Review Question - QID 219879

The most appropriate approach for fixation includes the Modified Judet approach, which utilizes the interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.) (Answer 3).

Scapula fractures are rare injuries, representing less than 1% of all fractures and often occurring secondary to high-energy trauma. Despite this, most scapula fractures receive 'benign neglect' and are treated nonoperatively secondary to the flat bone's robust soft tissue envelope and vascular supply. Rarely, scapula fractures require operative fixation, with intraarticular involvement resulting in glenoid incongruity, scapular neck fracture with significant medialization (typically greater than 20 mm), fractures resulting in angulation greater than 40° or a glenopolar angle of less than 22°, and floating shoulder ("double disruption" of the superior shoulder suspensory complex) injuries serving as indications. The practical approach to addressing the intra-articular step-off in glenoid fractures includes the Modified Judet approach, which utilizes the interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.).

Schroder et al. prospectively collected patients who sustained scapula fractures and met indications for ORIF over nine years, seeking to characterize the clinical and functional outcomes following fixation of these injuries. The authors noted a 100% union rate with strength and range of motion nearly equivalent to the contralateral, normal extremities. The authors conclude that scapula fractures that meet the criteria for operative fixation can expect to achieve good outcomes.

Cole et al. reviewed the presentation, management, and outcomes of scapular fractures. The authors note that surgical management of scapula fractures is controversial, given the high degree of healing associated with extra-articular fractures. Moreover, no consensus exists regarding surgical management, as most of the literature has been limited to low-level studies. The authors recommend performing ORIF only after meticulous evaluation, careful practice, and preparation.

Figures A & B represent orthogonal views of the right scapula demonstrating an intra-articular glenoid fracture with displacement. Figure C is an axial CT further delineating the intra-articular fracture pattern. Illustration A is a post-operative AP image of the right shoulder following ORIF.

Incorrect Answers:
Answer 1: The upper and lower subscapular nerves innervate the subscapularis, and represent no true internervous interval to the glenoid
Answer 2: This represents the deltopectoral approach, where the deltoid (axillary n.) and pectoralis major (medial and lateral pectoral nerves) are split to access the glenohumeral joint
Answer 4: This internervous plane lies between the teres minor and major, an interval not typically utilized when needing to access the glenoid
Answer 5: the only approach without a true internervous approach to access the glenohumeral joint is the deltoid-splitting approach, which is not utilized for glenoid fracture fixation