Updated: 5/24/2021

Scapula Fractures

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https://upload.orthobullets.com/topic/1013/images/scapula fx.jpg
https://upload.orthobullets.com/topic/1013/images/ap glenoid fracture.jpg
https://upload.orthobullets.com/topic/1013/images/glenoid 3d fracture 2.jpg
https://upload.orthobullets.com/topic/1013/images/posterior glenoid rim fx.jpg
https://upload.orthobullets.com/topic/1013/images/ideberg type 3.jpg
https://upload.orthobullets.com/topic/1013/images/type iv.jpg
  • summary
    • Scapula Fractures are uncommon fractures to the shoulder girdle associated with high energy trauma, associated pulmonary or head injury, and increased injury severity scores. 
    • Diagnosis can be made with plain radiographs. CT studies are helpful for fracture characterization and for surgical planning.
    • Treatment is generally nonoperative in a sling. Surgical management is indicated for intra-articular fractures, displaced scapular neck fractures, open fractures, and those associated with glenohumeral instability. 
  • Epidemiology
    • Incidence
      • Rare
        • less than 1% of all fractures
    • Anatomic location
      • 50% involve body and spine
  • Etiology
    • 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
      • 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
          • "double disruption" of the superior shoulder suspensory complex
        • outcomes
          • 70% good to excellent results with operative treatment
  • 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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(OBQ15.114) A 30 year-old male is involved in a motor vehicle collision and sustains a scapular fracture. In patients with scapular fractures, what other fracture is MOST commonly observed?

QID: 5799
1

Spine fracture

3%

(126/4453)

2

Rib fracture

87%

(3862/4453)

3

Clavicle fracture

6%

(268/4453)

4

Humerus fracture

1%

(31/4453)

5

Pelvic fracture

3%

(148/4453)

L 2 A

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

QID: 520
1

Supraspinatus and infraspinatus

7%

(185/2693)

2

Supraspinatus and subscapularis

2%

(49/2693)

3

Infraspinatus and teres minor

85%

(2285/2693)

4

Teres minor and teres major

3%

(77/2693)

5

Teres major and lattisimus

3%

(77/2693)

L 1 C

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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?

QID: 783
1

Lateral pectoral-axillary

1%

(11/759)

2

Subscapular-musculocutaneous

2%

(14/759)

3

Suprascapular-axillary

85%

(643/759)

4

Long thoracic-spinal accessory

3%

(19/759)

5

Suprascapular-subscapular

7%

(52/759)

L 1 B

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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?

QID: 345
FIGURES:
1

Immobilization in sling x 2 weeks then PT

53%

(803/1501)

2

Immobilization in sling x 8 weeks then PT

7%

(104/1501)

3

ORIF via a deltopectoral approach

6%

(97/1501)

4

ORIF via a posterior approach

32%

(484/1501)

5

ORIF via a lateral approach

0%

(5/1501)

L 3 D

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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?

QID: 277
1

Increased length of hospital stay

4%

(56/1306)

2

Increased mortality rate

16%

(215/1306)

3

Increased rate of extremity fracture(s)

6%

(79/1306)

4

Increased Injury Severity Scores

63%

(818/1306)

5

Increased length of intensive care unit stay

10%

(128/1306)

L 3 D

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