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The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?
Supraspinatus and infraspinatus
Supraspinatus and subscapularis
Infraspinatus and teres minor
Teres minor and teres major
Teres major and lattisimus
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The posterior or modified Judet approach to the scapula is typically used for internal fixation of scapular fractures. This approach utilizes a transverse incision over the scapular spine with detachment of the posterior deltoid. The interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.) is identified and used to gain access to the posterior aspect of the scapula and glenoid.
The reference by Obremskey et al argues the approach "combines several important goals including: 1) exposure of all bony elements of the scapula which have adequate bone stock for internal fixation; 2) minimal trauma to the rotator cuff musculature; and 3) protection of the major neurologic structures (suprascapular nerve superiorly and axillary nerve laterally)." They believe "the main advantage of the exposure is limiting muscular dissection, which can potentially improve rehabilitation and limit morbidity of the operation."
Obremskey WT, Lyman JR
J Orthop Trauma. 2004 Nov-Dec;18(10):696-9. PMID: 15507823 (Link to Abstract)
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A patient sustains a displaced scapular neck fracture. What is the internervous plane for a posterior approach to the glenohumeral joint?
Long thoracic-spinal accessory
Surgical fixation of a scapular neck fracture is performed via the Judet approach, a posterior approach to the scapula/glenoid. The internervous plane is between the infraspinatus (suprascapular nerve) and the teres minor (axillary nerve).
As outlined by Ball et al, the posterior branch of the axillary nerve has intimate association with the inferior aspects of the glenoid and shoulder joint capsule, which may place it at particular risk during a posterior approach to the shoulder.
Ball CM, Steger T, Galatz LM, Yamaguchi K
J Bone Joint Surg Am. 2003 Aug;85-A(8):1497-501. PMID: 12925629 (Link to Abstract)
Average 4.0 of 26 Ratings
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?
Immobilization in sling x 2 weeks then PT
Immobilization in sling x 8 weeks then PT
ORIF via a deltopectoral approach
ORIF via a posterior approach
ORIF via a lateral approach
The radiographs are consistent with a extra-articular glenoid neck fracture, which by definition is not significantly displaced. These fractures are best treated with a sling (2 weeks) and early mobilization. Significantly displaced fractures, have translational displacement greater than or equal to 1 cm or angulatory displacement greater than or equal to 40°. These typically need ORIF.
A schematic of the fracture types is shown in Illustration A.
McGahan et al review the epidemiology of scapula fractures and advocate conservative treatment with early mobilization.
Van Noort et al reviewed 13 scapular neck fractures and found that non-operative treatment in the absence of ipsilateral shoulder injury and associated neurological impairment lead to good functional outcomes, with or without significant translational displacement of the fracture.
McGahan JP, Rab GT, Dublin A.
J Trauma. 1980 Oct;20(10):880-3. PMID: 6252325 (Link to Abstract)
van Noort A, van Kampen A
Arch Orthop Trauma Surg. 2005 Dec;125(10):696-700. PMID: 16189689 (Link to Abstract)
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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?
Increased length of hospital stay
Increased mortality rate
Increased rate of extremity fracture(s)
Increased Injury Severity Scores
Increased length of intensive care unit stay
According to the reference by Veysi et al, patients presenting to a trauma center with scapula fractures have an increased rate of pulmonary complications and increased Injury Severity Scores (ISS), but have no difference in mortality, length of ICU stay, or overall hospital stay. No differences were seen in abdominal or head injury rates either. A lower rate of extremity fractures was seen as compared to non-scapular fracture patients in their series.
According to the referenced study by Brown et al, rib fx (44%) are the most common associated injury with scapula fractures.
Veysi VT, Mittal R, Agarwal S, Dosani A, Giannoudis PV.
J Trauma. 2003 Dec;55(6):1145-7. PMID: 14676662 (Link to Abstract)
Brown CV, Velmahos G, Wang D, Kennedy S, Demetriades D, Rhee P.
Am Surg. 2005 Jan;71(1):54-7. PMID: 15757058 (Link to Abstract)
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HPI - RTA - 2 wheeler rider collided with a stationary vehicle - closed fracture of the left clavicle, scapula and left multiple rib fractures with haemopneumothorax - haemodynamically stable.
Normal neurovascular examination of the upper limb. Other injuries - L3 wedge #, Left iliac crest fracture.
How would you manage the scapular fracture?
HPI - RTA - 2 wheeler rider - fall onto right outstretched hand - painful right shoulder movements - closed injury - neurovascularly intact
How would you classify this scapula fracture?
HPI - This unfortunate 28 year-old-male was shot by a machine gun in September 2014 in the Libyan civil war and sustained this isolated injury.
No surgical intervention was performed at that time.
How would you classify the scapula fracture?
HPI - Polytrauma 1,5 years ago. Fracture of left ribs (1st-8th). Fracture of C7, D1 and D2 vertebrae. Fracture of external maleoli of right ankle. All treated conservatively. And displaced fracture of left scapula which is also treated conservatively
At this time, the patient presents with moderate pain in the scapular area which referres to the lateral and anterior part of the chest together with sensation of numbness in the chest area. This symptoms appear after the mobilisation of the left shoulder
What is the cause of the patient´s symptoms?
HPI - RTA ... with right shoulder injury
HPI - RTA on 4/8/2015.Pt presented to ER complaining of difficulty to move his rt shoulder,
How you will manage this fructure.?
HPI - s/p skiing accident, had LOC at the site. R shoulder and chest pain currently.
How would you treat this injury?
HPI - 45 yo RHD laborer with hx of fall 4 weeks ago with worsening pain. evidence of AC joint separation and displaced coracoid fracture.
What are your pearls for coracoid reduction and screw fixation? Would you use standard deltopectoral approach and release CA ligament and pec minor? Would you perform a distal clavicle excision to assist with clavicle reduction? Tips on use of hook plate for AC joint??
What would be your treatment of combined AC joint and coracoid frx?
HPI - 35 yo left hand dominant male that fell on the ice 1 week ago with left shoulder glenoid fracture with displacement
What is the best treatment for this patient?
HPI - 33 year old male, right handed, handworker.
Motorcycle accident one year ago with left shoulder trauma.
Initially diagnosed as AC joint sprain and treated conservatively.
Long rehab, didn't regain his work because of shoulder pain.
Seen for the first time in our office one year after his accident.
Assuming an EMG shows normal function of the deltoid, How would you treat this injury?
HPI - 18 y.o. male trauma patient with R Type VI AC separation, and minimally displaced glenoid neck fracture. Other injuries include multiple C-spine fractures, without neurologic compromise.
How would you treat a Type VI AC joint separation?
Educational video describing fracture classifications of the scapula. Become a f...