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Arm sling for 1-2 weeks followed by graduated advancement of range of motion
15%
230/1516
Figure-of-Eight sling for 1-2 weeks followed by graduated advancement of range of motion
3%
51/1516
Open reduction internal fixation of only the scapula utilizing deltopectoral approach
1%
11/1516
Open reduction internal fixation of only the scapula only utilizing the extensile Judet approach
8%
123/1516
Open reduction internal fixation of the scapula and clavicle
72%
1089/1516
Select Answer to see Preferred Response
The imaging shows a displaced extra-articular scapula fracture and comminuted clavicle fracture, creating an unstable shoulder girdle which requires fixation of both fractures. Scapula fractures have traditionally been treated with benign neglect given the shoulder's great capacity for compensatory motion despite malunion. Not until recently have surgeons quantified the amount of disability displaced scapula fractures can cause and begun surgically treating these. Despite this, few high-level studies exist that delineate criteria for surgical stabilization. The few consensus indications that exist for extra-articular fractures include medial displacement over 2cm, flexion-extension angulation over 45 degrees, and glenopolar angle less than 22 degrees. Additionally, double disruptions in the superior shoulder suspensory complex (as in this case) create an unstable shoulder girdle and warrant fixation. Schroder et al. evaluated 61 patients with extra-articular scapula fractures following internal fixation. At an average of 33 months, all patients achieved union, had symmetric shoulder motion compared to contralateral side, and had DASH scores comparable to the normative population. This shows the effectiveness of internal fixation in restoring shoulder function and may lead to excellent patient outcomes. Cole et al. discussed surgical approaches for scapular fractures. They prefer the modified Judet approach for acute fractures, whereas for delayed presentations, the extensile Judet approach yields was preferred. Both approaches utilize a boomerang incision that outlines the scapular spine and medial border. The modified Judet splits the infraspinatus-teres minor interval, while the extensile Judet reflects the muscles laterally from their medial origin. Cole et al. discussed management of scapular fractures. They described the superior shoulder suspensory complex, which consists of the coracoid, coracoclavicular ligaments, clavicle, acromioclavicular joint, acromion, and glenoid/scapula. With injuries to 2 structures within this complex, the shoulder girdle is itself unstable and warrants surgical fixation. Figures A and B are Grashey and Scapular-Y radiographs showing the scapula and clavicle fractures. Figures C and D are 3D reconstructions from the CT which better detail the injury. Illustration A is the post-operative radiograph of this injury. Illustrations B-D depict the measurements of glenopolar angle, scapular medialization, and fracture angulations, respectively. Incorrect Answers: Answers 1 and 2- The is an unstable injury and would be best treated with surgery. Answers 3 and 4- Previously some surgeons would elect to fix only the clavicle in this situation but both structures require surgical fixation.
3.0
(6)
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