Proponents of the anterior plate argue that it is safer, since the screws are directed from anterior to posterior, thereby avoiding the lung and the neurovascular structures. Furthermore, it reduces the number of patients who may require sy mptomatic hardware removal. On the other hand, anterior plating requires additional dissection of the deltoid muscle, particularly distally, and it is more difficult to fit the plate on the thin anterior surface of the distal fragment.
With anterior plating, the insertion angle for screws in the plate may be difficult to achieve in large patients or women with generous breasts. Alternatively, surgeons who favor superior plating cite easier surgery and fixation with possibly improved biomechanics.
The disadvantages with this technique are a greater risk to the important adjacent structures when drilling and the higher incidence of sy mptomatic hardware. Regardless of the plate position, a plate of adequate strength is required. One-third of tubular plates and minifragment plates as stand-alone implants are rarely indicated in adults. Most studies support the use of thicker small fragment plate with 3. In y oung patients with excellent bone, nonlocking cortical screws are usually adequate. In older patients with compromised bone stock, or in any fracture with a short proximal or distal segments, locking screws unequivocally improve strength of fixation.
A minimum of three screws six cortices should be placed in the major proximal and distal fracture fragments Fig. Frequently, one or more screw holes in the plate are left empty at the level of the fracture. With fractures involving the distal one-fourth of the clavicle, special precontoured periarticular clavicle plates may be helpful. These implants have a flared or enlarged lateral end to the plate and accept four to six 2.
However, due to the wide variation in clavicular morphology, these plates do not alway s fit well. For most middle third fractures, I prefer to contour a straight pelvic reconstruction plate that allows me to precisely match the patients anatomy Fig. Invariably this. However, many surgeons favor the precontoured plates for diaphy seal fractures. Prior to closure, intraoperative fluoroscopy is used to assess the quality of the reduction as well as to ensure screws are of appropriate length.
In comminuted fractures when there are small residuals defects around the fracture site, 5 cc of demineralized bone matrix putty is packed around the fracture site to augment healing. The wounds are copiously irrigated and closed in lay ers. The deep soft-tissue closure should cover the plate.
In all patients, a careful subcuticular plastic closure is done. A firm pressure dressing is applied, and the affected arm is placed into a sling. Postoperative Management In healthy patients with uncomplicated surgery whose pain is minimal or moderate can be sent home on the day of surgery. In older patients, and those with complex fracture patterns, prolonged surgery, severe pain, or medical comorbidities are admitted to the hospital overnight and discharged on post-op day 1.
Hospitalized patients receive two postoperative doses of an intravenous cephalosporin antibiotic when there is no allergy. Except for the rare open fracture, no additional intravenous or oral antibiotics are administered. Virtually all patients require strong oral analgesics for the first week or two following surgery.
Patients are seen in the out-patient clinic approximately 7 to 9 day s after their surgery. Sutures are removed, and a radiograph of the clavicle is obtained and reviewed with the patient. The surgical incision is generally left open, and patients are allowed to bathe or shower and get the incision wet. When stable internal fixation has been achieved, patients are allowed to remove their sling for activities of daily living such as eating, grooming, and dressing. Most patients usually wear a sling for 2 to 4 weeks and then discard it. Phy sical therapy is not routinely employ ed as the glenohumeral joint is not affected, and most patients are moving their shoulder within the first 2 to 3 weeks.
Patients with office jobs are allowed to return to work within 2 or 3 weeks flowing surgery. On the other hand, return to work for patients with phy sically demanding jobs must be delay ed a minimum of 6 to 8 weeks and often up to 12 weeks. After the first postoperative visit, patients are followed at monthly intervals until the fracture has healed radiographically, which can range from 8 to 16 weeks.
Patients are allowed to return to noncontact sports such as walking, jogging, and cy cling at 6 weeks. Participation in more vigorous sports such as soccer, tennis, and baseball is delay ed until 10 weeks postoperatively. Return to football, rugby, judo, hockey, etc. All patients are asked to return 1 y ear after surgery for a discussion regarding the need for plate removal. Hardware removal is recommended for adolescents, teens, and y oung adults. However, in all other patients, the plate is only removed if there are strong clinical sy mptoms such as pain,.
In my experience, approximately one-third of patients eventually have their plate removed. Because of the close proximity of the lung, the subclavian vessels, and brachial plexus, they are vulnerable to iatrogenic injury. Nevertheless, with careful and meticulous surgery, injury to these important structures is rare. The use of a sharp drill bit reduces drill time and the amount of pressure needed to advance the drill bit, thereby decreasing the likelihood of sudden penetration of the far cortex.
The danger to the lung and vessels is greatest in the medial one-third of the clavicle necessitating increased vigilance. Placing a small Hohman retractor along the inferior surface of the clavicle opposite, the hole in the plate to be drilled is both practical and reassuring. Several orthopedic companies manufacture drills that have an oscillating mode in addition to the standard forward and reverse, which minimize sudden plunging bey ond the far cortex.
Injury to the lung leading to a pneumothorax or bleeding from a puncture in a major vessel can be extremely difficult to control and may be life threatening. Prevention is the best treatment. Infections in the first 2 to 3 weeks after surgery are treated with aggressive surgical irrigation and dbridement, culture-specific intravenous antibiotics, and retention of hardware if stable fixation has been achieved. In patients with chronic infections and those presenting late usually require hardware removal as well as thorough operative dbridement and long-term antibiotics Fig.
It is usually the result of technical errors or fixation failure. A nonunion is present when there are no progressive signs of healing on radiographs taken between 3 and 5 months following surgery Fig. Both local and sy stemic factors may contribute to the development of a nonunion.
Local factors that have been associated with fractures that fail to unite include excessive soft-tissue stripping, poor reductions, and inadequate fixation. In adults, one-third tubular plates, 2. They have been associated with high rates of loss of reduction and fixation failures.
Sy stemic factors that may contribute to the development of a nonunion include smoking, poor nutrition, diabetes, corticosteroids, and chronic sy stemic disease. Due to the relatively scant soft tissues around the clavicle, internal fixation devices may be prominent particularly after the initial posttraumatic swelling resolves.
Plate prominence can be minimized but not entirely eliminated by a careful closure of the deep soft tissues over the plate following the index procedure. When sy mptomatic, the plate can be safely removed after 1 y ear. Earlier plate removal has been associated with a small incidence of refracture. Outcomes and Results In the past 15 y ears, numerous studies have reported improved radiographic and functional outcomes following internal fixation of displaced clavicle fractures in adults when compared to nonoperative treatment. Hill, McGuire, and Crosby were amongst the first group of investigators to report that closed treatment of displaced middle third clavicle fractures was associated with poor results.
Robinson et al. While the nonunion rate for the entire group was only 6. Zlowodzki et al. In a randomized control trial comparing nonoperative versus plate fixation of displaced clavicle fractures, the Canadien Orthopedic Trauma Society reported the results of treatment in patients. There were less nonunions and malunions as well as better Constant and Dash scores in the operative group.
In a nonrandomized prospective single surgeon study, patients with a displaced clavicle fracture were treated by the author with plate osteosy nthesis between and One hundred three patients were followed for an average of 12 months range, 5 to These were 74 males and 29 females with an average age of 34 y ears range, 14 to The mechanism of injury included falls in 18 patients, motor vehicle accidents in 22, motorcy cle accidents in 32, and sports injuries in 31 patients. All were closed injuries. Treatment consisted of conventional plate osteosy nthesis in 15 patients and locking plates in 82 patients.
Alternative fixation techniques were utilized in six patients with extremely distal clavicle fractures. Of the five patients who did not heal primarily, four healed following revision surgery, while one patient failed to unite. Patient outcomes were evaluated using the DASH score, a validated patient-oriented outcome measure for assessing upper extremity disability. A zero score indicates a perfect extremity while a score of means completely disabled. The mean DASH score in this series was 16 range, 3 to Complications included one broken plate, seven reconstruction plates with minor deformation, and eight patients with some loss of shoulder motion.
There were no infections. The most frequent complication was. In conclusion, this study supports the use of internal fixation of widely displaced clavicle fractures in adults. The method is both safe and effective. Non-operative treatment campared with plate fixation of displaced mid-shaft clavicular fractures. J Bone Joint Surg Am ; Anterior-inferior plate fixation of middle-third fracture and nonunions of the clavicle. J Orthop Trauma ; Biomechanical evaluation of clavicle fracture plating techniques: does a locking plate provide improved stability?
Infection after clavicle fractures. Clin Orthop ; Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br ; Clavicular anatomy and applicability of precontoured plates. Jeray KJ. Acute midshaft clavicular fracture. J Am Acad Orthop Surg ; Deficits following nonoperative treatment of displaced midshaft clavicular fractures.
Mid-shaft mal-unions of the clavicle. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures a randomized, controlled, clinical trial. J Orthop Trauma ; Treatment of mid-shaft clavicle. A recent epidemiological study from Edinburgh showed that only 52 of 6, 0. The robust muscular envelope, the mobility of the scapula on the thoracic cage, its oblique orientation to the chest wall, and the surrounding bones, which are more vulnerable to fracture, protect the scapula making fracture of this bone infrequent.
In the past 25 y ears, several studies have documented poor results following nonoperative management of displaced scapular fractures With the development of modern techniques in internal fixation, surgeons began repairing selected scapula fractures utilizing the AO principles of restoration of articular reduction, alignment, and stable internal fixation leading to a renewed interest in the operative management of both displaced intra-articular and extra-articular scapular fractures 6, The surgical treatment of these fractures continues to evolve as our knowledge of shoulder anatomy , surgical approaches, and implants has improved.
There is no universally accepted classification for scapula fractures. In , Hardegger et al. Additionally, Ada and Miller 19 proposed a comprehensive classification that was anatomically defined. May o et al. Idebergs classification for intra-articular fractures 21,22 , based on radiographs and operative findings of 27 intra-articular glenoid fractures. This classification is also helpful in directing surgical decision making, as it takes into account associated scapular body and process fractures, which frequently occur in association with glenoid fractures Fig.
The Orthopaedic Trauma Association OTA classification sy stem is an alphanumeric sy stem that classifies both intra- and extra-articular fractures Fig. Its main weakness is that it does not correlate fracture patterns or combinations of injuries with real fractures.
Scapula fractures have also been mapped from 3D reconstructions to better illustrate the true nature of fracture patterns and could serve as a basis for a comprehensive classification scheme Fig. The main value of three dimensional mapping, however, is to serve as a useful roadmap for surgical planning and a greater understanding of the muscular force vectors acting on the scapula It is a classification specific for intra-articular glenoid fractures and accounts for commonly associated fractures of the body and processes and is helpful in determining surgical approach.
Though it provides a sy stematic way of classify ing scapula fractures, it has not been developed by correlating identified patterns of injury or combined injuries. Fracture and dislocation classification compendium Orthopaedic Trauma Association classification, database and outcomes committee. These include A the lateral border just inferior to the glenoid, B the spinoglenoid notch between the base of the acromion and the superior aspect of the glenoid fossa, and C the glenoid cavity with the fracture tracking medially into the body of the scapula.
Mapping of scapular fractures with threedimensional computed tomography. However, the literature varies considerably with other authors advocating surgery for articular stepoff ranging from 2 to 10 mm 20, The decision for surgery as well as the amount or degree of articular step-off, gap, and percentage of joint involvement should be correlated with the patients job, age, activity level, phy siologic status, and hand dominance Fig. The image demonstrates significant glenoid fracture displacement and comminution between the major cephalad and caudad fragments.
B: A 2D-CT axial image of a displaced intra-articular glenoid fracture that extends coronally dividing the glenoid into anterior and posterior fragments. The surgical indications for displaced extra-articular scapula fractures are controversial because there are no randomized controlled studies comparing operative versus nonoperative treatment.
Note that the displacement is measured from A the anatomic location of the lateral border inferior and medial to the glenoid to the tip of the displaced distal fragment B. Clin Orthop Relat Res ; 12 ,. Clin Orthop Relat Res ; 12 , with permission. On the Grashey view, measured from inferior glenoid rim to superior glenoid rim to most distal point of scapula inferior angle. We also advocate operative management of displaced scapular fractures in patients with complex ipsilateral upper extremity injuries particularly in y ounger highly active patients, when two or more of the above criteria are met Fig.
Active mobility of the elbow and wrist is encouraged immediately, but a sling and rest are indicated for 10 to 14 day s. Scapula fractures heal rapidly due to the rich blood supply in the shoulder girdle.
Active range of motion can be started by 4 weeks and advanced quickly. Resistive exercises are begun by 8 weeks and restrictions lifted as sy mptoms allow by 12 weeks. The term superior shoulder suspensory complex is the osseoligamentous relationship between the three scapula processes, described by Goss in Goss theorized that if there were two disruptions in this ring, made up by the acromion, coracoid, and glenoid, as well as their capsule-ligamentous connections, then the glenohumeral joint would be floating, a condition that describes discontinuity between the axial and appendicular skeleton Fig.
Though this theory has been challenged by some authors , Goss recommended surgery if two such disruptions occur simultaneously. We agree with Edwards et al. Goss theorized that if two structures in the ring were disrupted, then a floating shoulder lesion would be present, imply ing that there would be no osseous or ligamentous continuity between the axial skeleton and the forequarter.
Figure 2. Isolated fractures of the acromion or coracoid process are uncommon. Fractures of the acromion process or spine usually occur as a result of a direct blow to the superior shoulder region, whereas coracoid process fractures result from violent traction injuries through the biceps and coracobrachialis. While indications for operative management of these fractures have not been established, we use several criteria to aid in determining the need for surgery. If either an acromion or coracoid fracture is displaced more that 10 mm, or there is an ipsilateral scapula fracture or multiple disruption of the SSSC, then open reduction and internal fixation is warranted 19, When the acromion is displaced more than 5 mm, a supraspinatus outlet view should be obtained and evaluated for acromial depression, which may contribute to an impingement sy ndrome, much like a.
Outcomes following acromion and coracoid process fixation are good with high rates of union 13, Anavian et al. Most were treated with interfragmentary screw fixation and in selective cases with suture fixation. Supplemental mini or small fragment plate fixation was used for coracoid fractures that extended into the glenoid fossa or acromial spine. Similarly, 2. Distal acromion fractures were treated with a tension band or a mini fragment locking plate on the superior surface or along the anterior or posterior acromial edge.
Postoperatively, patients were treated with passiveand active-assisted range of motion for the first month, progressing to resistance exercises after 2 months and full, unrestricted activity by 3 months. All patients were pain free at rest and with upper extremity activities at the time of final follow-up mean 11 months, range 2 to 42 months. Mean DASH score for those patients with functional assessments was 7 0 to 26 , better than that of the uninjured population normative baseline DASH score The only complications in this series were softtissue irritation requiring hardware removal in two patients and removal of ectopic bone in one patient Partial articular fractures, usually involving the anterior glenoid, are commonly associated with anterior shoulder dislocations.
These fractures are often referred to as bony Bankart lesions 42 and may be characterized by anterior shoulder instability. If shoulder instability is present with subluxation of the humeral head on radiographic examination, or clinical examination, then operative intervention, given an appropriate surgical candidate, is recommended. A second ty pe of scapula fracture involves the glenoid neck and body with. In the seriously injured patient, scapular fractures are often overlooked leading to delay s in treatment. It is a common misconception that scapulothoracic dissociation occurs following high-energy blunt trauma, but this is not the case as this devastating injury results from a violent traction force to the upper extremity.
Physical Examination The phy sical examination must be thorough and complete as associated injuries are common particularly to the spine, cranium, and thorax. When possible, the shoulder and upper extremity should be examined with the patient sitting or standing to give good access to the posterior forequarter, which is difficult when the patient is supine in bed or on a gurney. Medial and caudal displacement of the shoulder may be obvious producing marked asy mmetry, particularly if the patient is upright.
Medialization may or may not be apparent on the initial radiographic studies, but once the patient is upright and attempts to move the extremity, the shoulder medializes as the scapula rotates forward over the thorax. In some patients with scapula and multiple rib fractures, the chest wall fails to support the scapula and contributes to deformity Fig. Patients with highly displaced scapula fractures, particularly when associated with multiple ribs or a clavicle fracture, are unable to forward elevate or externally rotate their shoulders, even a few weeks after injury.
Appreciate the dramatic depression and medialization of the forequarter. It is important to assess medialization clinically , and later, postinjury , rather than on a supine injury radiograph or CT scan. Skin integrity should be assessed as abrasions are common after the ty pical mechanism of a direct blow to the shoulder. If surgery is indicated, it should be delay ed until there is skin re-epithelialization around 7 to 14 day s, after injury Fig. Ipsilateral, concomitant, neurovascular injuries are common and require a very careful assessment of the brachial plexus and peripheral pulses.
Axillary nerve sensation should be documented; however, motor function to the deltoid is frequently impossible to determine with displaced fractures. The suprascapular nerve is vulnerable and commonly injured in association with fractures that extend into the spinoglenoid notch at the base of the acromion, so-called true scapula neck variants 18 Fig.
Based upon a review of 96 surgically treated scapula fractures, the senior author identified 14 cases of suprascapular nerve injury almost exclusively associated with these fracture patterns. These studies are of little diagnostic value immediately after injury and should be performed at least 2 weeks after injury when fibrillations and positive sharp waves may be present indicating denervation axonotmesis and neurotmesis 43, Every effort should be made to identify injury early and before surgical intervention, when possible Surgery was delay ed until the skin re-epithelialized in order to decrease the chance of infection.
This fracture pattern is often associated with suprascapular nerve injury. Intraoperative photo illustrating the lacerated suprascapular nerve and its proximity to the glenoid fragment. Intraoperative postreduction and fixation. The glenoid fragment is off of the suprascapular nerve. A Prolene stitch was utilized to tack the lacerated nerve to an adjacent nerve branch and muscle. Radiographic Studies Because high-energy scapula fractures often present in an emergent setting in patients with concomitant chest injuries, a chest x-ray and computed tomography CT scans are routinely acquired during the trauma evaluation.
If a scapula fracture is identified on the screening chest x-ray, dedicated scapular radiographs should be obtained. These include an AP shoulder,. Due to pain, the axillary view is often difficult to obtain. One simple technique we have found helpful is to have the patient hold an IV pole that is slowly abducted to 30 degrees. Another method is to forward elevate the patients arm 15 degrees while the x-ray gantry is directed toward the axilla from a caudal position next to the patients hip. The AP x-ray of the scapula should be taken 35 degrees off the sagittal plane to correspond with the same angular position of the scapula on the thorax, the so-called Grashey view.
The orthogonal scapular Y view is 90 degrees to the AP view. If there is an intra-articular glenoid fracture detected on any x-ray view, then a 2D-CT scan with 1- to 2-mm axial cuts plus coronal and sagittal reformation are helpful for the definition of articular displacement, comminution, and fracture extension Fig. If there is more than 1 cm of fracture displacement at the scapular neck on any view, an AP radiograph of the opposite shoulder is helpful to better define the fracture displacement.
It is not uncommon to be misled on the AP view of the injured shoulder because the glenoid may be angulated through the lateral border fracture, eliminating the normal glenohumeral joint clear space on a technically correct radiograph. In these circumstances, a 3D CT scan can be very helpful to assess the degree of angular deformity, as well as glenoid displacement see Figs. Obtaining an axial 2D-CT in addition to sagittal and coronal reformats is important when intra-articular fractures are present. Axial cuts depicting anterior glenoid comminution.
Semicoronal cuts depicting anterior and inferior comminution. SURGERY The scapula is part of the suspensory mechanism of the shoulder that attaches the upper extremity to the axial skeleton through the clavicle. Eighteen muscles originate or insert on the scapula, which provides a stable. The goal of the surgery is to restore the relationship of the axial and appendicular skeleton as well as length, alignment, rotation, and anatomic reduction of articular surfaces to allow early range of shoulder motion and rehabilitation.
The majority of scapula fractures that require internal fixation can be approached through an anterior deltopectoral or posterior Judet approaches. Additional approaches have been described for aty pical fracture patterns. In an effort to limit incisions and reduce potential surgical morbidity, we also use a minimally invasive posterior approach for select cases Isolated anterior glenoid fractures, as well as associated transverse fracture extending through the glenoid and into the base of the coracoid May o ty pe II fracture , are best treated through a deltopectoral approach.
In most other fractures involving the scapula including the scapular neck or body fracture with or without glenoid involvement are done through a posterior approach. Combined anterior and posterior approaches are rarely necessary. They are indicated with concomitant anterior articular fractures combined with scapula neck and body variants or when there is a highly displaced coracoid and comminuted glenoid in addition to a scapular body or neck fracture.
Lastly, the clavicle or acromioclavicular joint may require its own approach to address these injuries. Although clavicle fractures will be discussed in another chapter, it is important to point out that they can be approached when the patient is either in the beach chair or in the lateral decubitus position. From the posterior perspective, the scapula is a triangular flat bone, with a thin translucent body, surrounded by borders that are well developed and thick and serve as points for muscular origins and insertions.
The lateral border of the scapula sweeps up from the inferior angle, forming the thickest condensation of bone that ends in the neck of the glenoid process. The scapular borders and the glenoid neck provide the thickest and strongest bone for reduction and fixation with plates and screws. From the anterior perspective, the coracoid process is a curved osseous projection off the anterior glenoid neck and serves as the origin for the short head of the biceps, pectoralis minor, and coracobrachialis. The glenoid process, beneath the acromion, contains the pear-shaped glenoid fossa, which is approximately 40 mm in a superior-inferior direction and 30 mm in an anterior-posterior direction in its lower half in adults The patient is positioned in the lateral decubitus position, flopping slightly forward beneath a well-padded axillary roll.
Bumps should be positioned on an arm board to support the affected extremity. Prefabricated upper extremity positioners are very helpful to support the affected extremity Fig. The entire forequarter is widely prepped and draped to allow for unrestricted motion of the shoulder. The bony landmarks around the shoulder are palpated and marked with a sterile pen.
The prominent posterolateral portion of the acromion is palpated and traced medially to the superomedial angle of the scapula and turns distally along the vertebral border. Shucking the scapula with one hand, as if to protract and retract the shoulder to create scapula-thoracic excursion, allows the surgeon to better feel the bony landmarks in large or muscular patients.
Soft BoneFoam positioning wedges allow for a supportive working surface, while protecting the downside arm. The entire arm should be prepped free to allow for manipulation and motion of the glenohumeral joint during the procedure. A Judet posterior incision is made 1 cm below the acromion spine and 1 cm lateral to the vertebral border. This allows for lateral retraction of the flap with adequate coverage of the implants Fig. It is planned along these landmarks: 1 cm caudal to the acromion spine and 1 cm lateral to the vertebral border.
The incision is developed onto the bony ridge of the acromial spine, splitting the interval between the trapezius and deltoid insertions. The incision curves distally at an acute angle just under 90 degrees around the. For access to the lateral border of the scapula, the incision must be extended to allow for mobilization of the infraspinatus. Properly executed, the fascial incision along the acromial spine and medial border should provide a cuff of tissue that can be sutured back to its bony origin at the end of the procedure Fig.
This image shows the posterior Judet approach with the development of a flap from the acromial spine and vertebral borders. This extensile exposure allows full visualization of the entire infraspinatus fossa the posterior scapula from the vertebral border to the lateral border. The surgeons fingers are reflecting the entire flap en mass, and a Cobb elevator is used to dissect the flap off the flat posterior scapular surface. This approach is best reserved for cases that surgery is delay ed more than 10 day s or for cases that are severely comminuted with several displaced fracture lines exiting multiple scapular borders.
It cannot be used when the intra-articular inspection is required. Image of same patient in Figure 2. This patient has a fracture characterized by separation of the glenoid neck from the lateral border up into the spinoglenoid notch. There is extension of another fracture line into the scapular body , which is apparent in this image. What is not apparent is the severe lateral border offset and anteversion of the glenoid articular surface. Note the location and vulnerability of the suprascapular neurovascular bundle exiting from just below the acromion before it enters the infraspinatus muscle.
Based on the preoperative plan, the degree of exposure depends on the need for limited or complete exposure of the posterior scapula. Working through limited intermuscular windows is favored to limit dissection and can be used to access fracture intervals at the lateral border, acromial spine, and vertebral border Fig. Alternatively, an extensile exposure can be performed by elevating all of the muscles from the infraspinatus fossa exposing the entire posterior scapula. The flap can be elevated laterally as far as the lateral scapular border and allows exposure to the glenoid neck. While the extensile approach exposes the entire posterior surface of the scapular body, the entire subscapularis muscular sleeve on the anterior surface of the scapula is preserved, maintaining the blood supply to the scapular body Fig.
An extensile approach that elevates the deltoid, infraspinatus, and teres minor in a single flap is usually reserved for fractures that are over 10 day s old or for complex patterns with four or more exit points around the ring of the scapular perimeter. This extensile exposure allows the surgeon adequate control of the fracture at multiple points to allow mobilization and reduction of the fracture.
It will not allow for exposure of the articular surface of the glenoid due to the large flap, which cannot be retracted sufficiently lateral for joint exposure. For adequate intra-articular exposure, an intermuscular dissection is necessary over the posterior glenohumeral joint. AC illustrate development of this interval as well as mobilization of the infraspinatus from the scapular spine for additional exposure of the scapular body. If limited intermuscular windows are utilized, the Judet fasciocutaneous flap is elevated, and tactically created intermuscular intervals around the scapular perimeter are used to access specific fracture locations Fig.
Master Techniques in Orthopaedic Surgery: Sports Medicine
The intermuscle plane at the spine of the scapula is between the trapezius and the deltoid. By subperiosteal dissection, the inferior margin of the spine is uncovered to expose the rotator cuff muscles. The deltoid is elevated off. We have found that mobilization and careful retraction of the deltoid allow the surgeon to work anteriorly at the lateral border and scapula neck without taking down the deltoid. This technique is more tedious, but spares taking down the deltoid and the need for reattachment and postoperative immobilization.
At the vertebral border of the scapula, the intermuscular interval is between the infraspinatus and the rhomboids Fig. However, the most important window is between the infraspinatus and teres minor to gain access to the lateral border of the scapula and scapular neck. Furthermore, the glenohumeral joint can be exposed to treat intra-articular fractures. Knowledge of the correct intermuscular intervals is crucial to avoid denervation of the infraspinatus, axillary nerve, or posterior humeral circumflex vessels.
Once this interval is developed, the lateral border of the scapula can be exposed, allowing restoration of glenoid version and lateral border offset Fig. If the glenoid articular surface must be visualized, a transverse capsulotomy is made allowing a retractor to be placed on the anterior edge of the glenoid to retract the humeral head Fig.
During the arthrotomy, the capsule should be incised just distal to the labrum and is localized with an gauge needle. There is also an intra-articular glenoid fracture for which a capsulotomy has been performed to allow access to the glenohumeral joint. The lateral border can be reduced using small-pointed bone reduction clamps, small 4 mm external fixation pins as joy sticks, or a plate Figs.
Large reduction tenaculums are difficult to apply because of interference with the large muscular flap. In these cases, small external fixation pins in the proximal and distal fragments can be secured in proper. Alternatively, a 2. If the reduction is not stable, a provisional 2. Occasionally, a larger clamp can be placed at the medial extent of the fracture at the scapula spinal or vertebral borders to help decrease stress on the lateral border to improve the reduction. A Judet extensile approach was used and multiple pointed bone tenaculums are applied at the periphery wherever there is a fracture exit point with displacement.
The 2. In our experience, 2. These plates are lower profile than 3. Two pediatric Kocher clamps are useful for bending and twisting the plates. We favor longer plates and more screws for added stress distribution since each screw is only 8 to 10 mm for the vertebral border. The use of locked small and minifragment plates allows shorter plates given the better screw purchase over shorter working lengths. In the case of a posterior glenoid fracture with intra-articular or neck involvement where there is minimal displacement or involvement of the scapular spine or vertebral border, a direct posterior approach can be employ ed.
In these cases, reduction and fixation can be accomplished solely through the interval between infraspinatus and teres minor. If greater exposure to the glenoid fossa or superior glenoid is desired, an infraspinatus tenotomy can be performed leaving a centimeter of cuff insertion at the greater tuberosity for repair. This allows the slender musculotendinous portion of the infraspinatus to be retracted off the superior glenoid region for better access to the glenohumeral joint.
This maneuver is particularly helpful in large muscular patients and can be used in conjunction with an extensile approach in which the whole infraspinatus and teres minor are elevated. It is repaired with strong nonabsorbable sutures and requires protection from active external rotation for 6 weeks postoperatively. Before wound closure, it is important that any adhesions or shoulder stiffness be released by manipulation of the shoulder prior to waking the patient, especially in patients whose surgery has been more than 2 weeks postinjury.
We routinely use a suction drain under the flap and reattach the rotator cuff with strong nonabsorbable suture through several drill holes at the scapular spine and vertebral border to improve fixation. We prefer an absorbable subcuticular suture for the skin closure. A Minimally Invasive Posterior Approach Approximately three quarters of scapular fractures treated operatively are done through a posterior approach We have recently utilized a.
The use of small incisions distant from the fracture site to introduce implants and apply fixation is a well-accepted technique in the management of long bone fractures. We have applied this concept to fixation of the scapula. Because the scapula is a triangular ring-ty pe bone with predictable fracture exit points, incisions are made at each fracture end, allowing the majority of the scapular body to remain unexposed Fig.
This approach allows for direct reduction of the fracture at its margins without violating soft-tissue attachments along the majority of the fracture across the scapular body. These windows are often adequate for affecting reduction and plate application at these two common sites of displacement.
Clin Orthop Relat Res ; 12 B: Deeper exposure through these limited windows, retractor, and clamp placement, as well as plate positioning. Positioning is the same as for the previously described posterior approaches. Limited incisions are made as necessary depending on the fracture pattern, usually placed laterally over the glenoid neck and lateral border and also medially where the fracture exits at the spine or vertebral border Fig. Through the lateral incision, the dissection is developed to the fascia overly ing the inferomedial margin of the deltoid.
The deltoid is retracted cephalad with a wide retractor, exposing the fascia overly ing the external rotators. The fascia is opened, exposing the teres minor and infraspinatus. The muscular interval between these muscles is developed bluntly, exposing the fracture site as it exits the lateral scapular border. Care must be taken to avoid injury to the axillary nerve and posterior circumflex humeral artery as they pass through the quadrilateral space, distal to the infraspinatus muscle.
Additionally, the infraspinatus is carefully retracted superiorly to avoid injury to the suprascapular nerve as it exits at the spinoglenoid notch 48 Fig. One can clearly see the division between the deltoid and infraspinatus muscles. What is more difficult to discern is the interval between the infraspinatus and teres minor.
Once this important interval has been identified and developed, retractors can be placed to expose the lateral scapula border. Through the medial incision, at the base of the scapula spine at its medial border, dissection is developed to the fascia and then directly down to bone. Subperiosteal dissection is then extended along the vertebral border distally as needed to expose the medial border fracture line for reduction and plate application.
These two small windows are usually adequate for reduction and plate application at the two most common sites of displacement, the lateral and medial scapular borders. Once the lateral and medial incisions have been made and the fracture exposed, a small external fixation pin with small T-handled chuck is placed in the cephalad fragment glenoid neck ,.
The external fixation pins are used as joy -sticks to reduce the fracture. Small-pointed bone reduction forceps may be used laterally and medially to maintain reduction. The clamp may be applied through small pilot holes on either side of the fracture. The external fixation pins and pilot holes must be strategically placed to avoid interference with plate placement Figs.
Because longer plates are not feasible through these small windows, we recommend the use of 2. The fascia is closed with number 0 or 1 absorbable braided suture and the subcutaneous tissue with absorbable braided suture. The skin is closed with running absorbable subcuticular suture. Suction drains are not necessary. Often times, the orthopedic surgeon must coordinate patient care with a spine surgeon prior to positioning and induction of anesthesia. Intraoperative positioning must be carefully executed. It is desirable to have the spinal injury surgically stabilized first to insure protection of the spinal cord, if indicated.
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However, if the spine injury is managed nonoperatively, intraoperative in-line traction with skeletal tongs is preferred. Caliper or tong traction is easier to work around than a cervical collar, with regard to both safety and draping. Suprascapular Nerve Injury Suprascapular nerve injuries are commonly seen following high-energy displaced scapular fractures.
An electromy ogram and NCS should be obtained before surgery in patients who present more than 2 weeks after injury. Most injuries are contusions or neurapraxia. Lacerations to the suprascapular nerve occasionally occur in patients where the fracture extends into the spinoglenoid or suprascapular notches.
The nerve should be visualized and protected at the base of the acromion during the posterior approach in these fracture patterns. If a laceration is discovered, then repairing the lacerated nerve end or branches to the infraspinatus is useful and can promote some recovery of function. Suturing with a nonabsorbable monofilament suture is recommended. Anterior Surgical Approach The patient is placed in a beach chair position with an arm board attached to support the extremity.
A small towel roll is placed under the ipsilateral shoulder to help bring it forward. An x-ray cassette is positioned behind the shoulder during the setup so an intraoperative film can be obtained obviating the need for intraoperative fluoroscopy Fig. A classic anterior deltopectoral incision is made, and the cephalic vein is identified and retracted laterally. The interval between the deltoid and pectoralis major is developed down to the clavi-pectoral fascia, which is opened exposing the coracobrachialis and subscapularis.
The upper and lower borders of the subscapularis tendon are identified as they insert into the lesser tuberosity. At the inferior margin of the subscapularis, muscles are the transversely. With the humerus in a neutral position, the subscapularis tendon is sharply released 1 cm from its insertion on the lesser tuberosity leaving a cuff of tendon for later repair. Frequently adherent to the underly ing joint capsule, the subscapularis should be carefully separated from the underly ing capsule for later closure in distinct lay ers.
Stay sutures are placed on each side of the subscapularis muscle to facilitate closure as well as to prevent medial retraction. The joint capsule is incised longitudinally a few millimeters from the glenoid rim giving access to the glenohumeral joint. Following irrigation of the joint, the glenoid fracture is identified and reduced Fig. The patient is positioned with an x-ray plate behind the shoulder to allow for an intraoperative radiograph.
Because this exposure allows excellent visualization of the anterior glenoid, intraoperative fluoroscopy is rarely necessary. We also routinely place a towel roll under the ipsilateral shoulder to improve shoulder extension and. This patient has a clavicle malunion with clavicle displacement and deformity. The subscapularis has been incised 1 cm from its insertion on the lesser tuberosity , tagged with heavy stay sutures, and retracted medially. The joint capsule has been separated from the undersurface of the subscapularis, tagged with stay sutures, and retracted laterally.
B: With the subscapularis and joint capsule retracted, excellent exposure and visualization of the glenoid and anteroinferior glenoid fragment is obtained. Reduction can be obtained using a dental pick or small elevator and provisionally fixed with Kirschner wires Fig. Fluoroscopy is not needed because the articular fracture reduction is directly visualized. Depending on the size of the fragment or the degree of comminution, fixation is achieved with mini or small fragment screws.
When comminuted, a mini buttress plate is placed on the anteroinferior edge of the glenoid. Lay ered closure of the capsule and subscapularis is done. In cases where additional visualization is necessary due to a large or comminuted anterior glenoid rim that will require a buttress plate, a coracoid osteotomy can be helpful to increase exposure.
The coracoid is predrilled with a 2. Once released, the conjoined tendon and coracoid are reflected distally and medially, which gives excellent exposure of the anterior glenoid and scapular neck. Because the musculocutaneous nerve penetrates the coracobrachialis approximately 5 to 6 cm from the tip of the coracoid, it is important to protect the musculocutaneous nerve during retraction Coracoid osteotomy.
Postoperative AP and axillary lateral radiographs showing anterior glenoid fixation and the coracoid osteotomy repaired with a 3. Postoperative Management Rehabilitation following internal fixation of scapular fractures is based on the concept that stable internal fixation of the fracture allows early passive range of shoulder motion. We often use a regional anesthetic block with an indwelling interscalene catheter for the first 48 to 72 hours postoperatively to allow early range of motion. Passive range of shoulder motion is started on the first or second postoperative day under the direction of a phy sical or occupational therapist.
Active-assisted range of motion is advanced as the patients pain subsides. The goal during the first 4 weeks after surgery is to regain and maintain shoulder motion rather than strength training. Lifting and carry ing with the affected shoulder is delay ed at least 4 weeks and often longer. Following hospital discharge, patients continue therapy as well as a home exercise program using pulley s and supine-assisted motion with pushpull sticks. Ipsilateral elbow, wrist, and hand exercises including 3- to We recommend follow-up at 6 months and at 1 y ear with a single AP x-ray to document radiographic and functional outcomes.
Patients with associated injuries may warrant longer follow-up, especially those with a brachial plexopathy. At the 6-week follow-up visit, shoulder strengthening exercises with weights are begun and advanced as the patients sy mptoms permit. If the patient has persistent loss of shoulder motion, a manipulation under anesthesia should be considered.
This is more common in patients who have a brachial plexus injury, head trauma, cervical spine injuries, or complexassociated fractures of the ipsilateral extremity. Schandelmaier et al. With a mean follow-up of Four complications were reported, including one superficial and one deep infection, one patient had shoulder stiffness, and one patient developed subacromial impingement. In another series of 33 intra-articular glenoid fractures, Anavian et al. Scapula neck fractures should be treated operatively if significant displacement or angulation leads to deformity with functional imbalance of the parascapular musculature.
Ada and Miller 19 recommended internal fixation when the glenoid is displaced medially more than 9 mm or there was more than 40 degrees of angular displacement. Eight patients in this same study were treated operatively, and all achieved a painless range of motion. Hardegger et al. Armstrong and Van Der Spuy 8 noted that 6 of 11 patients with displaced scapula neck fractures had residual stiffness at 6 months. Herrera et al. In all cases, surgery was delay ed due to late referral or the presence.
Despite these challenges, the authors reported marked improvement in radiographic alignment with surgery as well as maintenance of reduction at follow up. Patients were followed for a mean of Radiographic and functional outcomes were obtained for 16 patients, and DASH scores were collected for 14 patients. The authors demonstrated that radiographic and functional outcomes were satisfactory even when surgical treatment was delay ed Recently, the senior author PAC reported the results of reconstruction of scapular malunions in five patients treated at a mean of 15 months after injury.
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All patients were initially treated nonoperatively and presented with debilitating pain, weakness, and were unable to return to work. Four of five patients had associated injury to the chest wall and two had ipsilateral clavicle fractures resulting in a floating shoulder or double disruption to the SSSC.
All patients underwent osteotomy and reconstruction, followed by early rehabilitation. Radiographic measurements, range of motion, strength testing, DASH, and SF questionnaires were performed preoperatively and postoperatively with a mean follow-up of 39 months 18 to months. All patients were pain free with regard to the shoulder, and all were united radiographically. Mean DASH scores improved from 39 27 to 58 to 10 0 to Mean ROM and strength improved in all six measures and were significantly different from the contralateral, uninjured extremity in only external rotation strength.
There were no complications, and four of the five patients returned to their previous occupation and recreational activities. One patient was unable to return to work as a truck driver and attributed this to a lower back condition related to spine fractures Herscovici et al. In this series, all patients achieved excellent functional results with no deformity at Two other patients in this series treated nonoperatively had significant shoulder drooping and decreased range of motion. Others have advocated internal fixation of just the clavicle as well for restoration of length and sufficient stability Leung et al.
Ramos et al. Ninety -two percent had good or excellent results at 7. A significant shortcoming of the three former studies is that none documented the degree of displacement of the scapula neck fracture, and in the latter, the radiologic outcome was noted to be good in all but one, suggesting minimal original displacement. In a recent retrospective study by Edwards et al. Nineteen of twenty healed uneventfully, with excellent range of motion and function, but only 2 of 20 scapula fractures and 8 of 20 clavicle fractures were displaced more than 1 cm.
Missed or delay ed diagnosis of a displaced fracture or nerve injury may result in malunion or nonunion, which may cause deformity, dy skinesis, or weakness, leading to pain, glenohumeral instability, crepitance, rotator cuff dy sfunction, and glenohumeral degenerative joint disease Fortunately, the rate of risk in ORIF for scapula fractures is quite low in the published literature. Peripheral nerve injury inclusive of suprascapular, axillary, and musculocutaneous nerves all have injury potential given their proximity to surgical approaches; however, the published incidence is rare, partly due to the difficulty of determining whether neurologic injury is due to the injury.
Scapula fracture patterns involving the suprascapular and spinoglenoid notches are associated with an increased risk of suprascapular nerve injury. The surgeon must command a thorough anatomical knowledge of the danger zones to avoid insulting surgical forces. The greatest risk is for suprascapular nerve injury during a posterior approach, given the excessive infraspinatus elevation that occurs from gaining exposure to the lateral border and glenoid neck. Wijdicks et al. Risks of iatrogenic nerve injury during anterior.
A well-reported complication is shoulder stiffness. This may be particularly true for patients who have been mobilized for excessive periods either before or after surgery. Our policy is to manipulate the shoulder after fixation and while the patient is still asleep to release all intrinsic and extrinsic contractures. This is salient when the patients surgery is delay ed.
Patients with cognitive delay, head injury, multiple extremity injuries are all vulnerable to stiffness, and occasionally if a patient is not progressing rapidly toward normal motion by 6 weeks postoperatively, a manipulation under anesthesia should be arranged. To this procedure, we alway s add an intraarticular steroid injection to prevent reoccurrence of scar tissue after intraarticular fractures. It is rare that patients need this formal procedure, but is effective at giving them a kick start when indicated.
There is a low rate of implant failure associated with ORIF of scapulas with plates and screws, and reported malunion rates are almost nonexistent. Lantry et al. Our strategy to prevent hardware failure includes the use of either locking plates or long plates with conventional screws to mitigate pullout and also provide stability to the whole scapular perimeter with the use of vertebral border and scapula spine plates when fractures. Due to the robust blood supply to the shoulder, both infection and nonunion should be rare occurrences if principles are followed, and the complications that tend to occur are treatable, assisting the surgeon and patient greatly with the decision to weigh the risks and benefits of operative management.
He was initially diagnosed with multiple bilateral rib fractures, bilateral pneumothorax, sternal fracture, complex spine fractures, acromioclavicular dislocation, renal injury, as well as a traumatic brain injury. The patient required an exploratory laparotomy and internal. He was subsequently transferred to our hospital for additional care. Phy sical examination at 5 weeks postinjury revealed that the left shoulder was significantly depressed with diminished sensation in axillary nerve, and there was a profound loss of left shoulder of motion due to stiffness and pain. An AP radiograph of the shoulder showed a displaced glenoid neck fracture with a dislocated acromioclavicular joint.
Due to the degree of displacement, a CT with 3D reconstructions was obtained for more accurate measurements and preoperative planning. Also seen on this view is a dislocated acromioclavicular joint. Hundred percent displacement of the scapular body is seen on the Y view. The malrotated position of the glenoid is clearly visible when compared to the contralateral shoulder in this image. The CT scan revealed: Lateral Border Offset: 38 mm Angular Deformity : 45 degrees Glenopolar Angle: 18 degrees The fracture pattern was aty pical in that there was a large segmental component of the lateral border.
The indications for surgery included a double disruption of the SSSC. Although there is no literature on glenoid version to suggest operative indications, the anteversion measured 32 degrees Figs. An EMG was performed preoperatively because of sensory changes noted and verified the presence of a complete axillary mononeuropathy.
The suprascapular nerve was not tested due to patient intolerance of the exam.
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B: 3D CT scan oriented in PA view demonstrates medial-lateral displacement of the glenoid fragment orange dashed line and lateral border green dashed line relative to the scapular body blue. C: 2D axial CT image depicting 32 degrees of glenoid anteversion relative to scapular body.
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B: 3D CT with images manipulated such that the lateral border is reduced to its normal, anatomic location note that the lateral border is straight from the glenoid neck to the inferior angle of the scapula. With the lateral border reduced, one can appreciate the true lateral border offset 38 mm of the glenoid relative to the anatomic position of the lateral border.
C: 3D CT with glenoid and lateral border reduced anatomically. The glenoid relative to the lateral border, increased GPA, restored glenoid retroversion and repositioning of the acromion more vertically , decreasing the potential for rotator cuff impingement. An extensile posterior Judet approach with elevation of the infraspinatus and teres flap was performed because the fracture was 6 weeks old and required osteoclasis to mobilize the four major fragments.
Furthermore, multiple exit points of the fracture along the scapula perimeter were needed for reduction and fixation. Longer plates were necessary for stable fixation of the segmental fracture at the lateral border, glenoid neck, and scapula spine Fig. Judet Flap. A: Marked displacement of the lateral border with angulation. B: There is a bone void after the fracture has been disimpacted, reduced, and fixed in an anatomic position. C: Callus removed at the time of exposure is used as bone graft before placing a drain and repairing the Judet flap.
The patient was placed in the lateral decubitus position, leaning forward. During flap elevation, care was taken to protect the neurovascular bundle. The callus was removed from the fracture site so that the reduction could be visualized. External fixation pin joy sticks with T-handled chucks were used in the glenoid neck and lateral border to achieve fracture reduction. A provisional reduction was obtained with clamps at all borders including the lateral border at two locations. A hole 2. These long plates were favored over multiple small plates to create a stronger construct.
A second plate was placed along the lateral border to reinforce this area, which was under significant deforming force post reduction. The callus was used as bone graft. The acromioclavicular joint was reduced and stabilized through a second incision using a tightrope technique Arthrex, Naples, Florida Fig. Phy sical therapy was begun for full active and passive range-of-motion exercises. At 6 months, the patient had significant improvement in both range of motion and strength. His DASH score was 22 at this visit, and we were optimistic for a full return in shoulder function in spite of his severe constellation of injuries.
Radiographs revealed a healed fracture. The epidemiology of fractures. In: Bucholz RW, ed. Fractures in adults. Butters KP. The scapula. The shoulder, vol 1. Imatani RJ. Fractures of the scapula: a review of 53 fractures. J Trauma ;15 6 Rowe CR. Fractures of the scapula. Surg Clin North Am ; The significance of scapular fractures. J Trauma ;25 10 Management of Scapula Fractures. J Am Acad Orthop Surg ;20 3 The operative treatment of scapular fractures. J Bone Joint Surg Br;66 5 The fractured scapula: importance and management based on a series of 62 patients. Injury ;15 5 Recent fractures of the scapula.
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