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Introduction
  • Uncommon fracture pattern associated with high energy trauma
    • 2-5% associated mortality rate
      • usually pulmonary or head injury
      • associated with Increased Injury Severity Scores
  • Epidemiology
    • incidence
      • less than 1% of all fractures
    • location
      • 50% involve body and spine
  • Associated injuries (in 80-90%) 
    • orthopaedic
      • rib fractures (52%) 
      • ipsilateral clavicle fracture (25%)
      • spine fracture (29%) 
      • brachial plexus injury (5%)
        • 75% of brachial plexus injuries resolve
    • medical
      • pulmonary injury
      • pneumothorax (32%)
      • pulmonary contusion (41%)
      • head injury (34%)
      • vascular injury (11%)
Classification
  • Classification is based on the location of the fracture and includes post
    • coracoid fractures
    • acromial fractures
    • glenoid fractures
    • scapular neck fractures
      • look for associated AC joint separation or clavicle fracture 
      • known as "floating shoulder" 
    • scapular body fractures
      • described based on anatomic location 
    • scapulothoracic dissociation topic
Coracoid Fracture Classification
Type I Fracture occurs proximal to the coracoclavicular ligament
Type II Fracture occurs towards the tip of the coracoid  

Acromial Fracture Classification 
Type I Nondisplaced or minimally displaced
Type II Displaced but does not compromise the subacromial space
Type III Displaced and compromises the subacromial space

Ideberg Classification of Glenoid Fracture
Type Ia  Anterior rim fracture      
Type Ib Posterior rim fracture  
Type II Fracture line through glenoid fossa exiting scapula laterally
Type III Fracture line through glenoid fossa exiting scapula superiorly  
Type IV Fracture line through glenoid fossa exiting scapula medially
Type Va Combination of types II and IV
Type Vb Combination of types III and IV  
Type Vc Combination of types II, III, and IV  
Type VI Severe comminution  

 

Imaging
  • Radiographs
    • recommended views
      • true AP, scapular Y and axillary lateral view 
  • CT
    • intra-articular fracture 
    • significant displacement
    • three-dimensional reconstruction useful 
Treatment
  • Nonoperative
    • sling for 2 weeks, followed by early motion
      • indications
        • indicated for vast majority of scapula fractures
        • 90% are minimally displaced and acceptably aligned
      • outcomes
        • union at 6 weeks
        • can expect no functional deficits
  • Operative
    • open reduction internal fixation
      • indications
        • glenohumeral instability
          • > 25% glenoid involvement with subluxation of humerus
          • > 5mm of glenoid articular surface step off or major gap
          • excessive medialization of glenoid
        • displaced scapula neck fx
          • with > 40 degrees angulation or 1 cm translation
        • open fracture
        • loss of rotator cuff function
        • coracoid fx with > 1cm of displacement
      • outcomes
        • 70% good to excellent results with operative treatment
Surgical Technqiues
  • Open Reduction Internal Fixation of Scapula
    • approach
      • based on fracture location
      •  Judet approach is most common 
        • utilizes internervous plane between infraspinatus (suprascapular nerve) and teres minor (axillary nerve)  
 

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