Scapula Fractures

Author: Brian Weatherford

Topic updated on 04/10/13 6:14am

Introduction

Uncommon fracture pattern associated with high energy trauma
- less than 1% of all fractures
- 50% involve body and spine
- 10-15% associated mortality rate
  - usually pulmonary or head injury
- associated with Increased Injury Severity Scores
Associated injuries in 80-90%
- rib fractures (52%)
- pulmonary injury
  - pneumothorax (32%)
  - pulmonary contusion (41%)
- head injury (34%)
- ipsilateral clavicle fracture (25%)
- spine fracture (29%)
- vascular injury (11%)
- brachial plexus injury (5%)
  - 75% of brachial plexus injuries resolve

Classification

Classification is based on the location of the fracture and includes
- 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

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 ▶

DISCUSSION: 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."

REFERENCES:

2. Obremskey WT, Lyman JR. A modified judet approach to the scapula. J OrthopTrauma. 2004 Nov-Dec;18(10):696-9. PMID:15507823 (Link to Abstract)

Question Authors:

Robert Boykin MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

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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 ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Ball CM, Steger T, Galatz LM, et al. The posterior branch of the axillary nerve: An anatomic study. JBJS. 203;85:1497-1501 PMID:12925629 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore,

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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 ▶

DISCUSSION: The radiographs are consistent with a Type I extra-articular glenoid neck fracture, which by definition is not significantly displaced. Type I fractures are best treated with a sling (2 weeks) and early mobilization. Significantly displaced fractures (Type 2), as defined by Goss, 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.

Illustrations: A

REFERENCES:

1. Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1291 -1301.

2. McGahan JP, Rab GT, Dublin A: Fractures of the scapula. J Trauma 1980;20;880-883. PMID:6252325 (Link to Abstract)

3. Van Noort A, van Kampen A: Fractures of the scapula surgical neck: Outcome after conservative treatment in 13 cases. Arch Orthop Trauma Surg 2005;123:696-700. PMID:16189689 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Michael Hughes MD,

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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 ▶

DISCUSSION: 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.

REFERENCES:

1. Veysi VT, Mittal R, Agarwal S, Dosani A, Giannoudis PV. Multiple trauma and scapula fractures: so what? J Trauma. 2003 Dec;55(6):1145-7. PMID:14676662 (Link to Abstract)

2. Brown CV, Velmahos G, Wang D, Kennedy S, Demetriades D, Rhee P. 2005 Jan;71(1):54-7. Association of scapular fractures and blunt thoracic aortic injury: fact or fiction? Am Surg. PMID:15757058 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Michael Hughes MD,

Please Rate Educational Value!

2.0

Average 2.0 of 26 Ratings

Cases

http://upload.orthobullets.com/cases/1082/sagittal ct shoulder.jpg

http://upload.orthobullets.com/cases/1082/ap shoulder.jpg

Type VI AC joint separation (C1082)

Trauma - - Scapula Fractures

HPI - 18 y.o. male trauma patient with R Type VI AC separation, and minimally displace...

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11/7/2011

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Videos

Scapular Fracture Classification Animation - Everything You Need To Know - Dr. Nabil Ebraheim

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Groups

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Van Noort A, van Kampen A: Fractures of the scapula surgical neck: Outcome after conservative treatment in 13 cases. Arch Orthop Trauma Surg 2005;123:696-700. PMID:16189689 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

McGahan JP, Rab GT, Dublin A: Fractures of the scapula. J Trauma 1980;20;880-883. PMID:6252325 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Browner BD, Jupiter JB, Levine AM (eds): Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1291 -1301.
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009

Undefined

Ball CM, Steger T, Galatz LM, et al. The posterior branch of the axillary nerve: An anatomic study. JBJS. 203;85:1497-1501 PMID:12925629 (Link to Abstract)
Brown CV, Velmahos G, Wang D, Kennedy S, Demetriades D, Rhee P. 2005 Jan;71(1):54-7. Association of scapular fractures and blunt thoracic aortic injury: fact or fiction? Am Surg. PMID:15757058 (Link to Abstract)
Obremskey WT, Lyman JR. A modified judet approach to the scapula. J OrthopTrauma. 2004 Nov-Dec;18(10):696-9. PMID:15507823 (Link to Abstract)
Veysi VT, Mittal R, Agarwal S, Dosani A, Giannoudis PV. Multiple trauma and scapula fractures: so what? J Trauma. 2003 Dec;55(6):1145-7. PMID:14676662 (Link to Abstract)

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Scapula Fractures

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