Review Question - QID 219951

The typical approach used for scapular fractures is the Judet approach. This posterior extensile approach uses the internervous plane between the infraspinatus and teres minor. The infraspinatus is innervated by the suprascapular nerve (B), and the teres minor is innervated by the axillary nerve (D) (Answer 4).

Scapular fractures are relatively uncommon injuries, accounting for less than 1% of all fractures, often resulting from high-energy trauma like motor vehicle accidents or falls. The scapula is a highly vascularized and well-protected bone with extensive muscular attachments, and as such, fractures typically occur in conjunction with other injuries, like rib fractures or pulmonary trauma. Treatment varies depending on the fracture's location and severity. Most scapular fractures can be managed conservatively with rest, immobilization in a sling, and physical therapy to restore range of motion and shoulder strength. Surgical intervention is generally reserved for significantly displaced fractures, glenoid articular surface involvement, or fractures leading to scapulothoracic dissociation, as these cases may significantly impair shoulder function if untreated.

Cole et al. perform a video review of the extensile Judet and the modified Judet posterior approaches to the shoulder. In their first segment, the authors highlight the modified Judet approach with its “boomerang” incision and fixation through an intermuscular window. This approach does not have the same level of exposure as the extensile approach but avoids significant muscular trauma. In the second video, the authors demonstrate the extensile approach with its accompanying single periosteocutaneous flap. While both procedures use the same incision, there is a significant difference in the final exposure obtained and soft tissue morbidity.

Gauger et al. review a minimally invasive approach to scapula neck and body fractures. In this technique, the incisions are made along the anatomic bony perimeter to access the scapular borders for reduction and fixation. Because the incisions are centered over sites of "perimeter" fracture displacement, there is minimal soft tissue retraction and less muscular stripping. The authors then review their series of seven patients who were treated with this technique. Six of the seven patients returned to their original occupation/activities, and both strength and motion returned to equivalency with the uninjured shoulder.

Pires et al. review current literature to address critical aspects of decision-making for the management of scapular fractures. In their review, the authors describe classification systems and treatment strategies, including conservative and operative treatments. Surgical indications include articular displacement or involvement, medialization of the scapula, and angulation. Although most scapula fractures may be safely managed with conservative treatment, caution should be taken to ensure that the correct surgical treatment is indicated in selected cases.

Figure A shows the brachial plexus with several nerves labeled as follows: (A) Dorsal scapular, (B) Suprascapular, (C) Long thoracic, (D) Axillary, (E) Musculocutaneous. Illustration A is a labeled version of Figure A.

Incorrect answers:
Answer 1-3,5: The internervous plane for the Judet approach is between the suprascapular nerve (B) and the axillary nerve (D).