It is not easy to break a shoulder blade. Breaking a shoulder blade—or scapula—takes a great deal of force. In 80% of the time a patient who has broken a scapula will also have major chest wall injuries. Half of the time there will be broken bones in the upper body, 15% of the time the victim will have severe cervical and cranial injuries.
Ronald Engleman, Jr., an engineer from New York City, understands broken scapulas. He broke his when the galloping horse he was riding took a sudden turn to its right and Ronald’s body continued straight ahead, over the head of the horse to a hard landing on his shoulder. Engleman had been focused on getting his foot out of the stirrup and landing somewhere besides on his face.
His friends got him to the nearest hospital in Wheeling, West Virginia, where doctors found that Engleman had broken his scapula and some ribs but that his lungs remained unpunctured and he had no bleeding in his chest. Doctors told him that the broken ribs and scapula would heal on their own and sent him home. They advised him to consult an orthopedic surgeon but no one mentioned to him that the bones of his scapula were not only broken but also displaced.
A week later Engleman, still sore and swollen, saw the chairman of the orthopedic department at a hospital in Brooklyn. The doctor told him “it looks like a pretty bad break. You may need an operation, I can’t tell without a CAT scan of the shoulder.”
For a week Engleman called daily, trying to schedule a CAT scan. When his insurance company told him it needed more information from his doctor before the scan could be scheduled, he decided to try a third hospital, the one at New York University in Manhattan. Here a surgeon who specialized in shoulders arranged for the scan. After the doctor saw it he told Engleman he would have to accept not being able to raise his arm and the pain. He advised him to just live with the disability. “If I were operating on you, ” he told Engleman, “I would risk more nerve damage.”
Doug Helfet, HSS to the Rescue
It had now been three weeks since the accident. Engleman was a young father and he could not accept not being able to lift and play with his children. He looked to his friends for advice and one of them suggested Dr. David Helfet, the chief of Orthopaedic Trauma at the Hospital for Special Surgery (HSS) in New York City.
Engleman, X-rays and NYU CAT scan in hand, got an appointment with Helfet the Friday before Hurricane Sandy was due to hit New York. Helfet confirmed that Engleman needed surgery but added that he, Helfet, was flying to India that evening and so could not schedule the operation. He told Engleman that, with the kind of displaced scapular fracture that he had, he should contact Dr. Peter Cole at Regions Hospital in Saint Paul, Minnesota.
Engleman did. He found Cole to be a fit young surgeon with curly reddish hair. A New Englander who had graduated from the University of Miami School of Medicine, Cole had done his internship and residency at Brown University Hospital in Rhode Island and a trauma fellowship at Harborview Medical Center in Seattle, Washington.
When he finished his training, Cole began looking for areas in orthopedics to specialize in what had been neglected or that had not been discovered or developed. He admits to having felt a bit of pioneer spirit when he found that the scapula or shoulder blade was the most neglected bone in the body.
No chapter had yet been written in a medical text about the scapula. No one had described the techniques for surgical repair and few had written papers on the problems associated with failure to treat the displaced parts of the scapula. As was the case with cracked ribs, doctors said to their patients, “Well, it will heal on its own and there is not much we can do about it.” There was a perception that “they will do fine.”
Cole believes doctors got away with that attitude because the shoulder has so much compensatory motion. It has more motion than any other joint in the body. Because of all the motion, people who had damaged their scapula were able to accommodate the deformity enough to get by. Observing this, doctors thought they were doing all right by their patients by not treating broken scapulas with surgery. The fact was that few knew how to approach the fracture anyway.
Cole’s Aha! Moment
Cole dedicated his career to changing that. It bothered him that surgeons were treating the scapula differently from how they treated every other bone in the body. As an orthopedic surgeon Cole had been trained to treat every bone in a manner to restore its alignment, length, rotation and stability. Yet he had been told by his mentors that the shoulder blade was different.
Cole did not believe that. There was no way that the shoulder blade could be different from every other bone in the body, he thought. His axiom was “function follows form.” “I decided I would establish indications for surgery on the scapula and if a patient met those standards on the displacement of the fracture or the angle of deformity, I would operate, ” he said.
That was a bold position for a young surgeon to take. He was doing surgery that was new and innovative. Because medicine in the United States is an evidence-based discipline he knew he would get criticism. Though he was busy gathering evidence, when he was starting out he had little of it. When asked to justify his treatment he would reply that he wanted to treat patients the way he, himself, wanted to be treated, “I do not want my shoulder blade to be deformed and not be able to raise my arm, ” he said. “I am doing for the scapula what I would do for any other bone. You need to prove to me why you are not doing surgery.”
Believing that it was irresponsible to do something innovative and not study it, Cole established a registry of his patients. He recorded everything: strength, motion, healing, X-rays, functional outcomes.
When he had data on about 70 scapular patients Cole presented his finding at a national conference. At the end of his presentation well known surgeons rushed the podium to severely criticize him for operating on bones that had not been operated on before—and for performing surgeries when there was no proof that he was making a positive difference.
Cole Answers Critics With 30 Peer Reviewed Papers
Cole, though certainly taken aback, says that he has a great deal of respect for the colleagues who took him to task in those early years and challenged him to prove the benefit of what he was doing. He calls that the “sharpening iron within our profession.”
Cole now finds himself invigorated in a different way. Now it is easier sailing. “The spinnaker is out, ” he says, “the wind is behind our backs.” Now he is defining new techniques, new ways to fix the bone, new approaches to the incision on the body, new diagnostic strategies. He says that his vision is to put himself out of business because “my colleagues will all know how to fix broken scapulas instead of me being the only guy who knows how to do it.”
Twelve years since he started, Cole and his associates have published more than 30 papers in peer reviewed journals, have 15 book chapters to their credit and Cole has conducted a master’s class in Switzerland on his surgery. Patients have come to their Regions Hospital Scapula Institute from all over the U.S. and other countries for surgery on broken scapulas.
Return to 80-90% Functionality
Ron Engleman had his surgery with Cole on November 6, 2012, a month following his accident. He was hospitalized at Regions for three days and then began out-patient physical therapy. Cole had him return to St. Paul for check-ups after six weeks and again after three months. At that point Engleman had achieved 80% of his former mobility in his shoulder but Cole was not satisfied. He wanted it to be over 90%. He told Engleman that his therapist was going too easy on him, that he had to have more intensive, aggressive therapy. Otherwise, he warned, scar tissue would become fibrous and he would lose mobility. Engleman took pain medication before his sessions with his therapist and complied with Cole’s recommendation.
Engleman is now pain free. “When the first couple of doctors said that there was nothing that they could do, I felt awful. I was just starting out with kids. I had to be a daddy who could do things and I could not lift my 35 pound son. I wanted to be able to teach my children to swim, ” he said.
Cole notes that the majority of scapula fractures—perhaps as many as 85%—do not require surgery. He is occupied finding out where that threshold is, developing new diagnostic and minimally invasive approaches and inventing new instrumentation to make the surgeries on a broken shoulder blade even more successful.
Dr. Peter Cole’s Claim to Fame