligamentous strain in the posterior longitudinal ligament at the C2-3 level, small amount of paraspinal hemorrhage on the left C2-3, within the interspinous ligaments C3-7 and marked edema/hemorrhage within the trunks and divisions of the left brachial plexus highly suspicious for brachial plexus injury. ENT and neurosurgeon diagnosed right facial palsy and began dexamethasone treatment. ID physician tailored antibiotics to vancomycin for human skin flora and ampicillin/sulbactam for Pasteurella multocida from the tiger. She was to switch to doxycycline, amoxicillin/clavulanate, and wound care after discharge. She was transferred for reconstructive surgery for the brachial plexus injury, electromyography, and electroneuronography testing.

Regional differential stretching of the pectoralis major muscle: An ultrasound elastography study

Pectoralis major (PMa) muscle injuries are becoming more prevalent, and their incidence differs among the PMa regions, i.e., the clavicular, sternal, and abdominal regions. Therefore, identifying the position for effectively lengthening each PMa region is critical in preventing PMa injuries. The purpose of this study was to determine the effective stretching position for each PMa region through shear wave elastography, which can indirectly assess individual muscle lengthening. Fifteen men participated in this study. Twelve stretching positions were compounded with shoulder abductions (45°, 90°, and 135°), pelvic rotation (with or without), shoulder external rotation (with or without), and shoulder horizontal abductions. The shear modulus of each PMa region was measured through shear wave elastography in the stretching positions mentioned above. At the clavicular region, the shear modulus was higher for three stretching positions: shoulder horizontal abduction at 45° abduction during pelvic rotation and shoulder external rotation, shoulder horizontal abduction at 90° abduction, and shoulder horizontal abduction at 90° abduction while considering shoulder external rotation. For the sternal region, the shear modulus was higher in two stretching positions: shoulder horizontal abduction at 90° abduction while adding external rotation, and combination of pelvic rotation and external rotation. For the abdominal region, the shear modulus was higher in the shoulder horizontal abduction at 135° abduction with pelvic and external rotation. These results indicated that the effective stretching position was different for each PMa region.

Medial clavicle fracture with bone destruction after radical neck dissection combined with postoperative chemotherapy for secondary cervical lymph node metastasis of tongue cancer: a case report

BackgroundClavicle fractures (CF) after radical neck dissection (RND) for oral cancer are rare but are thought to occur as a result of myotonia and decreased blood supply to the muscles around the clavicle after RND. The current report presents a rare case of a non-neoplastic pathological CF after RND, and discusses the role of imaging examinations for the timely detection of CF.Case reportAn 82-year-old Japanese man underwent RND followed by chemotherapy without radiotherapy for secondary metastasis of the right cervical lymph node after resection of tongue cancer. Computed tomography at 6 months after RND revealed a fracture with bone destruction in the proximal end of the right clavicle. He had no history of trauma at the site of the fracture and no symptoms. The possibility of bone metastasis of the clavicle was considered; however, the bone destruction had not advanced 6 years after the discovery of the fracture. The CF was thus finally considered to be a side effect of RND, rather than metastasis.ConclusionCF is a rare complication following treatment for head and neck cancer but can be caused by neck dissection. Regular imaging examinations, including the clavicular region, are therefore needed before and after surgery to ensure the timely detection of CF.

Microsurgical neck reconstruction in an elderly patient

Introduction: The incidence of dermatological malignancies increases with age and a considerable percentage of older adults will require radical surgeries and adjuvant treatments, microsurgery allows repair and coverage of major defects with success rates of up to 90%. Case Report: We present the case of an elderly patient with an ulcer in the left clavicular region without evidence of healing. Histological and imaging studies were performed, a basal cell carcinoma subtype morphea was found. A wide excision and axillary lymph node dissection were performed, subsequently covering the defect with a free flap. There is an 11-year follow-up. Conclusion: Complications in microsurgical reconstructions are more associated with comorbidities than with the age of the patient. The same success rates can be obtained in elderly patients.

CONSEQUENCE OF PATHYA-APATHYA AND LIFE STYLE IN THE DISORDERS OF URDHVAJATRU (SUPRACLAVICULAR) REGION-A REVIEW

Our ancient seers have given importance to Shirah (head) as it is part of the body where life along with sense faculties resides. All the sense organs and the channels carrying the sensory and vital impulses from the Shir (head) are like the rays of the sun. It is necessary to care for Urdhvajatru. In Ayurveda classics mentioned the concept of Pathya (wholesome) and Apathaya (unwholesome) as a part of the treatment of the diseases also a part of regime of healthy living. A person needs to follow a healthy diet and regimen so as to prevent any anomalies in life or to maintain good health. Shalakya Tantra has mentioned proper diet to take in particular disease which is necessary to enhance the effect of treatment and prevent the disease and also useful procedures which are part of Dinacharya to maintain routine health. The aim is to evaluate the role of Pathya- Apathya and dietary regimen mentioned in Shalakya Tantra to prevent the supraclavicular disease. Relevant Ayurveda and modern literature, available information on internet etc, were searched. The dietary advice and various Dinacharya modalities gives nourishment to the supra clavicular region and cures ailments of related and also provides preventive and curative benefits.

Using the venous angle as a pressure reservoir to retrogradely fill the subclavian lymphatic trunk with contrast agent for lymphatic mapping

BackgroundVisualizing the lymphatic system and recording the spatial relations between the subclavian lymphatic trunk (SLT) and the surrounding anatomical structures will improve radiotherapy treatment planning for breast cancer patients with lymphatic involvement. An experimental approach to retrogradely fill the SLT with contrast agent was explored. MethodsSix Thiel embalmed specimens were bilaterally dissected in the cervical and clavicular region to optimize the new experimental approach. A conservative dissection with minimum distortion of spatial relations between different anatomical structures was developed. A pressure reservoir was created inside the venous angle to allow retrograde filling of the SLT under the influence of time and pressure. ResultsThe new methodology proved feasible, showing successful pressure build-up inside the venous reservoir, resulting in filling of the proximal end of the subclavian lymphatic trunk. The pressures needed to significantly fill the subclavian lymphatic trunk proved to be higher than the pressures that the venous walls could withstand. ConclusionsThiel embalmed specimens proved useful for optimizing the experimental approach, but the embalming products could have negatively affected the vessel strength. The authors suggest that their method will be applied on fresh frozen specimens in future studies, to obtain SLT filling up to the axillary lymphatic plexus. Our findings also pointed out that there is still a lot to be learned about the anatomical variability of the SLT and its termination sites. The detailed description of our experimental approach offers valuable information for future lymphatic mapping studies.

Assessing breast lymphoedema following breast cancer treatment using indocyanine green lymphography.

Breast lymphoedema is a largely unrecognised survivorship issue for women following breast cancer treatment. While a few objective methods have previously been applied to assess breast lymphoedema, none are capable of imaging breast lymphatics or identifying lymphatic morphological changes indicative of breast lymphoedema. The purpose of this study was to determine if indocyanine green (ICG) lymphography, a validated assessment technique in breast cancer-related lymphoedema), can visualise breast lymphatics and identify breast lymphoedema. Additionally, ICG lymphography was utilised to investigate lymphatic drainage pathways of the affected breast following breast-conserving therapy. Twenty female participants (10 breast lymphoedema and 10 healthy controls) were recruited for this pilot study. All underwent a medical history, physical breast assessment, tissue dielectric constant measures of breast water content, and ICG lymphography. ICG lymphography identified lymphatic morphological changes in all breast lymphoedema participants (dermal backflow patterns = 10, collateral lymphatic drainage = 9) and none in the control group. The dominant lymphatic drainage pathway to the ipsilateral axilla was observed in all control participants but in only four breast lymphoedema participants. Collateral drainage pathways in the breast lymphoedema group were to: parasternal (6/10); contralateral axilla (4/10); intercostal (3/10); and clavicular (2/10) regions. These findings suggest ICG lymphography, through the identification of morphological lymphatic changes, is a potential qualitative objective assessment technique for breast lymphoedema. Furthermore, in this group of breast lymphoedema patients it identified changes to the normal drainage pathway of the breast. Understanding these changes will have implications for clinical management.

Identifying predictors of upper extremity muscle elasticity with healthy aging

Ultrasound shear wave elastography (SWE) can provide accurate in vivo measurements of the effect of advanced age on muscle elasticity. Our objective was to determine whether passive muscle elasticity was influenced by posture, chronological age, sex, body mass index, and clinical measures of upper extremity function for healthy adults. The dominant arm of 33 male and 33 female participants (ranging from 20 to 89 years old) was examined using a Supersonic Imagine Aixplorer ultrasound SWE system. The mean and standard deviation of shear wave velocity (SWV) was measured from elastography maps for five upper extremity muscles examined at rest: anterior deltoid (AD), biceps brachii (BB), clavicular (CL) and sternocostal (SC) region of the pectoralis major and middle trapezius (MT). Linear mixed models for each muscle were used to assess how SWV was influenced by humeral elevation, chronological age, sex, BMI and three functional measures. All significances are reported at α = 0.05. Humeral elevation influenced shear wave velocity at a statistically significant level for AD, BB, SC and MT (all p < 0.047). Chronological age was a significant predictor of mean SWV for the sternocostal region of the pectoralis major and the middle trapezius (both p < 0.03). These same muscles were also less homogenous (based on their standard deviations) with increased age, particularly for female participants. Performance-based functional assessments of the upper extremity were predictors of mean SWV for the clavicular region of the pectoralis major (all p < 0.04). These results suggest ultrasound SWE has potential utility for assessing age-related changes to muscle elasticity, but these associations were muscle-dependent.

Bowel perforation after ventriculoperitoneal-shunt placement: case report and review of the literature

Abstract Bowel perforation by a peritoneal catheter (BPPC) is a serious complication after ventriculoperitoneal shunting, with high mortality and morbidity rates. This patient presented with scalp ulceration over the shunt valve at the retromastoid region 26 years after shunt placement. During revision, the catheter distal to the valve was divided in the clavicular region. As there was no cerebrospinal fluid drainage, we decided to remove the ventricular catheter and valve. The ulceration was debrided and primarily closed. Distal to the clavicle, the disconnected peritoneal catheter was encased in a fibrous, calcified tunnel. To avoid piecemeal resection with multiple incisions, the catheter was not retrieved. Two years later, the patient presented with an abscess and pus draining from the clavicular wound. Cultures were positive for enteric bacteria. BPPC with retrograde spread of infection was suspected, and abdominal computed tomography confirmed perforation. We removed the disconnected catheter, but the perforation site could not be detected during laparotomy. The patient was treated with intravenous antibiotics and recovered without complications. To minimize complications, abandoned catheters should be avoided. Otherwise, patients unnecessarily have a life-long risk of developing abdominal complications. In patients with abandoned catheters and severe abdominal symptoms, BPPC is an important differential diagnosis.

A Rare Cause of Misplaced Port Catheter: Episternal Ossicles With Abundant Fibrous Capsule

A 71-year-old woman with newly diagnosed inferior vena cava leiomyosarcoma received a port catheter for chemotherapy. Resistance was noticed during the procedure. The chest radiograph showed that the catheter was kinked in clavicular region (Figure 1). There was no history of previous implantation of central venous catheter, a pacemaker, trauma, or surgery. Chest computed tomography demonstrated that episternal ossicles surrounded by excessive soft tissue (Figure 2, arrow) narrowed the space where the left brachiocephalic vein passed through and caused severe stenosis of the left brachiocephalic vein (Figure 2, arrowhead).

Chronic non-bacterial osteomyelitis of clavicle

The patient was a 10-year-old girl with pain and swelling of the left clavicle. The physical examination was normal except swelling and tenderness of the left clavicular region. All the...

What Regions of the Distal Clavicle Have the Greatest Bone Mineral Density and Cortical Thickness? A Cadaveric Study.

Osteosynthesis of distal clavicle fractures can be challenging because of comminution, poor bone quality, and deforming forces at the fracture site. A better understanding of regional differences in the bone structure of the distal clavicle is critical to refine fracture fixation strategies, but the variations in BMD and cortical thickness throughout the distal clavicle have not been previously described. /questions (1) Which distal clavicular regions have the greatest BMD? (2) Which distal clavicular regions have the greatest cortical thickness values? Ten distal clavicle specimens were dissected from cadaveric shoulders. Eight specimens were female and two were male, with a mean (range) age of 63 years (59 to 67). The specimens were selected to match known epidemiology, as distal clavicular fractures occur more commonly in older patients with osteoporotic bone, and clavicular fractures in older patients are more common in females than males. The clavicles were then imaged using quantitative micro-CT to create 3-D images. The BMD and cortical thickness were calculated for 10 regions of interest in each specimen. These regions were selected to represent locations where distal clavicular fractures commonly occur and locations of likely bony comminution. Findings were compared between different regions using repeated measures ANOVA with Geiser-Greenhouse correction, followed by Bonferroni method multiple comparison testing. Effect size was also calculated to estimate the magnitude of difference between regions. The four most medial regions of the distal clavicle contained the greatest BMD (anterior intertubercle space 887 ± 31 mgHA/cc, posterior intertubercle space 879 ± 26 mgHA/cc, anterior conoid tubercle 900 ± 21 mgHA/cc, posterior conoid tubercle 896 ± 27 mgHA/cc), while the four most lateral regions contained the least BMD (anterior lateral distal clavicle 804 ± 32 mgHA/cc, posterior lateral distal clavicle 800 ± 38 mgHA/cc, anterior medial distal clavicle 815 ± 27 mgHA/cc, posterior medial distal clavicle 795 ± 26 mgHA/cc). All four most medial regions had greater BMD than the four most lateral regions, with p < 0.001 for all comparisons. For the BMD ANOVA, η was determined to be 0.81, representing a large effect size. The four most medial regions of the distal clavicle also had the greatest cortical thickness (anterior intertubercle space 0.7 ± 0.2 mm, posterior intertubercle space 0.7 ± 0.3 mm, anterior conoid tubercle 0.9 ± 0.2 mm, posterior conoid tubercle 0.7 ± 0.2 mm), while the four most lateral regions had the smallest cortical thickness (anterior lateral distal clavicle 0.2 ± 0.1 mm, posterior lateral distal clavicle 0.2 ± 0.1 mm, anterior medial distal clavicle 0.3 ± 0.1 mm, posterior medial distal clavicle 0.2 ± 0.1 mm). All four most medial regions had greater cortical thickness than the four most lateral regions, with p < 0.001 for all comparisons. For the cortical thickness ANOVA, η was determined to be 0.80, representing a large effect size. No differences in BMDs and cortical thicknesses were found between anterior and posterior regions of interest in any given area. In the distal clavicle, BMD and cortical thickness are greatest in the conoid tubercle and intertubercle space. When compared with clavicular regions lateral to the trapezoid tubercle, the BMD and cortical thickness of the conoid tubercle and intertubercle space were increased, with a large magnitude of difference. Distal clavicular fractures are prone to comminution and modern treatment strategies have centered on the use of locking plate technology and/or suspensory fixation between the coracoid and the clavicle. However, screw pullout or cortical button pull through are known complications of locking plate and suspensory fixation, respectively. Therefore, it seems intuitive that implant placement during internal fixation of distal clavicle fractures should take advantage of the best-available bone. Although osteosynthesis was not directly studied, our study suggests that the best screw purchase in the distal clavicle is available in the areas of the conoid tubercle and intertubercle space, as these areas had the best bone quality. Targeting these areas during implant fixation would likely reduce implant failure and strengthen fixation. Future studies should build on our findings to determine if osteosynthesis of distal clavicular fractures with targeted screw purchase or cortical button placement in the conoid tubercle and intertubercle space increase fixation strength and decreases construct failure. Furthermore, our findings provide consideration for novel distal clavicular locking plate designs with modified screw trajectories or refined surgical techniques with suspensory fixation implants to reliably capture these areas of greatest bone quality.

Functional integrity of the shoulder joint and pectoralis major following subpectoral implant breast reconstruction.

Subpectoral implants for breast reconstruction after mastectomy requires the surgical disinsertion of the sternocostal fiber region of the pectoralis major. This technique is associated with significant shoulder strength and range of motion deficits, but it is unknown how it affects the underlying integrity of the shoulder joint or pectoralis major. The aim of this study was to characterize the long-term effects of this reconstruction approach on shoulder joint stiffness and pectoralis major material properties. Robot-assisted measures of shoulder strength and stiffness and ultrasound shear wave elastography images from the pectoralis major were acquired from 14 women an average of 549 days (range: 313-795 days) post reconstruction and 14 healthy, age-matched controls. Subpectoral implant patients were significantly weaker in shoulder adduction (p < 0.001) and exhibited lower shoulder stiffness when producing submaximal adduction torques (p = 0.004). The underlying material properties of the clavicular fiber region of the pectoralis major were altered in subpectoral implant patients, with significantly reduced shear wave velocities in the clavicular fiber region of the pectoralis major when generating adduction torques (p = 0.023). The clinical significance of these findings are that subpectoral implant patients do not fully recover shoulder strength or stability in the long-term, despite significant recovery time, and substantial shoulder musculature left intact. The impact of these procedures extends to the remaining, intact volume of the pectoralis major. Optimization of shoulder function should be a key aspect of the post-reconstruction standard of care. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1610-1619, 2019.

Abstract P1-12-18: Mechanical properties of the shoulder and pectoralis major in women undergoing breast conserving therapy with axillary dissection and regional nodal radiotherapy versus sentinel node biopsy and radiotherapy to the breast alone

Abstract Background: Breast conserving surgery (BCS) and radiotherapy (RT) reduce the risk of breast cancer recurrence, but can cause various functional deficits in breast cancer survivors. Side effects to the shoulder can include pain, stiffness, and restricted mobility, which are difficult to objectively assess in the clinic. Methods: The mechanical integrity of the shoulder and the pectoralis major (PM) was assessed in patients at least 1 year post-treatment with BCS and RT. Nine patients with node-negative breast cancer were treated with 2 RT fields to the breast alone after BCS and sentinel node biopsy (Group 1). Nine patients with node-positive breast cancer were treated with ≥3 RT fields to the breast and draining lymphatics after BCS and axillary lymph node dissection (ALND) (Group 2). Nodal RT was delivered to the supraclavicular and infraclavicular (level III axillary) nodes in 9/9 patients, the internal mammary nodes in 6/9 patients, and the full axilla (levels I, II, and III) in 1/9 patient. Nine age-matched healthy controls (mean age 54) with no history of breast cancer or shoulder injury were also examined. The mechanical integrity of the shoulder was objectively quantified using robot-assisted biomechanical measures of shoulder stiffness. The shear elastic modulus, or 'stiffness', of the clavicular and sternocostal fiber regions of PM was assessed using ultrasound shear wave elastography. Participants were examined while they were relaxed or actively contracting force with their shoulder muscles. Linear mixed effect models with Bonferroni-corrected multiple comparisons were used to determine if shoulder stiffness or PM shear elastic modulus differed between the two breast cancer groups and controls. Results: Patients in Groups 1 (mean age 54) and 2 (mean age 57) were an average (SD) 754(111) and 988(163) days since initiating RT (p=0.003). Shoulder stiffness did not differ between the 2 groups and healthy controls (F2,27=0.76, p=0.48), There was a significant group difference in PM shear elastic modulus (F2,27=8.33, p=0.0015), with Group 2 patients exhibiting an average greater stiffness of 14-21% in the sternocostal and 12-28% in the clavicular regions of the PM versus Group 1 patients (p&amp;lt;0.001) and healthy controls (p =0.021). There was no difference between patients treated with Group 1 and controls (p=0.29). Conclusions: Although power is limited due to small sample size, this study provides the first evidence that the mechanical integrity of the shoulder remains intact in patients who receive ALND combined with a supraclavicular field (generally without full axillary radiotherapy). The observation of altered PM function without subsequent changes to shoulder stiffness in patients treated with ALND and ≥3 RT fields suggests these patients likely develop new neuromuscular strategies to stabilize the shoulder joint to compensate for the PM. Future work is needed to appreciate whether certain muscle strategies are associated with poorer quality of life in breast cancer survivors, and to prospectively monitor the impact of breast cancer treatments on PM mechanical properties. Citation Format: Lipps DB, Leonardis JM, Lehmann S, Dess RT, McGinnis G, Strauss JB, Hayman JA, Pierce LJ, Jagsi R. Mechanical properties of the shoulder and pectoralis major in women undergoing breast conserving therapy with axillary dissection and regional nodal radiotherapy versus sentinel node biopsy and radiotherapy to the breast alone [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-12-18.

Radiation-induced thoracic necrosis with a pulmonary cutaneous fistula repaired using a free omental flap: a case report

BackgroundChest wall necrosis can manifest as a late effect of radiation therapy for breast cancer. Only two cases of fistulas communicating with the respiratory tract as a result of radiation-induced necrosis of the lungs or bronchi have been reported. To the best of our knowledge, we report the first case of a pulmonary cutaneous fistula arising as a late effect of radiation therapy for breast cancer, which was successfully repaired using a free omental graft.Case presentationA 64-year-old woman underwent Halsted surgery and postoperative radiation therapy for breast cancer 25 years earlier. One year before visiting our hospital, she developed a fistula and bleeding in her left clavicular region, which was expanding. On initial examination, a 6-cm-wide skin defect was observed in the left clavicular region and the clavicle appeared sequestrated. Computed tomography revealed part of the first to third left ribs, part of the left clavicle, the subclavian artery, and the brachial plexus to be missing. Several rounds of debridement revealed approximately 10 bronchial stumps on the surface of the collapsed lung, from which exhaled air and sputum were effusing. Surgery was performed to implant a free omental flap with vascular anastomosis and a skin graft in the neck region, and the pulmonary cutaneous fistula was closed. Two years after surgery, emphysema remained inside the omentum, which spontaneously resolved by the 3rd postoperative year.ConclusionsVarious treatment options are conceivable for the repair of pulmonary cutaneous and bronchocutaneous fistulas induced by radiation damage (e.g., free tissue grafts and endoscopic bronchial occlusion); however, these are rarely reported, and the most reliable method thus remains unclear. Positive outcomes in our case indicate that implanting a free omental graft may be effective. Furthermore, spontaneous healing can be expected for the residual emphysema inside the omentum.

Anatomical Study and Clinical Application of Free Thoracoacromial Artery True-Perforator Flap for Reconstruction of the Face.

The clavicular region is acknowledged as one of the most suitable donor sites for reconstruction of the face or neck. Recently, a free thoracoacromial artery (TAA) perforator (TAAP) flap was reported as a new option for reconstruction of the face. However, the TAAP flap has several drawbacks including tedious intramuscular dissection of the pedicle and loss of availability of a pectoralis major flap as a bailout option in case of cancer recurrence. We performed an anatomical study of the TAAP and developed a novel TAA "true-perforator" flap, in which we can preserve the main trunk of the TAA. Anatomical study of the TAAPs was performed in 6 patients while elevating a deltopectoral flap or a pedicled TAAP flap. Location and diameter of the perforators were recorded. Based on these anatomical findings, we developed a novel free TAA true-perforator flap, which we used for the reconstruction of a facial defect after cancer resection. The most dominant TAAP was identified 4.8-cm (4 to 7-cm) caudally from the upper border of the deltopectoral triangle along the cephalic vein and 1.7-cm (0.5 to 2-cm) medially from the cephalic vein. The diameter of the TAAPs at the level of fascial penetration was 0.78-mm (0.6 to 1.0-mm). The pedicle could be elongated up to 3-cm with proximal dissection. Clinical case showed a satisfactory aesthetic result with minimal donor-site morbidity. A free TAA true-perforator flap can be a new option for the reconstruction of the face with many advantages including reduced donor-site morbidity and satisfactory aesthetic outcome.