A reliable radiographic measurement technique for extra-articular scapular fractures

Morphometric Analysis of Glenopolar Angle of the Scapula in Indian Population

BACKGROUND

The glenopolar angle (GPA), usually ranges from 30° to 45°. GPA measures the tilt of the plane of the glenoid cavity in relation to the axis of the body of the scapula passing from the superior pole of the glenoid cavity to the inferior angle of the scapula. It is essential to assess the results of surgeries for dislocated shoulders. Worse long-term outcomes can arise from glenoid misalignment in scapular neck fractures. When evaluating prognosis and planning therapy for shoulder injuries including scapular fractures, GPA assessment is essential. Still, there is a dearth of data on the normal range of GPA and its contributing elements, which calls for more study. The purpose of this study is to determine typical GPA values by utilizing radiographs and a sizable sample of scapular bone specimens.

METHODS

In this study, the GPA was assessed in 50 chest radiographs of anteroposterior (AP) view and Neer's view of individuals as well as 100 dried scapulae of any gender. The mean GPA obtained using the various methods was then statistically compared.

FINDINGS

All scapulae had an average GPA of 42.6°. Twenty-nine scapulae had GPA observations higher than 45°, with an average of 47.2°. Twenty-seven scapulae had GPA measurements below 40°, averaging 37.3°. Right-sided 62 scapulae with an average GPA of 43.1° were present. Thirty-eight of left-side scapulae had a GPA of 41.7° on average. It was determined that the 1.6° mean difference in GPA between the two groups was not statistically significant. The Kolmogorov-Smirnov test verified that the GPA data had a normal distribution. The homogeneity of variances across various measuring techniques was confirmed using Levene's test. The average GPA measured using the dry scapula approach was 42.6°, the average GPA measured using the AP view was 39.8°, and the average GPA measured using the Neer I view was 42.3°. The GPA means from these three approaches differed considerably (p=0.0014) according to a one-way Analysis of Variance (ANOVA). Fisher's least significant difference post hoc testing showed that the scapular bone specimens and the Neer I view revealed significantly higher GPA values than AP shoulder radiographs. The GPA values obtained from the osteological group and the Neer I perspective had a mean difference of 0.21°, which was practically identical and suggested that there was no statistically significant difference between these approaches.

IN SUMMARY

In order to diagnose and treat a variety of shoulder joint diseases, this study estimates the normal values of scapular GPA. Furthermore, it offers support for improved implant design in the context of Indian shoulder joint replacement and repair. Using every measurement technique, the GPA values on the right and left sides did not differ significantly. GPA results from various measuring methods varied significantly, which emphasizes the significance of methodological consistency in clinical and research settings.

Three-Dimensional Mapping of Scapular Body, Neck, and Glenoid Fractures

OBJECTIVES

The purpose of this study was to report patterns of scapular fractures and define them with a contemporary methodology.

METHODS

.

DESIGN

Retrospective study, 2015-2021.

SETTING

Single, academic, Level 1 trauma center.

PATIENT SELECTION CRITERIA

Consecutive patients ≥18 years, presenting with unilateral scapula fracture, with thin-slice (≤0.5-mm) bilateral computed tomography (CT) scans of the entirety of both the injured and uninjured scapulae.

OUTCOME MEASURES AND COMPARISONS

Thin-slice (0.5-mm) CT scans of injured and normal scapulae were obtained to create three-dimensional (3D) virtual models. 3D modeling software (Stryker Orthopedics Modeling and Analytics, Stryker Trauma GmbH, Kiel, Germany aka SOMA) was used to create a 3D map of fracture location and frequency. Fracture zones were delineated using anatomic landmarks to characterize fracture patterns.

RESULTS

Eighty-seven patients were identified with 75 (86%) extra-articular and 12 (14%) intra-articular fractures. The dominant fracture pattern emanated from the superior lateral border (zone E) to an area inferior to the spinomedial angle (zone B) and was present in 80% of extra-articular fractures. A second-most common fracture line propagated from the primary (most-common) line toward the inferior medial scapular border with a frequency of 36%. Bare zones (with 1 or no fractures present) were identified in 4 unique areas. Furthermore, intra-articular fractures were found to be heterogenous.

CONCLUSIONS

The 3D fracture map created in this study confirmed that extra-articular scapular fractures occur in certain patterns with a relatively high frequency. Results provide greater insight into scapular fracture locations and may help to study prognosis of injury and improve treatment strategy including operative approaches and surgical tactics.

Investigation of Morphological and Biomechanical Properties of the Scapula for Shoulder Joint

Objective

The glenopolar angle is a helpful criterion for recommending operative treatment. This study aims to determine the morphometric features of the scapula and provide essential information that supplies scapular biomechanics to produce a formula.

Methods

The study was carried out on 34 dry scapulae in the laboratory of the Anatomy Department of the Faculty of Medicine, Bursa Uludag University. We used calipers for the linear measurements and the ImageJ program for the area and angle parameters. A total of 23 parameters were evaluated in the study. Statistical analyzes were performed using SPSS 22.0 software.

Results

According to the results of the correlation analysis, the highest correlation value of (R=0.957) was found to be the distance between the superior angle (angulus superior)-top of the glenoid plane and the inferior angle (angulus inferior)-the top of the glenoid plane. To estimate the glenopolar angle, we applied linear regression analysis and developed the following formula: Glenopolar angle =115.589 - (6.401 x the distance between the coracoid process and the top of the glenoid cavity) - (0.368 x angle between the glenoid plane and the lateral edge of the scapula extending towards the endpoint of the glenoid plane) (Adjusted R2=0.667).

Conclusions

Glenopolar angle can provide information about the fracture risk of the glenoid cavity and allows orthopedic surgeons to make quick decisions about the risk in the region. We believe that the study will provide a different perspective on designing different products in industrial designs for shoulder joints, especially in implantations.

Scapular fractures osteosynthesis via Judet's posterior approach: clinical and radiographic results

PURPOSE

Scapular fractures are uncommon and mainly treated nonoperatively. Judet's posterior approach allows access to the fracture site through the infraspinatus fossa and may be a technical option when ORIF is decided. The aims of this study were to determine clinical and radiographic outcomes of patients who underwent scapular body and/or glenoid fractures fixation via Judet's posterior approach.

METHODS

We conducted a retrospective single-centre study, and all patients admitted for scapular fracture who underwent osteosynthesis via Judet's approach between January 2014 and September 2021 were included. At a minimum follow-up of one year, clinical outcomes were analyzed through subjective shoulder value (SSV) and Constant-Murley score (CMS). Strength in external rotation was measured in adduction and in 90° abduction and compared to healthy side. Radiographic analysis evaluated postoperative fracture reduction on CT scan and glenohumeral osteoarthritis according to Samilson's classification at last follow-up.

RESULTS

Twenty-one patients were included with a mean follow-up of 44.9 months. Mean SSV, CMS, and adjusted CMS were 73.8% ± 21.0, 65.8 points ± 19.5, and 72.8% ± 20.8, respectively. Strength in external rotation in adduction of the affected shoulder showed significant impairment when compared with the contralateral side (respectively 7.79 kg ± 4.29 and 12.0 kg ± 3.84, p = 0.02). All fractures healed uneventfully, but five patients (23.8%) required early revision surgery for intra-articular screws in three. Intra-articular gap measure decreased from 3.75 mm ± 1.93 in preoperative to 0.59 mm ± 0.97 after ORIF. The rate of arthritis was 15% at last follow-up.

CONCLUSION

Patients who underwent scapular fracture osteosynthesis via Judet's posterior approach exhibited satisfactory but incomplete recovery of the affected shoulder as evidenced by functional scores and external rotation strength measurements at a mean follow-up of 44.9 months. Because of the risk of intra-articular screws, postoperative CT scan is mandatory.

Osteosynthesis of scapular fractures: a retrospective cohort study

PURPOSE

In recent years a trend from conservative to operative treatment of displaced scapula fractures has evolved. The aim of this study was to assess surgical and patient-based radiological and functional outcome after open reduction and internal fixation (ORIF) of displaced scapula fractures following predefined operative indications.

METHODS

We retrospectively analyzed data of a consecutive series of patients with displaced scapula fractures following operative fixation at our institution between 06/2010 and 02/2020. The primary endpoint was a functional outcome using the QuickDASH score. Secondary outcomes were the Subjective Shoulder Value (SSV), numeric rating scale (NRS) for pain, Activities of Daily Living score (ADL) and complications.

RESULTS

Twenty-six male patients were treated operatively. Twenty-three of whom were available for follow-up after a median follow-up time of 33 months (interquartile range [IQR] 8-70 months). In 18 (69%) cases a standard open approach and in 8 (31%) cases a minimal invasive (MI) approach was used. The median QuickDASH was 0 (IQR 0-0) with a median SSV of 95 (IQR 90-98). Patients reported a median NRS of 0 (IQR 0-1) and a median ADL score of 1 (IQR 1-1). Radiological fracture union was 100% without the occurrence of implant failure or mal-union. Two patients (7.7%) required early correction osteosynthesis, one patient (3.8%) developed a frozen shoulder 3 months postoperatively, and one patient (3.8%) presented with a superficial wound infection.

CONCLUSION

Following previously published indications for ORIF of displaced scapula body and neck fractures a good functional outcome and a low rate of complications could be achieved.

A new surgical approach for the treatment of scapular glenoid fractures- Axillary approach: A single center case series

Background

The purpose of this study was to assess the efficacy of the scapular glenoid fractures by a new surgical approach (Axillary approach) through follow-up studies.

Method

We retrospectively analyzed the prospectively collected data from 11cases of glenoid fractures were treated by open reduction and internal fixation through a Axillary approach approach between July 2019 and October 2020. All patients were required to conform to regular follow up postoperatively. X-ray film and CT scan was applied to all cases. The Constant score system, the UCLA score system and DASH score system were used to evaluate functional results.

Results

All patients achieved bone union. At the final follow-up, the mean Constant score was 92.5 ± 3.0 (range 85–97) points and the mean UCLA score was 33.5 ± 1.6 (range 31–36) points. According to the UCLA score system, two patients achieved excellent results and one patients had good results. The mean DASH scores were 7.7 ± 3.2 (range 4–12). Compared with the preoperative functional score, it was significantly improved (P < 0.01).

Conclusions

The axillary approach as a new method for scapular glenoid fractures (especially the fracture of the lower half of the scapular glenoid) has achieved desired results, and it can provide new options for clinical treatment.

Level of evidence

Level III; Development or Validation of Outcome Instrument© 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

•

The axillary approach as a new method for scapular glenoid fractures.

•

Through more than 1 year of case collection, we found that the therapeutic effect is positive.

•

It is a recommended method in clinical treatment.

Homemade 3D mirror imaging models utility for surgical treatment of complex fractures of scapula

The treatment of complex articular scapular fractures requires obtaining an anatomic reduction. The experience of the surgeon and the surgical skills needed are still the most important aspect in this surgical field. 3D printed models at a 1:1 scale provides tactile and visual experience. We used a specular healthy scapula (reverse engineering) as a reliable template for preoperative planning. We pre-contour plates directly over a printed mold, for direct application, without further corrections during the surgical procedure. This reduces improvisation during surgery, the risks of complications and the total costs while improving the accuracy of the anatomical restoration of the native glenopolar angle derived from the indirect reduction of the fracture. Until recently, the use of RP (rapid prototyping) models for managing complex fractures required contracting the services provided by external companies, with the constraints posed on cost and time. We made the whole process ourselves in a DIY mode: from the post-processed radiological images to the 3D model printing, pre contoured plates and surgical simulation.

Scapula fractures: a review

A consensus is beginning to emerge about the indications for fixation of fractures involving the glenoid fossa of the scapula. The same cannot be firmly said for extra-articular fractures of the blade or the processes of the scapula, with a good deal of reliance on expert opinion from high-volume centres. There are no randomized controlled studies and the systematic reviews that do exist can only pool the data from available case series, making meaningful meta-analysis of limited value. Interest in scapula fractures has increased of late due to the specific association of fractures of the scapular spine and acromion with reverse shoulder arthroplasty.

This review summarizes the available evidence that can assist decision making when faced with a patient with a scapula fracture. Which patients should at least be considered for open reduction and internal fixation, either in the centre where they present or after referral to a more specialist centre? These patients are those with a fracture sufficiently displaced that it interferes with the mechanical function of the shoulder girdle and the aim of fixation is to reduce pain and disability.

Since the majority of scapula fractures heal quickly with non-surgical treatment and do not cause significant disability, decision making can be difficult, and it is perhaps the case that it is easier to err on the side of caution.

However, it seems that there are fracture types, such as significantly displaced double disruptions of the superior suspensory complex, widely displaced lateral column fractures and fractures producing angular deformity of the glenoid process, that benefit from early reduction and stabilization with the expectation of a good outcome for the patient.

Cite this article: EFORT Open Rev 2021;6:518-525. DOI: 10.1302/2058-5241.6.210010

Scapular body fractures: Short-term results of surgical management with extended indications

INTRODUCTION

Scapular body fractures represent less than 1% of all skeletal fractures. Operative criteria and risk factors for scapular fracture instability are well defined. Non-operative management of scapular body fractures show satisfactory results but with shortening and medialization of the scapular body. The aim of this study is to evaluate if surgical treatment will result in an improved quality of life and shoulder function compared to non-operative treatment on patients suffering from a scapular body fracture.

MATERIALS AND METHODS

From a total of 381 retrospectively identified scapular body fractures, we included 45 patients. The enrolled patients were divided into two groups: the surgical treatment (ST, n = 20) group and the non-operative treatment (NOT, n = 25) group. The Non-Union Scoring System (NUSS) was used to assess bone healing on radiographs. The functional evaluation of the two groups during the follow-up were performed using the Constant Shoulder Score (CSS) and the Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH). Complications, reoperation rates, and time until bony union were also documented. The minimum follow-up for this study was designated as 12 months.

RESULTS

The ST group had better mean CSS and QuickDASH scores compared to the NOT group at 1, 3 and 6 months of follow-up. No statistically significant difference was detected at 12 months follow-up. ST group also demonstrated improved results in time until bone union, reduction of rehabilitation time, complications and return to work rates.

CONCLUSION

This study suggests that surgical treatment for extraarticular scapular fractures can achieve better short-term functional outcomes (3 to 6 months) compared to conservative treatment.

Radiographic correlation of clinical shoulder deformity and patient perception following scapula fracture

BACKGROUND

Interest in operative management of scapular fractures is increasing based upon defined radiographic displacement criteria and growing awareness that certain extra-articular fractures will not do well and result in dysfunction and deformity (slumped shoulder). We intend to quantify clinical deformity, analyze correlations of these novel measures with defined radiographic measures of fracture displacement and with the patients' reported perception of their deformity.

METHODS

Prospectively enrolled patients underwent standardized questioning regarding their perception of the deformity. Radiographs were utilized to measure glenopolar angle medial/lateral displacement, and angulation of the displaced scapula fracture. Novel measurements of clinical deformity (shoulder area, shoulder angle and shoulder height difference) were calculated. All measurements were repeated post-operatively for patients undergoing operative treatment.

RESULTS

Fifty-one patients (39 operative) were examined within 30 days of injury. Follow-up (≥2 months post-op) was obtained for 31/39 (79%). Medial-lateral displacement significantly correlated with all measures of clinical deformity and with patient reported shoulder appearance bothersome score. Angulation significantly correlated with patient perception and two clinical measures (shoulder area and shoulder angle difference). All post-operative radiographic measures, clinical measures of deformity, and patient reported scores statistically improved from baseline measures.

DISCUSSION

Patients with scapula fracture do perceive deformity, and there is a significant correlation between the patients' perception, radiographic and clinical measurements of deformity after scapula fracture. All measures statistically improved in patients with operative treatment compared to baseline measurements. This study reinforces the importance of the clinicians' clinical examination and observation of shoulder deformity in the scapula fracture patient.

LEVEL OF EVIDENCE

IV.

Long-term Functional Outcomes of Nonoperatively Treated Highly Displaced Scapular Body and Neck Fractures

Historically, extra-articular scapular body fractures were treated nonsurgically, but displaced fractures of the glenoid neck can lead to dysfunction. Controversy exists regarding which extra-articular scapular fractures should be treated surgically; however, nonsurgical management of severely displaced scapular body fractures can result in satisfactory outcomes. Inclusion criteria for this study were medial or lateral displacement greater than 2 cm, angular deformity between fracture fragments greater than 45°, or glenopolar angle less than 22°. Functional outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) score, Short Form-36 (SF-36) score, and American Shoulder and Elbow Surgeons (ASES) shoulder score. Radiographs and computed tomography scans were available for all patients. Range of motion (ROM), strength, other injuries, and complications also were recorded. Twelve patients (10 males, 2 females) with a mean age of 45.6 years (range, 29-57 years) underwent follow-up for a mean of 54.1 months (range, 28.2-74.4 months). At latest follow-up, mean DASH score was 8.9 (range, 0-35), mean SF-36 score was 72.2 (range, 57.3-96.1), and mean ASES score was 85.9 (range, 46.7-100). Mean ROM and strength expressed as a percentage of the contralateral side ranged from 88% to 99% and 70% to 93%, respectively. At longest follow-up, 10 patients reported excellent satisfaction with their treatment. There were no radiographic non-unions. One patient with concomitant clavicle and acromion fractures treated surgically had a postoperative infection requiring operative irrigation and debridement. None of the patients required or sought additional treatment. Nonoperative treatment of highly displaced scapular body fractures resulted in good patient satisfaction, satisfactory long-term functional outcomes, and only minor loss of motion and strength. [Orthopedics. 2020;43(3):e177-e181.].

Open Reduction and Internal Fixation of Extraarticular Scapular Neck and Body Fractures With Good Short Term Functional Outcome

Background: The study aims to evaluate the short-term functional outcome of open reduction and internal fixation of extraarticular scapular neck and body fractures treated at our center over a period of 2-year duration at a tertiary referral center.

Patients and Methods: Between October 2015 and October 2017, we operated on 20 extraarticular scapular neck and body fracture. Ten were available for a one-off assessment. The mean time to surgery was 10 days (range, 3–19 days) and one-off assessment was done within 6–24 months (mean, 13 months). Indications includes (1) medial/lateral displacement (M/L) ≥ 20 mm, (2) M/L ≥ 15 mm if angular deformity ≥ 30°, (3) Angular deformity ≥ 45°, (4) Double lesion of superior shoulder suspensory complex (SSSC), with displacement ≥10 mm in both lesion, (5) Glenopolar angle (GPA) ≤ 22°, and (6) open scapular fracture. The functional outcome was measured using range motion and strength. Patient-reported outcome was assessed using Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Short-Form-36 (SF-36) version 1.

Results: All patients achieved radiological union at time of assessment. None of the patients had post-operative complications. The mean DASH score was 19.3 (range, 1.7–39.3). All subcategories of SF-36 questionnaire scores between 70 and 89.6, with exception to REE (role limitations due to emotional problems) and REP (role limitations due to physical health). The average range of motion for the injured shoulders; forward flexion 157°, abduction 114°, and external rotation 42°. The strength of operated and non-operated shoulders, respectively, 6.5 and 8.1 kgF of forward flexion, 5.5 and 7.2 kgF of abduction, and 4.1 and 6.3 kgF of external rotation.

Conclusion: Open reduction and internal fixation of surgically indicated scapular neck and body fracture is feasible with predictably good functional outcome. The reduced external rotation ROM and strength may be due to the use of Classic Judet approach, however we do not enough data to support this.

Clinical Outcomes and Shoulder Kinematics for the "Gray Zone" Extra-articular Scapula Fracture in 5 Patients

AIMS

There is a subset of scapula fractures, which can be considered in the "gray zone," where treatment guidelines are not clear-cut, based on published literature. Our paper presents the outcomes of five such scapula fractures treated non-operatively.

METHODS

Adult patients who had been treated non-operatively at our institution for an isolated scapula fracture from 2003-2012 were found using Current Procedural Terminology (CPT) codes. Based on injury imaging, these five patients had scapula fractures in the "gray zone."Subjects completed questionnaires [Simple Shoulder Test (SST), PROMIS Global Health Scale vs 1.1, PROMIS SF vs 1.0 Physical Function 12a, and the American Shoulder and Elbow Surgeons Score (ASES)] and physical exams were performed to assess range of motion and strength. Glenohumeral kinematics were obtained via motion analysis using the Trackstar 6 Degree of Freedom (DOF) motion tracking system by Northern Digital Incorporated.

RESULTS

All subjects were right hand dominant. 3/5 fractures involved left, non-dominant, scapulae. Motion analysis demonstrated similar recruitment of the scapula during the glenohumeral rhythm for the fractured shoulders compared with the same arm of age matched control subjects. No significant differences occurred in either range of motion (ROM) or scapula-humeral coordination when comparing uninjured scapulae to the same arm of age matched control subjects.

CONCLUSIONS

All subjects' demonstrated acceptable clinical outcomes when treated non-operatively. Minor differences were seen in subjective surveys. However, the kinematic analysis showed no differences in measured scapula-humeral rhythm or range of motion. It is proposed that immediate controlled range of motion and rehabilitation be considered in these patients and could be the focus of a larger prospective study.

LEVEL OF EVIDENCE

Level IV (Case Series).

EYE LENS DOSES OF RADIOLOGY TECHNOLOGISTS WHO ASSIST PATIENTS DURING RADIOGRAPHY

The International Commission on Radiological Protection (ICRP) revised a drastic decrease of the annual eye equivalent dose limit. The present study aimed to evaluate the amounts of radiation to which the eye lenses of radiological technologists (RT) become exposed and the effects of wearing lead glasses on dose reduction while assisting patients during radiographic assessments. Lens equivalent doses (Hp(3)) were measured at the neck using personal dosemeter. In addition, Hp(3) was estimated by converting air kerma determined using small optically stimulated luminescence (OSL) dosemeters at six positions on lead glasses near the eyes and at the neck. The estimated mean Hp(3) from personal dosemeter at the neck varied from 3.92 to 18.6 mSv/y. Compare to OSL for which the dose varies from 8.95 to 54.75 mSv/y, personal dosimeter underestimate Hp(3).Therefore, Hp(3) for RT might exceed the revised eye equivalent dose limit 20 mSv/y recommended by the ICRP.

[Internal fixation of lateral and medial borders for displaced scapular body fractures via minimally invasive approach:results of 23 cases]

OBJECTIVE

To evaluate the efficacy of internal fixation of lateral and medial borders for displaced scapular body fractures via the minimally invasive approach.

METHODS

The internal fixation of lateral and medial borders via minimally invasive approach was applied in surgical treatment of 23 patients with scapular body comminuted fractures from January 2014 to June 2018. The lateral approach was made straightly orienting over the lateral border of scapula. The dissection was taken down to the deltoid fascia. The deltoid was retracted cephalically, revealing the external rotators. Blunt dissection was used down to the lateral border between infraspinatus and teres minor, exposing the fracture site. The medial incision was done along the medial border of the scapula over site of the fracture. Dissections were taken down to the fascia and the periosteum. A subperiosteal dissection was then performed to elevate the infraspinatus to the degree necessary to visualize the fracture. The medial and lateral borders of scapula body were fixed with plates and screws in a frame-like way.

RESULTS

One patient developed the delayed healing of the incisions due to liquefactive fat necrosis. The other 22 patients showed no complications of the incisions. The glenopolar angle (GPA) of fractured scapula was increased from preoperative (25±12) degrees to postoperative (41±5) degrees (P<0.01). The healing time of fractures healed was 3-8 months, with an average time of (4.4±1.3) months.

CONCLUSIONS

The lateral-medial combined fixation through minimally invasive surgical approach for the scapula body fractures allows visualization of fracture reduction without extensive muscular or subcutaneous flaps, and is associated with successful fracture healing and high functional scores of the shoulder.

Posterior Scapula Approaches: Extensile and Modified Judet

The Extensile Judet has been widely used in the management of scapula fractures. An enhanced understanding of these injuries, however, has allowed for the strategic development of alternative methods in which soft tissues may be better spared. The purpose of this video is to highlight the indications and techniques for 2 posterior approaches to the scapula: The Extensile Judet and the Modified Judet. Case 1 demonstrates the Modified Judet approach. The "boomerang" incision follows the curve of the scapula spine and vertebral border, and fixation occurs through an intermuscular window. Case 2 illustrates the Extensile Judet. The incision is identical to that of the Modified Judet, but differs in that posterior musculature is elevated in 1 periosteocutaneous flap. The utility of 2 different posterior approaches to the scapula are described. Both include the same incision, but differ with regards to management of the musculature overlying the fracture. The Modified Judet lacks the exposure of the Extensile approach, but significant soft-tissue trauma is avoided. Regarding the Extensile Judet, substantial tissue trauma is incurred to gain the exposure necessary for complex fracture patterns. Reduction goals, wound closure, and postoperative care remain the same for both approaches. Both approaches are valuable in terms of operative management of scapula fractures, although certain populations may benefit from tissue-sparing procedures.

Five to Ten-Year Outcomes of Operatively Treated Scapular Fractures

BACKGROUND

The purpose of this study was to assess the 5 to 10-year clinical and patient-reported functional outcomes after open reduction and internal fixation (ORIF) of intra-articular and extra-articular scapular fractures.

METHODS

We conducted a retrospective review of prospectively collected data on 106 patients who underwent ORIF of a scapular fracture at a single level-I trauma center between January 2005 and December 2010. Eight patients were excluded from the study because they had either severe neurologic injury or an isolated process fracture, and 66 patients (37 with an isolated extra-articular fracture and 29 with an intra-articular fracture) participated in the 5 to 10-year follow-up, yielding a follow-up rate of 67%. A physical examination including a strength assessment and range-of-motion measurements was performed on 89% of the follow-up cohort. Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-12 version 2 (SF-12v2) or SF-36v2 questionnaires were completed by all participating patients. Intra-articular and extra-articular fractures were analyzed in separate groups.

RESULTS

The mean follow-up was 7.8 years in the extra-articular group and 7.3 years in the intra-articular group, with a range of 4.7 to 10.3 years. The mean DASH score was 8.9 in the extra-articular group and 9.1 in the intra-articular group (normal population = 10.1). Strength examination revealed no significant differences between the injured and uninjured shoulders for any movement (p > 0.05), while the range of external rotation was slightly decreased in both the extra-articular (p = 0.01) and the intra-articular (p = 0.01) group. The abduction range of motion was also slightly decreased in the intra-articular cohort (p = 0.03). Arthroplasty was indicated as a subsequent procedure for 2 patients in the intra-articular cohort. Sixty-one of the 66 patients returned to their original occupation or changed occupations for reasons unrelated to the shoulder injury.

CONCLUSIONS

At 5 to 10 years after ORIF of a scapular fracture, patients have excellent functional outcomes albeit with a small decrease in external rotation motion relative to the contralateral, normal shoulder. Interestingly, we found the outcomes after intra-articular and extra-articular fractures to be comparable.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Single lateral versus medial and lateral plates for treating displaced scapular body fractures: a retrospective comparative study

BACKGROUND

This study compared the outcomes and complications of single lateral plating vs. dual plating for treating displaced scapular body fractures.

METHODS

Open reduction and internal fixation using locking plates was performed in 45 patients with displaced scapular fractures. A single lateral plate fixed in the lateral border was used in 22 patients (group A), and dual plates fixed in both the lateral and medial borders were used in 23 (group B).

RESULTS

The average follow-up duration in both groups was 20 months. A remarkable difference was seen between the 2 groups in mean operative time and blood loss, although the Disabilities of the Arm, Shoulder and Hand and Constant Shoulder scores at the final follow-up were similar. The prominence rate of the hardware was 27.3% (6 of 22) in group A and 65.2% (15 of 23) in group B. The plate removal rate was 31.8% (7 of 22) in group A and 78.3% (18 of 23) in group B.

CONCLUSIONS

Open reduction using a single plate on the lateral border for treating displaced scapular body fractures can lead to good functional outcomes, shorter operative time, less blood loss, and fewer plate-related complications compared with the dual-plating technique.

Comparison of 2 versus 3 dimensional fracture mapping strategies for 3 dimensional computerized tomography reconstructions of scapula neck and body fractures

Fracture mapping has been used in the understanding of injury patterns in different bones. To our knowledge, there are no applications of this technique using three-dimensional (3D) morphologic fracture characteristics. Previously, scapula fractures were mapped by transferring information from 3D computed tomography to a two-dimensional (2D) template. Cole et al. determined that 3D Computerized Tomography (CT) scans were more reliable compared to plain radiographs in terms of scapular angulation, translation, and glenopolar angle measurements. Thus, we hypothesized that if there is a difference between fracture lines drawn in 3D and in 2D, then the 3D mapping would yield more accurate fracture patterns. We completed a retrospective, comparative study (evidence level III) utilizing CT imaging from a single center scapular registry. We studied ten patients with scapula fractures in whom bilateral CT scans were obtained. Fractures were mapped both two and three-dimensionally, and we measured deviations between the fracture lines that were drawn with each approach. The measured deviations ranged from 10.4 mm to 28.0 mm when comparing 2D versus 3D techniques, with the mean deviation being 4.0 mm and 10.4 mm, respectively. Half of the 2D renderings possessed hidden fracture lines that were later revealed on 3D imaging. Three-dimensional renderings were more accurate when compared to 2D fracture mapping methods. This more accurate technique will allow for better understanding of 3D morphology and provide a basis for future fracture mapping in any bone. Accurate mapping is important because surgical approach, reduction, fixation, and implant design and selection are based on fracture patterns. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:265-271, 2018.

Arthroscopic Lateral Border Resection in Medialized Scapula Neck Fractures

Scapula neck fractures are rare injuries, leaving several treatment options. Standardized markers for operative treatment are a decreased glenopolar angle ≤22°, lateral border offset (LBO) of the glenoid ≥20 mm, angular deformity ≥45°, or LBO ≥15 mm plus angular deformity ≥35°. If operative treatment is not performed before union, the fracture heals malaligned with possible mechanical complications due to a medialized glenoid and the protruding lateral border. Common operative treatment comprises a corrective osteotomy for the anatomic correction of the malunited fracture, leaving intra-articular pathologies like adhesive capsular stiffness unaddressed. Our presented arthroscopic technique for the treatment of sequelae of scapula neck fractures combines a 270° capsulotomy with arthroscopic resection of a protruding lateral border. With use of this technique, excellent shoulder function can be restored with a minimally invasive procedure. Therefore, arthroscopic treatment could be favorable in selected cases of malunited scapula neck fractures.

Does the position of the scapula in relation to the glenopolar angle change the preferred treatment of extra-articular fractures?

OBJECTIVE

To analyse the glenopolar angle (GPA) at different inclinations of the scapula using 3D CT, to test the hypothesis that the result could change the indication from conservative treatment to surgery.

MATERIALS AND METHODS

Analysis of 30 3D CT images of patients' scapulae, measuring the GPA. The GPA was measured with scapulae at 0^° and at 20^° and 30^° of internal and external rotation. Angles were compared by age, sex and examiner for the different angles of rotation of the scapulae.

RESULTS

The GPA of scapulae in rotation tended to be smaller than the GPA without rotation, and the larger the degree of rotation, the more the angle was underestimated. Additionally, for the same degree of rotation, internal rotation was associated with greater underestimation of the GPA than external rotation. Two different examiners achieved an excellent level of agreement between angle measurements. The GPA with the scapula at 0^° was significantly higher among elderly patients. The variation in GPA with the scapula in rotation (20^° and 30^°) in relation to the GPA without rotation was significantly greater for female patients.

CONCLUSIONS

As the rotation of the scapula was displaced from the scapula in the coronal position (GPA 0^°), both in internal rotation and in external rotation, the GPA reduced. Therefore, rotational displacement may lead to an error in GPA measurement, resulting in incorrect indication of treatment. It is recommended that whenever possible, GPA measurements should be taken in neutral rotation, with the scapula in a neutral position at 0^°.

Postoperative Evaluation of Reduction Loss in Proximal Humeral Fractures: A Comparison of Plain Radiographs and Computed Tomography

OBJECTIVE

To compare postoperative CT images with plain radiographs for measuring prognostic factors of reduction loss of fractures of the proximal part of the humerus.

METHODS

A total of 65 patients who sustained fractures of the proximal humerus treated with locking plates from June 2012 to October 2015 were retrospectively analyzed. There were 24 men and 41 women, with a mean age of 60.0 years (range, 22-76 years). According to the Neer classification system of proximal humeral fracture, there were 26 two-part, 27 three-part and 12 four-part fractures of the proximal part of the humerus, and all fractures were treated with open reduction and internal fixation (ORIF) using locked plating. All postoperative CT images and plain radiographs of the patients were obtained. Prognostic factors of the reduction loss were the change of neck shaft angle (NSA) and the change of humeral head height (HHH). The change of NSA and HHH were evaluated by the difference between postoperative initial and final follow-up measurement. Reduction loss was defined as the change ≥10° for NSA or ≥5 mm for HHH. The NSA and HHH were measured using plain radiographs and 3-D CT images, both initially and at final follow-up. The paired t-test was used for comparison of NSA, change of NSA, HHH, and change of HHH between two image modalities. The differences between two image modalities in the assessment of reduction loss were examined using the χ² -test (McNemar test). Intraclass correlation coefficients (ICC) were used to assess the intra-observer and inter-observer reliability.

RESULTS

3-D CT images (ICC range, 0.834-0.967) were more reliable in all parameters when compared with plain radiographs (ICC range, 0.598-0.915). Significant differences were found between the two image modalities in all parameters (plain radiographs: initial NSA = 133.6° ± 3.8°, final NSA = 130.0° ± 1.9°, initial HHH = 17.9 ± 0.9 mm, final HHH = 15.8 ± 1.5 mm; 3-D CT: initial NSA = 131.4° ± 3.4°, final NSA = 128.8° ± 1.7°, initial HHH = 16.8 ± 1.2 mm, final HHH = 14.5 ± 1.1 mm; all P < 0.05). In the assessment of reduction loss, the percentage was 16.9% (11/65) for the plain radiographs and 7.7% (5/65) for the 3-D CT scans (P < 0.05). For the 5 patients with reduction loss, which were observed by two imaging modalities, the mean Constant-Murley score was 61.0 ± 1.6. The patients with reduction loss, observed only in plain radiographs but not CT images, had good shoulder function (Constant-Murley score: 82.7 ± 1.0).

CONCLUSIONS

Our data reveal that 3-D CT images are more reliable than plain radiographs in the assessment of the prognostic factors of reduction loss of fractures of the proximal part of the humerus with treatment of locking plates; this reliable CT technique can serve as an effective guideline for the subsequent clinical management of patients.

Comparison of measurements of the glenopolar angle in 3D CT reconstructions of the scapula and 2D plain radiographic views

AIMS

The aim of this study was to analyse the effect of altered viewing perspectives on the measurement of the glenopolar angle (GPA) and the differences between these measurements made on 3D CT reconstructions and anteroposterior (AP) scapular view radiographs.

MATERIALS AND METHODS

The influence of the viewing perspective on the GPA was assessed, as were the differences in the measurements of the GPA between 3D CT reconstructions and AP scapular view radiographs in 68 cadaveric scapulae.

RESULTS

The median GPA in 3D reconstructions and AP scapular views were 42.7° (95% confidence intervals (CI), 42.0° to 43.5°) and 41.3° (95% CI 40.4° to 42.0°) respectively (p < 0.001). All but five of 20 malpositions demonstrated a significant difference in GPA compared with the respective AP scapular view (p ≤ 0.005). The GPA was most susceptible to malposition in retroversion/anteversion. Inter- and intra-observer reliability for all measurements of the GPA was excellent for 3D CT reconstructions (intraclass correlation (ICC) 0.93 (95% CI 0.87 to 0.96) and 0.94 (95% CI 0.89 to 0.97), respectively) and higher than on AP scapular radiographs (p < 0.001). The intra- and inter-observer reliability was excellent in AP scapular views and malpositions in extension/flexion (ICC ≥ 0.84) but tended to decrease with increasing viewing angle in retroversion/anteversion.

CONCLUSION

These data suggest that 3D reconstructions are more reproducible than AP scapular radiographs in the assessment of the GPA and should be used to compare data in different studies, to predict outcome, define malunion, and act as an indication for surgery in patients with a scapular fracture. Cite this article: Bone Joint J 2016;98-B:1510-16.

Is radiograph glenopolar angle accurate for extraarticular scapular neck fractures?

BACKGROUND

Plain radiographs still play a role in management of extraarticular scapular neck fractures. Glenopolar angle (GPA) is one of the radiograph measurements that is used to determine the necessity for surgery. Our aim was to establish reliability of GPA on plain radiograph in patients with extraarticular scapular neck fractures.

METHODS

We performed a multicentre retrospective study including all patients with extraarticular scapular neck fractures with available imaging between 2006 and 2012. We excluded intra-articular glenoid fractures, scapular blade fractures, acromion fractures, and scapular spine fractures. We compared GPA on plain radiograph with three dimensional computed tomography (3D CT) measurement, as well as contribution of radiograph rotational error, glenoid inclination, and medial shortening of glenoid fragment towards GPA measurement.

RESULTS

One hundred patients met the inclusion criteria. The mean difference between the GPA measurements on radiographs and 3D CT was 6.1±0.85° (95% confidence interval) as an absolute value. In terms of contribution to GPA values, GPA changed by one degree with ten degrees of radiograph rotational error, three degrees of glenoid inclination, and three millimetres of glenoid fragment medial shortening.

CONCLUSION

Plain radiograph can provide a clinician with a reasonable estimation of the GPA. Glenoid inclination has a greater influence on GPA compared to medial shortening.

Functional Outcomes After Operative Management of Extra-Articular Glenoid Neck and Scapular Body Fractures

BACKGROUND

This study's purpose was to assess patient-based functional outcomes following open reduction and internal fixation (ORIF) of displaced scapular body and glenoid neck fractures. This series represents a 9-year experience at a level-I trauma center and referral destination for this injury.

METHODS

A database was established to record surgical and functional outcomes of scapular fractures treated with ORIF. For this report, the cases of all patients who had a glenoid neck or scapular body fracture (AO/OTA 14-A3 or 14-C1) without intra-articular involvement were reviewed. Operative indications included medial/lateral displacement of ≥20 mm, angulation of ≥45°, medial/lateral displacement of ≥15 mm with angulation of ≥30°, double disruptions of the superior shoulder suspensory complex with both displaced ≥10 mm, a glenopolar angle of ≤22°, and an open fracture. The results of clinical testing, including measurements of range of motion and strength and scores on the Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) questionnaires, were recorded at each follow-up appointment.

RESULTS

Between 2002 and 2011, 61 patients with an extra-articular scapular fracture were treated surgically within 20 days after the injury; 19 patients (31%) had ≥2 operative indications. Of the 61 patients, 49 (80%) were followed for ≥1 year (mean, 33 months; range, 12 to 138 months) following surgery. There was a 100% union rate at the time of final follow-up, with a mean DASH score of 12.1 points (range, 0 to 54 points). For all parameters, the mean SF-36 scores of the study patients were comparable with normative population scores. The range of motion of the operatively treated and contralateral shoulders averaged, respectively, 154° and 159° of forward flexion, 106° and 108° of abduction, and 66° and 70° of external rotation. The strength of the operatively treated and contralateral shoulders averaged, respectively, 20 and 23 lb (89.0 and 102.3 N) of force in forward flexion, 14 and 16 lb (62.3 and 71.2 N) in abduction, and 19 and 23 lb (84.5 and 102.3 N) in external rotation. Complications and/or secondary surgery were recorded for 8 patients (16%).

CONCLUSIONS

Displaced scapular body and glenoid neck fractures that meet current published standards for ORIF can be treated operatively with predictably good functional outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Compared to X-ray, three-dimensional computed tomography measurement is a reproducible radiographic method for normal proximal humerus

BACKGROUND

Accurate comprehension of the normal humeral morphology is crucial for anatomical reconstruction in shoulder arthroplasty. However, traditional morphological measurements for humerus were mainly based on cadaver and radiography. The purpose of this study was to provide a series of precise and repeatable parameters of the normal proximal humerus for arthroplasty, based on the three-dimensional (3-D) measurements.

METHODS

Radiographic and 3-D computed tomography (CT) measurements of the proximal humerus were performed in a sample of 120 consecutive adults. Sex differences, two image modalities differences, and correlations of the parameters were evaluated. Intra- and inter-observer reproducibility was evaluated using intraclass correlation coefficients (ICCs).

RESULTS

In the male group, all parameters except the neck-shaft angle of humerus, based on 3-D CT images, were greater than those in the female group (P < 0.05). All variables were significantly different between two image modalities (P < 0.05). In 3-D CT measurement, all parameters expect neck-shaft angle had correlation with each other (P < 0.001), particularly between two diameters of the humeral head (r = 0.907). All parameters in the 3-D CT measurement had excellent reproducibility (ICC range, 0.878 to 0.936) that was higher than those in the radiographs (ICC range, 0.741 to 0.858).

CONCLUSIONS

The present study suggested that 3-D CT was more reproducible than plain radiography in the assessment of morphology of the normal proximal humerus. Therefore, this reproducible modality could be utilized in the preoperative planning. Our data could serve as an effective guideline for humeral component selection and improve the design of shoulder prosthesis.

Extra-articular scapular fractures: comparison of theoretical and actual treatment

BACKGROUND

Discrete radiographic thresholds of scapular fracture deformity proposed as a guide for when to utilize operative treatment are a matter of debate. The purpose of the present study was to determine how many patients would have received operative treatment according to these criteria and how many actually received operative treatment.

METHODS

Three hundred and thirty patients with an extra-articular fracture of the scapula at two level 1 trauma centers were retrospectively analyzed. Glenopolar angle, translation, angulation and medial/lateral displacement were measured on computed tomogaphy scans or radiographs to determine the theoretical operative treatment recommendation according to Cole's criteria.

RESULTS

Sixty-two patients (19%) had one or more radiographic indications for operative treatment, half of them had more than 20 mm of lateral displacement, and one fourth of them had substantial translation. No patients had operative treatment of the scapular body. Two patients had operative treatment of an acromion fracture, neither of which met radiographic criteria for surgery.

CONCLUSIONS

At least in our centres, there is a striking discrepancy between theoretical and actual recommendations for surgery. There is clearly a need for more research to determine whether patients are being undertreated or whether the guidelines are too stringent.

Scapular Malunion in a Vietnam War Veteran: Superior Medial Angle of the Scapula Impinging on the Clavicle: A Case Report

CASE

Scapular malunion can be overlooked as a source of substantial upper-extremity pain and dysfunction and can generate unnecessary studies or treatments. We present the case of a Vietnam War veteran who sustained a projectile injury in the left shoulder and had persistent symptoms limiting his activity and quality of life for a number of years until surgical resection was performed.

CONCLUSION

Scapular malunion should be considered in the differential diagnosis of a patient presenting with persistent upper-extremity pain and weakness following scapular fracture. Making the correct diagnosis based on the history, examination, and imaging will prevent unnecessary studies and invasive procedures.

Triple and quadruple disruptions of the superior shoulder suspensory complex

OBJECTIVES

The purpose of this study is to report on a series of patients who sustained triple and quadruple disruptions to the superior shoulder suspensory complex (SSSC), their associated injuries, and functional outcomes of open reduction and internal fixation.

DESIGN

Prospective observational study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Patients who sustained more than 2 lesions to the SSSC that underwent surgery.

OUTCOME MEASUREMENTS

Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion, and shoulder strength measurements.

RESULTS

Fifteen patients with greater than 2 disruptions (12 triple and 3 quadruple) were identified. There were 14 scapula neck fractures, 8 clavicle fractures, 6 acromioclavicular separations, 10 coracoid, and 10 acromion fractures. Rib fractures were present in 87% (13 of 15) patients. Thirteen patients (87%) sustained nerve injuries with 13 lesions distal to the brachial plexus, 5 at the level of the brachial plexus, 3 nerve root, and 2 spinal cord injuries. At final follow-up (14 of 15 patients, mean follow-up = 30.7 months), DASH scores averaged 14.9 and mean range of motion when expressed as the percentage of injured shoulder over the contralateral shoulder was 95% forward flexion, 92% abduction, and 78% external rotation. Mean strength measured by a hand-held dynamometer and expressed as the percentage of injured over contralateral was 67% forward flexion, 61% abduction, and 65% external rotation.

CONCLUSIONS

Patients with triple and quadruple disruptions of the SSSC had a high rate of associated injuries including a majority with spinal and peripheral nerve lesions. Treatment with open reduction internal fixation of the scapula was associated with satisfactory functional outcomes despite decreases in shoulder strength measurements.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A comparison of actual and theoretical treatments of glenoid fractures

BACKGROUND

There is no consensus on the operative treatment of glenoid fractures. The purpose of this study was to see whether there was a difference between how patients with a glenoid fracture would receive treatment according to theoretical operative indications based on the measurement of computed tomography (CT) scans and radiographs and the treatment they actually received in our institutions.

METHODS

A total of 457 patients with a scapular fracture were treated in two level 1 trauma centres between January 2002 and August 2011. Ninety-eight patients with a glenoid fracture were retrospectively analyzed. Intra-articular gap, medial or lateral (M/L) displacement, angular deformity, and glenopolar angle (GPA) were measured on CT scans or radiographs to determine theoretical indications for operative treatment.

RESULTS

Twenty-four patients (25%) actually had operative treatment, while 35 patients (36%) fulfilled at least one theoretical criterion to proceed with operative treatment with a medium correlation between theoretical indications for surgery and the actual operative treatment. All the patients with a theoretical indication for surgery had an intra-articular gap with a step-off of >4 mm. A bony Bankart lesion with shoulder dislocation and injury in sports was retained in the best multivariable model as indications for the actual surgery.

CONCLUSION

Theoretical guidelines for surgery on glenoid fractures may not have much influence on the current treatment.

LEVEL OF EVIDENCE

Therapeutic, level III.

A meta-analysis of operative versus nonoperative treatment in 463 scapular neck fractures

BACKGROUND AND AIMS

Treatment of scapular neck fractures remains controversial. Advantages of surgical treatments, such as anatomical restoration of fracture displacement, are counterbalanced by approach morbidity. We conducted a meta-analysis of 463 scapular neck fractures and compared clinical, functional, and radiographical outcomes in operatively and nonoperatively treated scapular neck fractures.

MATERIAL AND METHODS

A literature search was conducted, including the databases PubMed/MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. Manuscripts were included if they reported a precise description of treatment, complications, functional outcomes, and/or radiographic evaluation. Data about day-to-day activities, level of pain-freeness, range of motion, functional grading, and radiographical assessment were pooled and compared using fixed effects models.

RESULTS AND CONCLUSIONS

A total of 22 manuscripts were relevant, including 1 prospective cohort study and 21 retrospective studies. The studies showed a high heterogeneity in the result assessment. Most patients had concomitant injuries. In total, 234 out of the 463 fractures were treated operatively. Pain-freeness and radiographic outcome measurements were significantly better in the operatively treated group, whereas range of motion was significantly improved in the nonoperative treated patients. Complication rate for surgical treatment was about 10%. From the achievable data, there was no bias detected when comparing the two treatment groups. However, those data could not be analyzed for all included studies. For the same reason, the role of additional surgical treatment for concomitant injuries to the shoulder girdle could not be cleared completely. Caution should be exercised, and individual injury patterns have to be taken into consideration when considering the best treatment options.

Scapula fractures in complex shoulder injuries and floating shoulders: a classification based on displacement and instability

Background

Scapula fractures with injuries of the Superior Shoulder Suspensory Complex are often referred to as floating shoulders. However, present studies do not allow comparative evidence on indication for surgical treatment mostly due to the lack of precise definitions and comparable classifications. The aim of this study was to retrospectively analyze common types of complex shoulder injuries and develop a feasible classification allowing a therapeutic algorithm.

Methods

The study group consisted of 107 patients with scapula fractures combined with ipsilateral injuries of the shoulder girdle treated in a single trauma center between 2003 and 2010. Three-dimensional computed tomography was analyzed for dislocation and instability and assigned to subgroups of a defined classification system. Clinical data was acquired from a previously established database of all patients treated for the diagnosis of a scapula fracture.

Results

Fifty-seven of 107 (53.3%) complex scapula fractures were non-displaced and stable representing Type A fractures. Depending on the fracture pattern, three subgroups were defined. Treatment of Type A injuries should be non-operative. Displaced fractures of the scapula with a stable shoulder girdle were considered Type B injuries and represented 18.7% of all fractures. Thirty fractures (28%) with an unstable shoulder girdle were classified as Type C injuries. Again, subgroups with common injury patterns were identified. For both groups, operative treatment is recommended.

Conclusions

The described classification system is a proposal able to categorize complex shoulder injuries and allows a comparison of injury patterns in further studies.

The scapular glenopolar angle: standard values and side differences

OBJECTIVE

The aim of this study is to determine normal glenopolar angle (GPA) values on bone specimens of the scapula and compare them with various radiological views and CT examination.

MATERIALS AND METHODS

GPA values were measured on 100 mature, dry, non-paired scapulae, 20 pairs of dry scapulae, 50 AP radiographs of the shoulder, 50 Neer I views, 50 AP chest radiographs and 20 3D CT reconstructions of the scapula.

RESULTS

Measurements made on bone specimens of the scapula showed an average GPA value of 42.3°; the mean absolute side-to-side difference was on average 1.6°. The average GPA measured on 50 AP shoulder radiographs was 35.9°, on Neer I views 40.6° and AP chest radiographs 37.1°, with the mean absolute side-to-side difference on average 4.9°; on 3D CT the average GPA was 43.0° and the mean absolute side-to-side difference on average 1.4°.

CONCLUSION

GPA values depend on the method of measurement used. Measurements made on 3D CT reconstructions and Neer I views showed almost the same values as those measured on bone specimens. The values measured on AP shoulder views and AP chest radiographs were statistically significantly lower. Side-to-side variability (right and left) measured on 3D CT reconstructions was insignificant, and the obtained values corresponded to the values from bone specimens. Therefore, the best method to measure the GPA is a 3D CT reconstruction and an exact Neer I projection.

Scapula fractures: interobserver reliability of classification and treatment

OBJECTIVES

There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment.

DESIGN

Web-based reliability study.

SETTING

Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey.

PARTICIPANTS

One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns.

MAIN OUTCOME MEASUREMENTS

Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons.

RESULTS

The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA.

CONCLUSIONS

The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

The assessment of scapular radiographs

The glenopolar angle assesses the rotational alignment of the glenoid and may provide prognostic information and aid the management of scapula fractures. We have analysed the effect of the anteroposterior (AP) shoulder radiograph rotational offset on the glenopolar angle in a laboratory setting and used this to assess the accuracy of shoulder imaging employed in routine clinical practice. Fluoroscopic imaging was performed on 25 non-paired scapulae tagged with 2 mm steel spheres to determine the orientation of true AP views. The glenopolar angle was measured on all the bony specimens rotated at 10° increments. The mean glenopolar angle measured on the bone specimens in rotations between 0° and 20° and thereafter was found to be significantly different (p < 0.001). We also obtained the AP radiographs of the uninjured shoulder of 30 patients treated for fractures at our centre and found that none fitted the criteria of a true AP shoulder radiograph. The mean angular offset from the true AP view was 38° (10° to 65°) for this cohort. Radiological AP shoulder views may not fully project the normal anatomy of the scapular body and the measured glenopolar angle. The absence of a true AP view may compromise the clinical management of a scapular fracture.

Cite this article: Bone Joint J 2013;95-B:1114–20.

Operative techniques in the management of scapular fractures

Operative fixation of the scapula is associated with good outcomes. Techniques have been developed to facilitate surgical exposure of the osseous anatomy so that stability can be achieved. Although the familiar deltopectoral approach can be used for anterior glenoid fractures, the more common exposure is a posterior approach for fractures involving the neck and body of the scapula. The posterior approach has been nuanced to match needs related to fracture pattern and timing of surgery. Reducing the fragments and stabilizing them can be challenging but, a satisfactory reduction and stable fixation can be achieved, which allows immediate motion and rehabilitation.

The AO Foundation and Orthopaedic Trauma Association (AO/OTA) scapula fracture classification system: focus on glenoid fossa involvement

BACKGROUND

Fractures of the glenoid frequently require surgical treatment. A comprehensive and reliable scapula classification system involving the glenoid fracture patterns is needed to describe the underlying pathology. The AO Scapula Classification Group introduces an appropriate novel system that is presented along with its inter-rater reliability and accuracy.

MATERIALS AND METHODS

An iterative consensus process (involving a series of face-to-face meetings and agreement studies) with an international group of 7 experienced shoulder surgeons was used to specify and evaluate a scapular fracture classification system with a focus on fracture patterns of the glenoid fossa. The last evaluation was conducted on a consecutive collection of 120 scapular fractures documented by both plain radiographs and computed tomography scans including 3-dimensional surface rendering. Inter-rater reliability was analyzed with κ statistics, and accuracy was estimated by latent class modeling.

RESULTS

Of 120 scapular fractures, 46 involved the glenoid (38%), with 38 classified as F1 articular rim fractures. The overall median sensitivity and specificity in identifying these fractures were 95% and 93%, respectively. Surgeons' accuracy in classifying F1 fractures ranged from 86% to 100% (median, 94%). Subsequently, classification of simple F1 fractures resulted in a proportion of 36% of anterior rim fractures, 19% of posterior rim fractures, and 45% of short oblique fractures, with accuracies ranging from 85% to 98%.

CONCLUSION

This new system for scapular glenoid fractures has proved to be sufficiently reliable and accurate when applied by experienced shoulder surgeons. Further validation of the most detailed system, as well as involvement of surgeons with different levels of training in the framework of clinical routine and research, however, should be considered.

Scapula fractures

Over the past decade, there has been an increased interest in understanding the operative indications and techniques in treating scapular fractures and tracking their outcomes. Multiple studies have documented poor functional outcomes following nonoperative management of displaced scapular fractures. There is a groundswell of recognition that severe deformity from scapular malunion is associated with functional consequences for patients. This has led to a growing recognition that scapular fractures should be held to the same standards as other bodily fractures with regard to fracture fixation principles, including anatomic articular reduction, proper alignment, and stable internal fixation. Through research, there has been an improved understanding of scapular fracture patterns and the relevant surgical approaches and exposures used for fracture fixation. As with many bones, however, there still remains the absence of a compelling study that defines thresholds for surgical indication based on degrees of deformity and amounts of displacement.

Management of scapular fractures

With the exception of displaced articular glenoid fractures, management of scapular fractures has largely consisted of benign neglect, with an emphasis on motion as allowed by the patient's pain. Better understanding of this injury has resulted in greater acceptance of surgical management of highly displaced variants. However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. Scapular fractures are the result of high-energy mechanisms of injury, and they often occur in conjunction with other traumatic injuries. In addition to performing meticulous physical and neurologic examination, the surgeon should obtain plain radiographs, including AP shoulder, axillary, and scapular Y views. Three-dimensional CT is used to determine accurate measurements in surgical candidates. Surgical approach, technique, and timing are individualized based on fracture type and other patient-related factors.