Scapula Fractures

Topic updated on 04/20/14 5:59am
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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Qbank (4 Questions)

TAG
(OBQ08.134) The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles? Topic Review Topic

1. Supraspinatus and infraspinatus
2. Supraspinatus and subscapularis
3. Infraspinatus and teres minor
4. Terers minor and teres major
5. Teres major and lattisimus

PREFERRED RESPONSE ▶
TAG
(OBQ07.122) A patient sustains a displaced scapular neck fracture. What is the internervous plane for a posterior approach to the glenohumeral joint? Topic Review Topic

1. lateral pectoral-axillary
2. subscapular-musculocutaneous
3. suprascapular-axillary
4. long thoracic-spinal accessory
5. suprascapular-subscapular

PREFERRED RESPONSE ▶
TAG
(OBQ06.159) A 35-year-old male is involved in a motor vehicle accident and suffers the fracture shown in Figure A. This is an isolated shoulder injury, and he has no neurologic deficits on physical exam. CT scan of the scapula shows the glenoid to be translated medially 3mm, and anglulated 20 degrees from its anatomic axis. What is the most appropriate initial treatment for this injury? Topic Review Topic
FIGURES: A          

1. Immobilization in sling x 2 weeks then PT
2. Immobilization in sling x 8 weeks then PT
3. ORIF via a deltopectoral approach
4. ORIF via a posterior approach
5. ORIF via a lateral approach

PREFERRED RESPONSE ▶
TAG
(OBQ06.266) In trauma patients with multiple injuries, patients with scapula fractures have been shown to have an association with which of the following, as compared to patients without scapula fractures? Topic Review Topic

1. Increased length of hospital stay
2. Increased mortality rate
3. Increased rate of extremity fracture(s)
4. Increased Injury Severity Scores
5. Increased length of intensive care unit stay

PREFERRED RESPONSE ▶



Cases

http://upload.orthobullets.com/cases/1867/m_upperext_20140407_194939.jpg http://upload.orthobullets.com/cases/1867/m_upperext_20140407_194810.jpg http://upload.orthobullets.com/cases/1867/m_upperext_20140407_194756.jpg
HPI - 45 yo RHD laborer with hx of fall 4 weeks ago with worsening pain. evidence of...
poll What would be your treatment of combined AC joint and coracoid frx?
2 weeks ago
235 responses
5
http://upload.orthobullets.com/cases/1780/l shoulder glenoid fx..jpg http://upload.orthobullets.com/cases/1780/m_upperext_20140206_220858..jpg http://upload.orthobullets.com/cases/1780/m_upperext_20140206_220928..jpg
HPI - 35 yo left hand dominant male that fell on the ice 1 week ago with left shoulder...
poll What is your planned treatment?
2/6/2014
71 responses
3
http://upload.orthobullets.com/cases/1678/andrtg.jpg http://upload.orthobullets.com/cases/1678/ct1.jpg http://upload.orthobullets.com/cases/1678/ct2.jpg
HPI - fall on right shoulder (alcohol) CT: humerus AO 11B2, scapula Ideberg II
poll What is the best treatment option?
11/3/2013
846 responses
4
http://upload.orthobullets.com/cases/1544/first.jpg http://upload.orthobullets.com/cases/1544/first 2.jpg http://upload.orthobullets.com/cases/1544/recent.jpg
HPI - 33 year old male, right handed, handworker. Motorcycle accident one year ago w...
poll What do next?
6/25/2013
1453 responses
4
http://upload.orthobullets.com/cases/1082/coronal ct shoulder.jpg http://upload.orthobullets.com/cases/1082/sagittal ct shoulder.jpg http://upload.orthobullets.com/cases/1082/ap shoulder.jpg
HPI - 18 y.o. male trauma patient with R Type VI AC separation, and minimally displace...
poll How would you treat this Type VI AC joint injury?
11/7/2011
27 responses
4
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Videos

video
Educational video describing fracture classifications of the scapula. Become a f...
8/13/2012
1403 views
4
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Posts

post
Obremskey WT, Lyman JR
J Orthop Trauma. 2004 Nov-Dec;18(10):696-9. PMID: 15507823 (Link to Pubmed)
1/18/2014
20 responses
4
post
Ball CM, Steger T, Galatz LM, Yamaguchi K
J Bone Joint Surg Am. 2003 Aug;85-A(8):1497-501. PMID: 12925629 (Link to Pubmed)
1/18/2014
4 responses
0
post
van Noort A, van Kampen A
Arch Orthop Trauma Surg. 2005 Dec;125(10):696-700. PMID: 16189689 (Link to Pubmed)
12/15/2013
34 responses
0
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