Surgical exposure and fixation of displaced type IV, V, and VI glenoid fractures

Deltoid-Sparing Modified Judet Approach: Technique and Clinical Series

SUMMARY

Posterior approaches provide the mainstay for treatment in most of the scapula body and neck fractures, even those associated with many intraarticular variants. Several posterior approach modifications for minimizing soft-tissue damage and limiting muscular detachment, have previously been described in the literature; however, little or no clinical evidence is available specifically applied to the various approaches.In this study, we describe complete sparing of the deltoid muscle origin during the "modified Judet" approach. The modified approach as previously described detaches the deltoid origin. Deltoid sparing allows for satisfactory visualization and fixation of extra-articular scapula fractures and even some intraarticular variants. The purpose of this article was to describe the deltoid-sparing modified Judet approach and report clinical outcomes for 23 patients after surgical treatment.

Operative treatment of complex intra-articular scapular fractures: long-term functional outcomes in a single-center study

BACKGROUND

Scapula fractures occur in the setting of high-energy trauma. Operative treatment of complex intra-articular scapular fractures can result in adequate surgical and functional outcomes.

MATERIALS AND METHODS

Twenty-seven patients with complex, displaced intra-articular scapular fractures with or without involvement of the scapular body, were treated operatively in a single trauma center between 2010 and 2021. Associated injuries such as ipsilateral upper limb fractures and nerve injuries were identified in the majority of the patients. Fixation with anatomical medial and lateral border precontoured plates was utilized following posterior modified Judet approach or/and anterior deltopectoral approach. Functional outcome was assessed using the Oxford Shoulder Score and detailed shoulder range of motion and return to work/activities data were obtained.

RESULTS

At a mean follow-up of 69 months (range 4-135 months), individual functional outcomes for 25 of the 27 patients revealed a mean Oxford Shoulder Score of 33 (69%), mean active flexion of 120 degrees, active abduction of 110 degrees, mean active external rotation of 35 degrees and mean internal rotation to the level of T5. All patients were pain-free at the latest follow-up, and 23 of 25 had returned to their preinjury occupation and activities.

CONCLUSION

Operative treatment for these complex injuries is a viable option at centers equipped to handle critically ill patients and can result in satisfactory range of motion and functional score measurements along with a relatively low number of complications.

Surgical stabilization of the ipsilateral scapula and rib fractures using the mirror Judet approach: a preliminary result

BACKGROUND

We report our preliminary results using a single approach, the mirror Judet approach, for patients with both ipsilateral scapula and multiple rib fractures.

METHODS

Five consecutive patients [median age: 56 years (range: 44 ~ 60)] with ipsilateral scapula and multiple rib fractures that met the surgical indications were retrospectively reviewed. A single approach, the mirror Judet approach, was used for surgical stabilization of the scapula and targeted rib fractures. Thoracoscopic surgery was performed first for management of associated lung lesions and marking the targeted rib. All patients received the same rehabilitation protocol and a minimum 12-month follow-up.

RESULTS

All surgically-fixed fractures eventually united without malunion. No complaints of intercostal neuralgia, infection, or other complications were seen. The mean range of motion in the injured shoulder returned to at least 90% of the contralateral side range. The mean Disabilities of the Arm, Shoulder, and Hand score at the 12th month was 2.0 (range: 0-7). All patients were able to return to their previous work.

CONCLUSION

The mirror Judet approach allows for the surgical stabilization of the ipsilateral scapula and multiple rib fractures using the same approach and provides acceptable functional outcomes in well-selected patients.

LEVEL OF EVIDENCE

Level IV.

Instability and results after non-operative treatment of large anterior glenoid rim fractures: is there a correlation between fragment size or displacement and recurrence?

INTRODUCTION

There is little data available on non-operative treatment of anterior glenoid rim fractures (GRF). Nothing is known about fracture size and displacement in comparison to clinical outcomes and instability in a mainly middle-aged patient population. The aim of this study was to demonstrate the results of non-operative treatment in anterior glenoid rim fractures with the special focus on potential instability/recurrence.

METHODS

The inclusion criteria were non-operatively treated anterior GRF of at least ≥ 5 mm width using the age- and gender-matched Constant/Murley score (a.-/g.-CMS) and the Western Ontario Instability Index (WOSI). Radiographic parameters (fracture morphology, displacement, major tuberosity fractures and Hill-Sachs lesion using initial CT and radiographs) and the proportion of the fractured glenoid were detected (2D-CT-circle-method) and osteoarthritis (A.P. and axial radiographs) was classified according to Samilson/Prieto. Proportion of fractured glenoid and medial displacement were correlated with the recurrence rate and the clinical scores.

RESULTS

N = 36 patients could be followed-up after a mean of 4.4 years [12-140 month, average age: 58 (± 13, 33-86) years]. The a.-/g.-CMS was 93 (± 11, 61-100) points, and the WOSI was 81% (± 22%, 35-100%) on average. The mean intraarticular displacement was 4 mm (± 3 mm; 0-14 mm). The 2D-circle-method showed a mean glenoid fracture involvement of 21% (± 11, 10-52%). Two cases of frozen shoulders and one case with biceps pathology were associated with the trauma. Within the followed-up patient group re-instability has occurred in n = 2 patients (6%) within the first two weeks after trauma. Osteoarthritis was found in n = 11 cases. There was no correlation between the scores and the fracture size/displacement [(a.-/g.-CMS vs. displacement: r = - 0.08; p = 0.6; vs. size: r = - 0.29; p = 0.2); (WOSI vs. displacement: r = - 0.14; p = 0.4; vs. size: r = - 0.37; p = 0.06)], but very large (≥ 21%) fractures with displacement ≥ 4 mm showed slightly worse results without significant difference (a.-/g.-CMS p = 0.2; WOSI p = 0.2). The apprehension test was negative in all patients at final follow-up.

CONCLUSION

Non-operative treatment of anterior GRF was associated with overall good results within a mainly middle-aged larger patient group. Re-instability is rare and is not associated with fragment size but can occur in the first weeks after trauma. Size and dislocation of the fracture is not a criterion for the prognosis of potential instability.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Functional outcomes of internal fixation of scapula fractures due to high-velocity gunshot injuries

BACKGROUND

Open fractures of the scapula are relatively rare and only a few studies are interested in this subject. This study aims to demonstrate the results of internal fixation of open scapula fractures due to gunshot injuries.

MATERIALS AND METHODS

Eight patients who had open scapula fractures and were treated by internal fixation through the conventional Judet approach included in this study. Patients were followed up monthly in the first 6 months and every 2 months in the rest of the follow-up. Shoulder range of motion, Constant Shoulder Score, and Disabilities of the Arm, Shoulder, and Hand score were used for functional evaluation.

RESULTS

The average follow-up period was 34.6 ± 11.9 months. The average time between injuries and the surgery was 10.5 ± 5.1 days. The average shoulder abduction of the patients was 135.6 ± 18.8°, the average forward flexion of the shoulder was 160 ± 19.2°. The average internal and external rotations of the shoulders were 80 ± 14.1° and 63.1 ± 17.3°, respectively. CSS was calculated as 79.8 ± 14.4, and DASH was calculated as 14.1 ± 14.9.

CONCLUSIONS

In the treatment of open scapula fractures due to gunshot injuries, an internal fixation is a reliable option and the results were comparable with previous studies.

Current challenges and controversies in the management of scapular fractures: a review

Fractures of the scapula are rare and usually associated with high-energy trauma. The unfavorable scapular anatomy, combined with the complexity of the approaches for fracture fixation, make the treatment challenging, even for experienced surgeons. Furthermore, the literature is controversial regarding surgical indications and rationale for treatment. The present review article was designed to address and discuss critical aspects of decision-making for the management of scapular fractures, including surgical indications and patient safety considerations.

Contouring Plates in Fracture Surgery: Indications and Pitfalls

Effective fracture surgery requires contouring orthopaedic implants in multiple planes. The amount of force required for contouring is dependent on the amount and type of material contained within the plane to be altered. The type of contouring used depends on the desired plate function; for example, buttress mode often requires some degree of undercontouring, whereas compression plating may require prebending. Other reasons to contour a plate include matching patient anatomy either to maximize fixation options or to reduce implant prominence. Precontoured plates can be convenient and help to facilitate soft-tissue friendly techniques but have the potential to introduce malreduction if the plate position and fit are not carefully monitored.

Infraspinatus Tenotomy Improves Glenoid Visualization With the Modified Judet Approach

OBJECTIVES

To determine if the addition of an infraspinatus tenotomy to the modified Judet approach (MJA) improves glenoid visualization.

METHODS

We performed an MJA on 14 human cadaveric shoulders. After exposing the glenoid, the boundary of the visualized glenoid surface was marked with a 1.8- and 2.0-mm drill bit before and after performing an infraspinatus tenotomy, respectively. The humerus was disarticulated, and the pre- and post-tenotomy drill marks were verified. The area of the entire glenoid, and each of the 4 quadrants [anterior-superior (AS), anterior-inferior (AI), posterior-superior (PS), and posterior-inferior (PI)] were analyzed using a custom image-processing program. The amount of glenoid exposure and percentage of area visualized before and after the tenotomy were compared.

RESULTS

Adding an infraspinatus tenotomy to the MJA significantly increased total glenoid area (cm) exposure by 33%, P < 0.0001. Three of 4 glenoid quadrants (PS, AS, and AI) had a significant increase in glenoid visualization, with the AS quadrant having the most substantial improvement after the tenotomy (+67%), P < 0.0001.

CONCLUSIONS

The results provide the percentage of glenoid fossa that can be seen using an MJA and demonstrate that visualization significantly improves after adding an infraspinatus tenotomy.

Landmarks for Identifying the Suprascapular Foramen Anteriorly: Application to Anterior Neurotization and Decompressive Procedures

BACKGROUND

Additional landmarks for identifying the suprascapular nerve at its entrance into the suprascapular foramen from an anterior approach would be useful to the surgeon.

OBJECTIVE

To identify landmarks for the identification of this hidden site within an anterior approach.

METHODS

In 8 adult cadavers (16 sides), lines were used to connect the superior angle of the scapula, the acromion, and the coracoid process tip thus creating an anatomic triangle. The suprascapular nerve's entrance into the suprascapular foramen was documented regarding its position within this anatomical triangle. Depths from the skin surface and specifically from the medial-most point of the clavicular attachment of the trapezius to the suprascapular nerve's entrance into the suprascapular foramen were measured using calipers and a ruler. The clavicle was then fractured and retracted superiorly to verify the position of the nerve's entrance into the suprascapular foramen.

RESULTS

From the trapezius, the nerve's entrance into the foramen was 3 to 4.2 cm deep (mean, 3.5 cm). The mean distance from the tip of the corocoid process to the suprascapular foramen was 3.8 cm. The angle best used to approach the suprascapular foramen from the surface was 15° to 20°.

CONCLUSION

Based on our study, an anterior suprascapular approach to the suprascapular nerve as it enters the suprascapular foramen can identify the most medial fibers of the trapezius attachment onto the clavicle and insert a finger at an angle of 15° to 20° laterally and advanced to an average depth of 3.5 cm.

Scapular fractures: a common diagnostic pitfall

Scapular fractures are one of the most difficult fractures to diagnose on radiographs. Detection can be challenging because of the obscuration by the overlying structures or incomplete imaging due to difficult patient collaboration. Familiarity with imaging characteristics of these abnormalities will allow radiologists to better diagnose and characterize scapular fractures. Three-dimensional computed tomographic scans are considered the gold standard for scapular diagnoses. Treatment strategies differ depending on the type of scapular fractures, but the site and degree of displacement will determine whether surgical intervention should be considered. Complications can occur in fractures that are undiagnosed or improperly evaluated. The purpose of this article is to describe imaging features of traumatic scapular injury, and discuss the role of diagnostic imaging in clinical decision making after shoulder trauma. (www.actabiomedica.it)

Inferior glenoid fossa fractures: patho-anatomy and results of operative treatment

INTRODUCTION

A typical feature of inferior glenoid fractures is a distal fragment separated from the glenoid fossa. In most cases, the inferior glenoid fractures are associated with a fracture of the scapular body. However, there are no detailed studies of inferior glenoid fractures, and only brief mentions can be found in the literature in this respect.

MATERIAL AND METHODS

The basic group comprised 42 patients, with the mean age of 48 years, who sustained 42 fractures of the inferior glenoid. In this group, the scapular fracture anatomy was evaluated, based on 3D CT reconstructions. A total of 29 patients operated on were followed up for 12 to 128 months after injury (average, 52 months), three patients were lost to follow up. The results of the operative treatment, including complications, were assessed radiologically and functionally.

RESULTS

Fracture anatomy was described from various aspects, i.e., the size of the articular surface carried by the separated glenoid fragment, the existence of multiple articular fragments, the size of the separated glenoid fragment and the extent of injury to the scapular body. All 29 operatively treated fractures radiologically healed within three months. Full and pain-free range of motion was restored in 18 patients; in eight patients it was limited by 20 degrees and in three patients by more than 40 degrees. The mean Constant score was 82.

CONCLUSION

Fractures of the inferior glenoid fossa requires CT examination, including 3D CT reconstruction with subtraction of the surrounding bones. Displaced fractures are indicated for operative treatment.

Results of non-operative treatment of fractures of the glenoid fossa

AIMS

Our aim was to investigate the outcomes of patients with a displaced fracture of the glenoid fossa who are treated conservatively. There is little information in the literature about the treatment of these rare injuries non-operatively.

PATIENTS AND METHODS

We reviewed 24 patients with a mean age of 52 years (19 to 81) at a mean of 5.6 years (11 months to 18 years) after the injury.

RESULTS

At final follow-up, the mean Constant and Murley score was 79 points (18 to 98); the mean Western Ontario Shoulder Instability Index score (WOSI) was 77% (12 to 100) and the mean Rowe score was 93 points (50 to 100). Fractures with little intra-articular displacement (≤ 3 mm) had an uneventful outcome. Those with intra-articular displacement of ≤ 3 mm had a significant better mean Constant and Murley score than those with displacement of ≥ 5 mm and/or a fracture gap of ≥ 5 mm. Poor clinical results such as nonunion and post-traumatic osteoarthritis were associated with displaced or angulated glenoid fragments and significant intra-articular displacement.

CONCLUSION

Glenoid fossa fractures with displacement of ≥ 5 mm should be treated surgically if the patient's condition allows. Displacement and angulation can lead to nonunion and a poor outcome if the degree of displacement results in a persistent fracture gap in the glenoid fossa or if the angulation of fragments leads to malunion. Cite this article: Bone Joint J 2016;98-B:1074-9.

A Comparison of Exposure Between the Classic and Modified Judet Approaches to the Scapula

OBJECTIVES

A debate exists over the optimal approach for addressing fractures of the scapula and glenoid. The purpose of this study is to (1) quantify and compare osseous exposure using modified Judet (MJ) and classic Judet (CJ) approaches and (2) assess the change in scapular exposure after triceps release from the inferior glenoid.

METHODS

Ten arms on 5 fresh-frozen torsos underwent MJ and CJ approaches. A triceps release was performed following the CJ approach in all specimens. Visual and/or palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J (NIH, Bethesda, MD) to calculate the surface area of exposed bone.

RESULTS

The MJ and CJ approaches exposed 16.8 (±7.58) cm(2) and 98.6 (±25.39) cm(2) of bone, respectively (P < 0.001). The full medial and lateral borders of the scapula were visualized in all approaches with mobilization of the teres minor. Palpable access to the full scapular spine was possible in all cadavers. Although the MJ and CJ approaches only allowed the inferior gleniod neck to be visualized in 1 and 2 specimens, respectively, performing a triceps release provided access to this structure. It also increased the CJ exposure by 12.6 cm(2) (P < 0.001) and allowed palpation of the anterior glenoid margin in 100% of specimens.

CONCLUSIONS

In conclusion, the MJ approach allows similar access to landmarks important for reduction and fixation while exposing only 20% of the surface area typically visualized with the CJ approach.

Pathoanatomy and computed tomography classification of glenoid fossa fractures based on ninety patients

PURPOSE

The aim of the article is to present the pathoanatomy and a new classification of glenoid fractures developed on the basis of analysis of 3D computed tomography (CT) examinations and intra-operative findings.

MATERIALS AND METHODS

The study group comprised 90 patients (69 men and 21 women) who sustained glenoid fractures. Mean patient age was 47 years (17-92). In 77 nonpolytraumatised patients, anteroposterior (AP) radiographs of the affected shoulder girdle were taken, including Neer I and II views. All 90 patients underwent CT examination, combined in 73 of them with 3D CT reconstruction including subtraction of the humeral head, ribs and clavicle, from the anterior and posterolateral views. In total, 52 patients (58 %) were operated on and 38 42 %) were treated non-operatively.

RESULTS

In total, five basic types of injuries to the glenoid were identified based on analysis of the separated portion of the glenoid fossa: including fractures of the superior glenoid (14 cases, 16 %), the anterior glenoid (23 cases, 23 %), the posterior rim of the glenoid (5 cases, 6 %), the inferior glenoid (38 cases, 42 %) and the entire glenoid (10 cases, 11 %).

CONCLUSION

The proposed classification of glenoid fractures defines five basic types of fractures verified by 3D CT reconstructions and intra-operative findings. It respects the anatomical architecture of scapula, fracture mechanism, associated injuries to the shoulder girdle and, where appropriate, the preferred surgical approach.

Open reduction and internal fixation of Ideberg IV and V glenoid intra-articular fractures through a Judet approach: a retrospective analysis of 11 cases

OBJECTIVES

To evaluate the methods and the outcomes of complex intra-articular glenoid fractures, treated by open reduction and internal fixations.

METHODS

The outcomes of 11 cases of complex intra-articular glenoid scapular fractures were retrospectively analyzed. The fractures were classified as type IV in five cases, type Va in two and Vb in four cases, according to Ideberg classification system. The mean step or gap between the main articular fragments was 6.3 ± 6.2 (4-25) mm. The fractures were openly reduced through a Judet approach and fixed with reconstructive plates or bands placed on the lateral and medial side of affected scapula, respectively. The main articular fragments were strengthened with a 4.0-mm cannulated screw in five cases. The bone union, the anterior flexion, the external and internal rotation of the shoulders were checked and recorded. The functional outcomes were evaluated using DASH questionnaire, Constant and UCLA shoulder score systems, respectively.

RESULTS

11 patients were followed up with an average of 28.2 ± 12.6 (12-50) months. All the fractures were united smoothly without second intervention. At the latest visiting, the mean anterior flexion of affected shoulder was 157.3 ± 7.37° (range 150°-170°), the mean external rotation of the affected shoulder was 58.2 ± 7.5° (range 50°-70°). When the shoulder in the internal rotation, the extended thumb reached to L4 or L1 or T10 or T7 in one case, to T12 in two cases and to T8 in four cases, respectively, the mean Constant score was 91.7 ± 2.8 (86-96) points. The mean UCLA score was 32.7 ± 1.7 (30-35) points, leading to four cases of excellent and seven cases of good results. The mean DASH score was 7.4 ± 3.3 (3.4-13) points.

CONCLUSION

Good outcomes could be obtained when Ideberg IV and V glenoid fractures were treated by open reduction and internal fixation through a Judet approach.

Quantitative comparison of exposure for the posterior Judet approach to the scapula with and without deltoid takedown

BACKGROUND

The purposes of this study are to quantify the extent of the scapula exposed and to describe the osseous landmarks within the dissection of a posterior Judet approach with and without takedown of the posterior deltoid muscle.

METHODS

The posterior Judet approach using the muscular interval between the teres minor and infraspinatus muscle with and without takedown of the deltoid muscle was performed on 10 fresh-frozen cadaveric shoulders. Retractors with 2 kg of force were used at the wound margins for retraction. Upon completion of the exposure, a calibrated digital image was taken from the surgeon's perspective and specific anatomic landmarks were identified. The digital images were then analyzed with a computer software program, ImageJ (National Institutes of Health, Bethesda, MD, USA), to calculate the area (in square centimeters) of bone exposed.

RESULTS

The mean area of posterior scapula exposed by the traditional Judet approach with takedown of the deltoid muscle was 30.2 cm(2) (95% confidence interval, 27.7-32.7 cm(2)) compared with 27.3 cm(2) (95% confidence interval, 24.8-29.9 cm(2)) when the deltoid was not detached (P < .0001). In all 10 cadaveric shoulders, the posterior Judet approach without takedown of the deltoid muscle allowed access to the posterior glenoid, lateral scapula border, and spinoglenoid notch.

CONCLUSIONS

Although takedown of the deltoid muscle improves exposure, the posterior Judet approach without takedown of the posterior deltoid muscle allows for safe exposure to 91% of the bony scapula obtained by removing the deltoid muscle and access to the critical osseous fixation points of the posterior scapula.

Surgical management of coracoid fractures: technical tricks and clinical experience

The coracoid process plays a pivotal role in the foundation of the coracoacromial arch and in cases of displaced fractures; surgical management may be warranted to avoid functional compromise or impingement. A direct approach through Langer's lines allows for easy exposure and direct visualization for an anatomic reduction of simple fractures through the shaft or base of the coracoid. An anterior approach for fractures that extend into the superior glenoid fossa allows for direct exposure to obtain an anatomic articular reduction and indirect reduction of the coracoid fracture. In cases where a complex glenoid or scapula neck/body fracture is being addressed simultaneously either a posterior Judet approach can be used with an indirect reduction method or a separate anterior approach must be combined to address it if not in continuity with the superior scapular segment. Implant selection, primarily interfragmentary screws or a buttress plate, should be based on the size of the fragment, the degree of comminution, and the degree of articular involvement to ensure adequate stabilization. The purpose of this manuscript was to describe a stepwise approach to the surgical management of displaced coracoid fractures, describe surgical tips and techniques, and to present the clinical outcomes in 22 patients after surgical treatment with this approach.

Glenoid fossa fractures: Outcome of operative and nonoperative treatment

BACKGROUND

Glenoid fossa fractures are rare injuries having a prevalence of 0.1%. These fractures may be managed operatively if substantially displaced. However, several fractures of glenoid fossa are managed nonoperatively, even if displaced, due to high incidence of associated injuries which may render patient unfit to undergo major orthopaedic surgery. There is a relative paucity of articles reporting on outcome of treatment of glenoid fossa fractures. We present our experience of treating these injuries over past decade with operative and nonoperative methods.

MATERIALS AND METHODS

21 patients of glenoid fossa fractures were included in this series with 14 males and 7 females. Patients with displacement of >5 mm who were fit to undergo surgery within 3 weeks of injury were operated using a posterior Judet's approach. Overall 8 patients with displaced fractures were operated (Group A) while 9 patients with displaced fractures (Group B) and 4 patients with undisplaced fractures (Group C) were managed nonoperatively.

RESULTS

The mean age and followup period in this series was 29 years and 7.3 years respectively. In group A, average constant score was 87.25. The least constant score was observed for group B (58.55) while group C had an average constant score of 86. Brachial plexus injury and fracture-dislocations had poorer outcome.

CONCLUSION

Operative treatment for displaced glenoid fractures is a viable option at centers equipped to handle critically ill patients and subset of patients with fracture-dislocation as opposed to fracture alone should always be treated operatively due to persistent loss of function.

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.

Surgical and functional outcomes after operative management of complex and displaced intra-articular glenoid fractures

BACKGROUND

Operative treatment is indicated for displaced fractures of the glenoid fossa. However, little is known regarding functional outcomes in these patients. This study assesses surgical and functional results after treatment of displaced, high-energy, complex, intra-articular glenoid fractures.

METHODS

Thirty-three patients with displaced intra-articular fractures of the glenoid were treated surgically between 2002 and 2009. The indications for operative treatment included articular fracture gap or step-off of ≥ 4 mm. Twenty-five patients also had extra-articular scapular involvement. A posterior approach was utilized in twenty-one patients, an anterior approach in seven, and a combined approach in five. Functional outcomes, including Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores, shoulder motion and strength, and return to work and/or activities, were obtained for thirty patients (91%).

RESULTS

At a mean follow-up of twenty-seven months (range, twelve to seventy-three months), all patients had radiographic union of the fracture. The mean DASH score was 10.8 (range, 0 to 42). All mean SF-36 subscores were comparable with those of the normal population. Twenty-six patients (87%) were pain-free at the time of follow-up, and four had mild pain with prolonged activity. Twenty-seven (90%) of thirty patients returned to their preinjury level of work and/or activities.

CONCLUSIONS

Our data suggest that surgical treatment for complex, displaced intra-articular glenoid fractures with or without involvement of the scapular neck and body can be associated with good functional outcomes and a low complication rate.

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.

Radiographic follow-up of 84 operatively treated scapula neck and body fractures

BACKGROUND

Certain scapula fractures may warrant surgical management to restore shoulder anatomy and promote optimal function. The purpose of this study is to determine the early radiographic follow-up of open reduction internal fixation (ORIF) for displaced, scapular fractures involving the glenoid neck and body.

METHODS

Eighty-four patients with a scapula body or neck fracture (with or without articular involvement) underwent ORIF between 2002 and 2010 at a single level I trauma centre. This study represents a retrospective review of data prospectively collected into a dedicated scapula fracture database. All patients met at least one of the following operative criteria: ≥20 mm medial/lateral (M/L) displacement (lateral border offset), ≥45° of angular deformity on a scapular-Y X-ray, the combination of angulation ≥30° plus M/L displacement ≥15 mm, double disruptions of the superior shoulder suspensory complex both displaced ≥10 mm, glenopolar angle (GPA) ≤22° and open fractures. Eighty-eight percent (74/84) had sufficient follow-up defined as at least 6 months. Measured outcomes included rates of scapula union and malunion, as well as surgical complications and re-operations.

RESULTS

All fractures were caused by high-energy trauma with 24 (29%) resulting from motor-vehicle collisions. Associated injuries occurred in 94% of patients, most commonly involving the chest (70%) and ipsilateral shoulder girdle (43%). Forty-eight patients had M/L displacement as an operative indication with a mean displacement of 25.7 mm (range=20-40). Thirty-eight (45%) had ≥2 operative indications. A single surgeon performed ORIF in all patients using a posterior approach. Five patients also required an anterior (deltopectoral) approach. The fixation strategy included lateral and vertebral border stabilisation with dynamic compression and reconstruction plates, respectively. Union was achieved in all cases. There were three cases of malunion based on a GPA difference >10° from the uninjured shoulder. Re-operations included removal of hardware (seven patients) and manipulation under anaesthesia (three patients). There were no infections or wound dehiscence.

CONCLUSIONS

ORIF for displaced scapula fractures is a relatively safe and effective procedure for restoration of anatomy and promotion of union.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Surgical technique: a minimally invasive approach to scapula neck and body fractures

BACKGROUND

The approach of choice for open reduction internal fixation of displaced fractures involving the scapula neck or body is from posterior. We describe a new approach that minimizes the surgical insult to the soft tissues but preserves the ability to restore alignment and stability to the fracture.

DESCRIPTION OF TECHNIQUE

Based on the fracture pattern, incisions are made along the anatomic bony perimeter to access the scapula borders for reduction and fixation. Since the incisions are centered over sites of "perimeter" fracture displacement of this relatively flat bone, minimal soft tissue retraction and less muscular stripping are necessary, while indirect reduction of the intervening scapula body is accomplished to restore anatomic alignment.

PATIENTS AND METHODS

We retrospectively reviewed seven men with a mean age of 39 years (range, 19-75 years) who underwent open reduction internal fixation of a displaced scapula body or neck fracture using this minimally invasive approach. The minimum followup was 12 months (mean, 16 months; range, 12-23 months).

RESULTS

Six of the seven patients returned to their original occupation/activities. The mean Disabilities of the Arm, Shoulder and Hand score at followup was 8.1 (range, 0-52; normative mean, 10.1). For all parameters, the mean SF-36 scores of the study patients were comparable to those of the normal population. Both strength and motion returned to equivalency with the uninjured shoulder. There were no intraoperative or postoperative complications.

CONCLUSIONS

This novel surgical approach to the scapula allows visualization of fracture reduction without an extensile incision or muscular or subcutaneous flaps and was associated with high functional scores.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A reliable radiographic measurement technique for extra-articular scapular fractures

BACKGROUND

Currently, neither well-defined nor standardized measurement techniques exist for assessing deformity of extra-articular scapular fractures. To properly evaluate these injuries, compare observations across studies, and make clinical decisions, a validated measurement protocol for evaluating scapular fractures is needed.

QUESTIONS/PURPOSES

We describe techniques to quantitatively characterize extra-articular scapular fracture deformity; evaluate the reliability of these characterizations in plain film radiographs and CT scans; and determine potential differences in the characterization of the deformity between the two imaging modalities.

PATIENTS AND METHODS

We evaluated injury radiographs and three-dimensional CT images of 45 patients with extra-articular scapular fracture. Techniques for measuring medial/lateral displacement, angulation, translation, glenopolar angle, and glenoid version were established and utilized in two trials, performed 6 weeks apart, by three observers. We determined descriptive statistics for each measurement parameter.

RESULTS

Interobserver reliability based upon interclass correlation coefficients ranged from 0.36 to 0.76 for radiographs and from 0.48 to 0.87 for three-dimensional CT. Intraobserver reliability using Pearson r coefficient ranged from 0.60 to 0.75 for radiographs and 0.64 to 0.89 for three-dimensional CT. Both individual and pooled measurements for angulation and glenopolar angle were higher on three-dimensional CT versus radiographs.

CONCLUSIONS

Our data suggest three-dimensional CT is more reliable than plain radiography in the assessment of scapula fracture displacement. Therefore, we believe this modality should be utilized if fracture deformity warrants surgical consideration and to adequately compare data across studies.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Scapular body fractures: results of operative treatment

The authors operated on 22 patients with scapular body fractures, with a mean age of 35 years. The minimal follow-up was 12 months. All patients were treated from the Judet posterior approach. The study included 14 cases of an isolated body fracture, three of scapular body fracture combined with fracture of the scapular neck and five of glenoid fossa fracture. In all 14 cases where a 3D computed tomography (CT) reconstruction was performed prior to operation, intraoperative findings corresponded to this reconstruction. In eight cases without preoperative 3D CT reconstruction, the correct type of fracture was identified in only two cases. We also identified three basic types of fractures of the lateral border of the scapula. The anatomical relationship between the glenoid fossa and scapular body, congruency and stability of the shoulder joint was achieved in all cases. The average constant score was 94.

Modified Judet approach and minifragment fixation of scapular body and glenoid neck fractures

OBJECTIVES

To describe the technique and to determine the outcome of operatively treated displaced scapular body or glenoid neck fractures using minifragment fixation through a modified Judet approach.

DESIGN

Retrospective review of scapular or glenoid fractures.

SETTING

Level 1 teaching trauma center.

PATIENTS

All treated scapular or glenoid fractures over 7 years (1999-2005) were determined. Of a total of 227 scapular or glenoid fractures, 37 were treated with open reduction internal fixation and formed the basis of study. All patients were followed for a minimum of 1 year until healing or discharge from care.

INTERVENTIONS

All operatively treated scapular fractures were performed in the lateral position on a radiolucent table. A modified Judet approach was used in all patients. The posterior deltoid was incised off the scapular spine cephalad reaching the lateral scapular border. The interval between the teres minor and infraspinatus was paramount for fracture reduction and implant insertion. The 2.7-mm minifragment plates were applied along the lateral border of the scapula.

MAIN OUTCOME MEASUREMENT

Radiographic assessment of fracture healing and clinical assessment of shoulder function.

RESULTS

The majority of patients were males (31 males, 6 females) who sustained blunt trauma. All scapular fractures maintained fixation and reduction. No wound or muscle dehiscence problems were noted. Average range of motion was 158 degrees (range 90-180 degrees). There were no fixation failures or instances of implant loosening.

CONCLUSIONS

The modified Judet approach allows for excellent scapular and glenoid fracture visualization and reduction while preserving rotator cuff function. Minifragment fixation along the lateral scapular border provides excellent plate position, screw length, and fracture stability.

Vulnerable neurovasculature with a posterior approach to the scapula

Anatomic studies have described areas where there is no direct threat of inadvertent suprascapular nerve injury; however, these studies did not describe danger zones during open reduction and internal fixation of the fractured scapula. We therefore sought to define the topographic distribution in which these vulnerable structures most commonly are found, thus establishing danger zones. Twenty-four nonpaired cadaveric specimens were dissected. The infraspinatus and teres minor musculature were elevated off the posterior scapula body to reveal critical areas where the suprascapular neurovasculature and circumflex scapular artery were vulnerable to injury. We established radial coordinates to determine this relation to osseous landmarks. The mean distance from the spinoglenoid notch to the inferior border of the danger zone was 2.4 cm (range, 1.2-3.8 cm). The mean distance from the medial extent of the scapular spine to the medial border of the danger zone was 4.3 cm (range, 3.0-6.7 cm). The entry of the ascending branch of the circumflex scapular artery was located at the lateral border 5.6 cm (range, 4.5-7.0 cm) inferior to the spinoglenoid notch. These danger zones can aid the surgeon in determining the risk for suprascapular nerve injury, specifically with scapula fractures involving the spinoglenoid notch and/or lateral border.

Intraoperative reduction of the scapular body--a technical trick

When internal fixation of the scapular neck and body fractures is performed, a problem may occur with reduction and retention of position of the lateral border of the scapula during surgery. For this purpose, the authors have developed their own technique of stabilization using a K-wire in a novel way. The technique is indicated in a 2-part shear unstable fracture of the lateral border. It cannot be used in fractures with an intercalated segment. A 2.5-mm drill bit is used to drill a 1.5-cm deep hole into the "medullary cavity" of each of the 2 fragments of the lateral border. A K-wire, 1.5 mm in diameter and 2.5-cm long, is inserted into the distal fragment. The protruding end of the K-wire is inserted into the hole in the proximal fragment. This intramedullary peg helps to maintain reduction and keeps both fragments stable. Subsequently, the lateral border is stabilized with a 3.5-mm reconstruction plate. This technique is quite simple and allows for a temporary stabilization of fragments without compromising the subsequent fixation by plate screws.