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

Risk factors and incidence of short-term complications following open reduction and internal fixation of scapula fractures

PURPOSE

To determine the short-term complication rates following open reduction and internal fixation of scapula fractures, factors affecting the development of adverse events, and complication rates based on the anatomic location of the fracture.

METHODS

Thirty-day complication rates for patients who underwent open reduction and internal fixation of the scapula were compared between glenoid, body, coracoid, and acromion fracture locations, as identified by International Classification of Disease codes. Possible adverse events included postoperative surgical site infection, renal insufficiency, intubation, pneumonia, deep vein thrombosis, pulmonary embolism, urinary tract infection, wound dehiscence, stroke, and blood transfusion.

RESULTS

A total of 251 scapula fractures were identified, with 161 having known fracture locations: 105 glenoid, 20 body, 9 coracoid, and 27 acromial fractures. The rate of any adverse event for all scapular fractures was 2.0%, with no significant difference between anatomic locations (p = 0.79). The overall rates of transfusion, surgical site infection, and return to OR were 0.4%, 0.8%, and 3.98%. Steroid use associated with a significantly increased risk of any adverse event (OR: 55.57, p = 0.038) and outpatient status demonstrated a protective effect on reoperation (OR: 0.11, p = 0.014). There were no significant differences in the rates between groups [transfusion (p = 0.91); surgical site infection (p = 0.17); reoperation (p = 0.85)].

CONCLUSION

Complication rates within thirty days of ORIF for scapula fracture were low. Reoperation was the most common complication, followed by surgical site infection, wound dehiscence, stroke, transfusion, and pneumonia. Steroid use was a risk factor for developing any adverse event, and outpatient status was protective against reoperation. The 30-day complication profile of glenoid, body, coracoid, and acromial fractures was not significantly different. The low complication rates support the relative short-term safety of operative intervention with internal fixation.

LEVEL OF EVIDENCE

Level III.

Finite element analysis of the treatment of a minimally invasive approach combined with a novel anatomical locking plate for scapular body fractures

BACKGROUND

The minimally invasive approach for the treatment of displaced scapular neck or body fractures has the advantages of less trauma and minimal muscle dissection. In clinical practice, the minimally invasive approach combined with an anatomical locking plate has been used to treat scapular body fractures. In addition, we have made minor modifications to the minimally invasive approach. However, the biomechanical study about the approach combined with an anatomical locking plate in treating scapular body fractures was limited.

METHODS

Finite element analysis (FEA) was used to conduct the biomechanical comparison between the anatomical locking plate (AP model) and reconstructive plate (RP model) in the treatment of scapular body fractures through the modified minimally invasive approach. A healthy male volunteer with no history of scapula or systemic diseases was recruited. High-resolution computed tomography images of his right scapula were obtained. Two scapula models were constructed and analyzed by the software of Mimics 21.0, Geomagic Wrap 2021, SolidWorks 2021, and ANSYS Workbench 2022, respectively.

RESULTS

Through static structural analysis, in terms of equivalent von Mises stress, equivalent elastic strain, and total deformation, the AP model exhibited superior safety characteristics, enhanced flexibility, and anticipated stability compared with the RP model. This was evidenced by lower maximum stress, lower maximum strain and displacement.

CONCLUSION

The minimally invasive approach combined with an anatomical locking plate for scapular body fractures had better biomechanical stability. The study provided a biomechanical basis to guide the clinical treatment of scapular body fractures.

Significance of Scapular Fracture Existence in Blunt Chest Trauma: A Retrospective Cohort Study

Background

Scapular fracture is a rare encounter in blunt trauma patients. The scapula is surrounded by strong groups of muscles offering good protection for the bone. Therefore, a high-energy trauma is needed to cause a scapular fracture. We aim to study scapular fractures and their relation to injury severity and mortality in blunt chest trauma (BCT) patients.

Methods

We retrospectively collected data from all patients with BCT who were admitted to our hospital from December 2014 through January 2017. The injury details of all BCT patients were retrieved from the trauma registry of the hospital and were supplemented by patients' electronic files for missing information. Collected data included demography, mechanism of injury, vital signs, Glasgow Coma Score (GCS) on admission, injured body regions, management, Injury Severity Score (ISS), New Injury Severity Score (NISS), length of hospital stay (LOS), and mortality.

Results

During the study period, 669 patients had BCT. Scapular fracture was present in 29 (4.3%) of the BCT patients. The scapular fracture was missed by chest X-ray in 35.7% of the patients; however, it was accurately diagnosed by computed tomography (CT) scan of the chest. Neck injury was significantly higher in patients with scapular fracture compared with patients without fracture (p < 0.001). ISS and NISS were significantly higher in patients with scapular fractures compared to other patients without fractures (p=0.04 and p=0.003 Mann-Whitney U test, respectively). Two patients with scapular fractures died due to severe associated injuries (the overall mortality was 9.6%).

Conclusions

Scapular fracture in BCT patients indicates a high-energy type of trauma. Compared to a chest X-ray, CT scan was more accurate for the diagnosis of scapular fracture. Associated injuries are the main cause of trauma-related mortality rather than the direct effect of the fractured scapula. Particular attention and meticulous evaluation should be paid to head and neck injuries to avoid missing injuries.

Management of Extra-articular Scapular Fractures: A Narrative Review and Proposal of a Treatment Algorithm

The management of scapular fractures can be either conservative or operative, but it is still unclear how to choose the treatment option. Scapular fractures can be classified anatomically into four types: scapular spine, scapular body, and scapular neck where the treatment is conservative most of the time except for certain indications that are specific to each one, and inferior angle of the scapula where the operative treatment yields the best results but conservative treatment can be contemplated in some cases.

Finite element analysis of titanium anatomic plate and titanium reconstructive plate for treatment of extra-articular fractures of the scapula

BACKGROUND

Due to the lack of postoperative reporting outcomes and bio-mechanical studies, an optimal management of scapular fractures has not been well-established in clinical treatment, even though there are many options available. This study aimed to compare the stability of the new titanium anatomic and traditional titanium reconstructive plates for extra-articular scapular fractures through finite element analysis.

METHODS

Two models of scapular assembly were constructed, including one anatomic plate (AP model) and one reconstructive plate (RP model). After meshing, material parameter, and boundary condition settings, we applied four loading conditions to simulate forces acting on the scapula and osteosynthesis material. To evaluate the bio-mechanical properties, the equivalent von Mises stress, equivalent elastic strain, and total deformation were investigated.

RESULT

The stress and strain distribution of model AP has better performance than model RP, with more uniform and lower values. The maximum stress value of the scapula in model AP is smaller than that of the scapula in model RP (102.83 MPa vs. 166.71 MPa). The maximum stress of the anatomic plate is half that of the reconstructive plate (218.34 MPa vs. 416.01 MPa). The maximum strain of the scapula in model AP is smaller than that of the scapula in model RP (0.0071 vs. 0.0106). The maximum strain of the anatomic plate is half that of the reconstructive plate (0.0019 vs. 0.0037). The maximum displacement of each model is all at the acromion, with a similar value (2.2947 mm vs. 1.8308 mm).

CONCLUSIONS

With sufficient bio-mechanical stability, the anatomic plate to support scapular fracture fragments was superior to that of the reconstructive plate.

Open reduction internal fixation with bone grafting for scapular body nonunion: A case report

Scapular body fractures are rare fractures that represent less than 1 % of all fractures and are typically associated with a high energy mechanism of injury. Traditionally these fractures have been treated non-operatively, resulting in union of the fracture and acceptable patient outcomes. We present a case of symptomatic scapular body fracture nonunion following non-operative management that was treated with open reduction and internal fixation with local autologous bone grafting. Our patient went on to successful union of his fracture as well as drastic improvement in shoulder function, range of motion, strength, and patient reported outcome measures assessed throughout his treatment course. The authors believe that scapular body fracture nonunion should be of clinical suspicion in forming the differential diagnosis for a patient who had previously sustained a scapular body fracture with persistent pain and failure to improve following non-operative management. We believe that open reduction and internal fixation with bone grafting can help promote fracture union in these patients and may result in improved shoulder function post-operatively.

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.

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

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

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It is a recommended method in clinical treatment.

The Effect of Scapular Fixation on Scapular and Humeral Head Movements during Glenohumeral Axial Distraction Mobilization

Background and Objectives: Glenohumeral axial distraction mobilization (GADM) is a usual mobilization technique for patients with shoulder dysfunctions. The effect of scapular fixation on the movement of the scapula and the humeral head during GADM is unknown. To analyze the caudal movement of the humeral head and the rotatory movement of the scapula when applying three different intensities of GADM force with or without scapular fixation. Materials and Methods: Fifteen healthy subjects (mean age 28 ± 9 years; 73.3% male) participated in the study (twenty-eight upper limbs). Low-, medium- and high-force GADM in open-packed position were applied in scapular fixation and non-fixation conditions. The caudal movement of humeral head was evaluated by ultrasound measurements. The scapular rotatory movement was assessed with a universal goniometer. The magnitude of force applied during GADM and the region (glenohumeral joint, shoulder girdle, neck or nowhere) where subjects felt the effect of GADM mobilization were also recorded. Results: A greater caudal movement of the humeral head was observed in the non-scapular fixation condition at the three grades of GADM (p < 0.008). The rotatory movement of the scapula in the scapular fixation condition was practically insignificant (0.05−0.75°). The high-force GADM rotated scapula 18.6° in non-scapular fixation condition. Subjects reported a greater feeling of effect of the techniques in the glenohumeral joint with scapular fixation compared with non-scapular fixation. Conclusions: The caudal movement of the humeral head and the scapular movement were significantly greater in non-scapular fixation condition than in scapular fixation condition for the three magnitudes of GADM force.

Supine harvest of vascularised scapular bone grafts-Anatomical study and clinical application

BACKGROUND

We report our findings from an anatomical study on harvest of a vascularized scapular bone graft from a supine position. A clinical case is presented to illustrate the operative approach.

METHODS

Twenty cadaveric hemibody specimens were dissected in the supine position. Outcomes of interest included the characterization of anatomical variants and measurements of pedicle length. Specific measurements included distance from the origin of the subscapular artery (at the axillary artery) to the branch point of the angular artery from the thoracodorsal artery or serratus branch and the length of the angular branch proper.

RESULTS

There are five reported anatomic variations regarding the origin of the angular branch of the thoracodorsal artery. In our cadaveric cohort only four known types were seen, and an entirely new variant was encountered. Six cadaveric dissections exhibited a type 3 configuration, six were type 1, four were type 2, three were type 4, and one was a previously unreported variant we termed a type 6, with multiple angular artery branches originating from the posterior branch of the thoracodorsal. The mean distance between the origin of the subscapular artery and the takeoff of the angular branch was 6.3 ± 2.0 cm. The mean length of the angular branch was 3.7 ± 1.4 cm.

CONCLUSIONS

Supine positioning for harvest of a vascularized bone graft obviates the need for an intraoperative position change and allows reconstruction of bone defects in the hand and upper extremity within a single surgical field.

Treatment of lower part of glenoid fractures through a novel axillary approach: A case report

BACKGROUND

Based on the location and size of the fracture block, open reduction and internal fixation can be employed or assisted for shoulder arthroscopy in the treatment of glenoid fractures. However, the treatment of lower part of glenoid fractures through a novel axillary approach has not been reported so far.

CASE SUMMARY

A 22-year-old right-handed man was transferred to our outpatient clinic because of right shoulder injury during a traffic accident. X-ray examination after admission suggested the fracture of the lower part of the right glenoid and an ipiselial proximal humeral fracture. Three-dimensional (3D) computed tomography (CT) further suggested that the size of the fracture block of the lower part of the right glenoid was 3.4 mm × 16.2 mm. The patient was diagnosed as the fracture of the lower part of the glenoid, also known as bony Bankart lesion without shoulder dislocation. After general anesthesia, the patient was surgically treated with the open reduction internal fixation through a novel axillary approach. 3D CT and shoulder joint function were reexamined at 12 mo of follow-up, showing acceptable recovery.

CONCLUSION

This case report describes a novel axillary approach adopted in an open reduction with cannulated screw and wire anchor internal fixation. After a follow-up for more than 12 mo, 3D CT and shoulder joint function examinations display a good recovery.

Comparison of the Acute Effects of Kinesio Taping and Sleeper Stretching on the Shoulder Rotation Range of Motion, Manual Muscle Strength, and Sub-Acromial Space in Pitchers with Glenohumeral Internal Rotation Deficit

BACKGROUND AND OBJECTIVES

Sleeper stretching (SS) can improve the shoulder's range of motion (ROM) for pitchers with glenohumeral internal rotation deficit (GIRD). However, no evidence has proven the effect of Kinesio taping (KT) on shoulder strength and ROM. Therefore, this study compared the effects of SS and KT on shoulder rotation ROM, muscle strength, and sub-acromial distance in pitchers with GIRD.

MATERIALS AND METHODS

Thirty-one pitchers with GIRD were allocated into control, KT, and SS groups. Shoulder rotation ROM, muscle strength, and sub-acromial space were measured before and after treatment with SS or KT.

RESULTS

The results revealed that KT and SS significantly enhanced shoulder rotation ROM in pitchers with GIRD. External rotator strength significantly increased following KT but significantly decreased after SS. KT and SS exerted no effects on the sub-acromial space.

CONCLUSIONS

KT and SS improve shoulder rotation ROM in pitchers with GIRD. In addition, KT improves shoulder external rotator strength, and SS reduces it.