http://upload.orthobullets.com/topic/1013/images/scapula fx.jpg
http://upload.orthobullets.com/topic/1013/images/scapula fx - coracoid classification.jpg
http://upload.orthobullets.com/topic/1013/images/acrom class.jpg
http://upload.orthobullets.com/topic/1013/images/ideberg illustration 2.jpg
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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Questions (4)

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

QID:520
1

Supraspinatus and infraspinatus

7%

(81/1145)

2

Supraspinatus and subscapularis

1%

(16/1145)

3

Infraspinatus and teres minor

85%

(974/1145)

4

Terers minor and teres major

3%

(30/1145)

5

Teres major and lattisimus

3%

(39/1145)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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."


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

QID:783
1

Lateral pectoral-axillary

2%

(6/322)

2

Subscapular-musculocutaneous

1%

(3/322)

3

Suprascapular-axillary

85%

(274/322)

4

Long thoracic-spinal accessory

3%

(10/322)

5

Suprascapular-subscapular

7%

(24/322)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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:

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(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? Review Topic

QID:345
FIGURES:
1

Immobilization in sling x 2 weeks then PT

58%

(452/775)

2

Immobilization in sling x 8 weeks then PT

6%

(50/775)

3

ORIF via a deltopectoral approach

5%

(41/775)

4

ORIF via a posterior approach

29%

(228/775)

5

ORIF via a lateral approach

0%

(3/775)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.

ILLUSTRATIONS:

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(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? Review Topic

QID:277
1

Increased length of hospital stay

3%

(11/352)

2

Increased mortality rate

21%

(73/352)

3

Increased rate of extremity fracture(s)

6%

(21/352)

4

Increased Injury Severity Scores

58%

(205/352)

5

Increased length of intensive care unit stay

11%

(40/352)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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.


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