Updated: 10/5/2016

Scapula Fractures

Topic
Review Topic
0
0
Questions
8
0
0
Evidence
9
0
0
Videos
1
Cases
11
https://upload.orthobullets.com/topic/1013/images/scapula fx.jpg
https://upload.orthobullets.com/topic/1013/images/scapula fx - coracoid classification.jpg
https://upload.orthobullets.com/topic/1013/images/acrom class.jpg
https://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 (8)
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(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%

(145/2164)

2

Supraspinatus and subscapularis

2%

(39/2164)

3

Infraspinatus and teres minor

85%

(1846/2164)

4

Teres minor and teres major

3%

(58/2164)

5

Teres major and lattisimus

3%

(63/2164)

ML 1

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PREFERRED RESPONSE 3
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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%

(7/457)

2

Subscapular-musculocutaneous

1%

(5/457)

3

Suprascapular-axillary

85%

(388/457)

4

Long thoracic-spinal accessory

2%

(11/457)

5

Suprascapular-subscapular

7%

(34/457)

ML 1

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PREFERRED RESPONSE 3

(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

56%

(586/1049)

2

Immobilization in sling x 8 weeks then PT

6%

(63/1049)

3

ORIF via a deltopectoral approach

6%

(63/1049)

4

ORIF via a posterior approach

31%

(328/1049)

5

ORIF via a lateral approach

0%

(3/1049)

ML 3

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PREFERRED RESPONSE 1

(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

4%

(31/729)

2

Increased mortality rate

19%

(139/729)

3

Increased rate of extremity fracture(s)

6%

(47/729)

4

Increased Injury Severity Scores

59%

(430/729)

5

Increased length of intensive care unit stay

10%

(74/729)

ML 3

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PREFERRED RESPONSE 4
ARTICLES (15)
VIDEOS (1)
CASES (11)
Topic COMMENTS (7)
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