Functional outcomes of extra-articular scapula fracture fixation with distal humeral Y-type locking plate: a retrospective study

[Treatment of Ideberg type scapular glenoid fracture with compression screw combined with Buttress plate through direct axillary approach]

Objective

To investigate the effectiveness of compression screw combined with Buttress plate through direct axillary approach for Ideberg typeⅡ scapular glenoid fractures.

Methods

A retrospective analysis was conducted on 11 patients with Ideberg type Ⅱ scapular glenoid fractures treated with compression screws combined with Buttress plate fixation through the direct axillary approach between January 2014 and June 2022. There were 7 males and 4 females, aged from 34 to 75 years, with an average of 56.0 years. The causes of injury included 4 cases of falling from height injury, 4 cases of heavy object injury, and 3 cases of traffic accident injury. The time from injury to operation was 2-5 days, with an average of 3.8 days. The operation time, intraoperative blood loss, hospital stay, complications, and fracture healing time were recorded. The Constant-Murley score, American Society of Shoulder and Elbow Surgeons (ASES) score, and shoulder joint flexion, abduction, external rotation (neutral position), and internal rotation (neutral position) range of motion were used to evaluate shoulder joint pain and function.

Results

The operation time was 45-105 minutes, with an average of 79.0 minutes; the intraoperative blood loss was 80-200 mL, with an average of 99.2 mL; the hospital stay was 3-8 days, with an average of 5.8 days. One patient had poor wound healing after operation, and the wound healed after strengthening dressing change; the rest wounds had primary healing, and no axillary nerve paralysis occurred. Except for 1 patient lost follow-up, the remaining 10 patients were followed up 10-54 months, with an average of 26.4 months. The postoperative X-ray film examination showed that the fractures healed well within 8-15 weeks, with an average of 11.0 weeks. There was no complication such as fracture displacement, internal fixator failure or fracture during follow-up. At last follow-up, the patient's shoulder joint flexion, abduction, external rotation (neutral position), and internal rotation (neutral position) range of motion, Constant-Murley score, and ASES score significantly improved when compared with those before operation ( P<0.05).

Conclusion

Compression screw combined with Buttress plate through direct axillary approach is an effective way to treat Ideberg typeⅡ scapular glenoid fracture, with advantages of small trauma, concealed incision, and good effectiveness.

Novel Claw-shaped Bone Plate in Complex Unstable Scapular Neck and Body Fractures: Comparison with Reconstruction Locking Plate

OBJECTIVE

For complex and unstable scapular fractures requiring simultaneous fixation of the glenoid neck, the lateral margin of the body, and/or the scapular diaphysis, reconstruction locking plate is difficult to achieve satisfactory fixation. In order to optimize the fixation effect, the newly designed claw-shaped bone plate was designed for fixing such fractures. We also evaluate the clinical effects and follow-up at an average of 1 year after treatment in scapular internal fixation by using reconstruction locking plate and claw-shaped bone plate in complex unstable scapular body and glenoid neck fracture.

METHODS

A retrospective study was conducted from 2018 to 2021, thirty-three patients (27 males and six females) who were defined unstable scapular fractures by Ada-Miller. Fifteen patients (52.86 ± 8.26 years) received claw-shaped bone plate and 18 cases (51.61 ± 11.31 years) received reconstruction locking plate with the intermuscular approach. The clinical effect was evaluated based on the operation time, intraoperative blood loss, surgical complications, clinical healing time and Constant-Murley score (CMS). The data analysis by Student t, Mann-Whitney U test and Pearson's chi squared test.

RESULTS

Compared with reconstruction locking plate, the claw-shaped bone plate showed shorter operation time (102.73 ± 18.43 min vs. 156 ± 37.53, P < 0.0001), higher CMS (94.00 ± 4.07 vs. 89.88 ± 5.42, P = 0.02) and no differences between the two groups regarding intraoperative blood loss (208.00 ± 96.45 mL vs. 269.44 ± 120.21, P = 0.12) and clinical healing times (9.96 ± 1.52 vs. 10.05 ± 1.67, P = 0.87). Follow-up were conducted at first, third, 6 and 12 months after surgery. The operation was successful in all patients with no intraoperative complications.

CONCLUSIONS

For the treatment of complex and unstable scapular neck body fractures, the application of claw-shaped bone plate demonstrated short operation time, better stability of the fracture block, and higher CMS. In the intraoperative and postoperative follow-up showed better clinical results and rehabilitation effects.

Finite element analysis of a novel anatomical locking plate for scapular neck fracture

OBJECTIVES

Reconstruction plates (RPs) are commonly used in scapular neck fractures (SNFs): however, RPs have many defects. In this study, we evaluated a newly designed scapular neck anatomical locking compression plate (SNALCP).

METHODS

An SNF finite element model (Miller-type IIB) was constructed. Plates were subsequently implanted into the scapula and fixed with screws that were grouped according to the plate used: SNALCP (A) and RP (B). Finally, loads were applied to record and analyze performance.

RESULTS

Under lateral, anteroposterior, and vertical compression loads, the maximum von Mises stresses on the scapula and implants of group A were smaller than those of group B. There were some differences in stress distribution between the two groups.

CONCLUSIONS

SNALCP can effectively reduce the stress of the scapula and implant, making stress distribution more uniform and continuous, and has mechanical conduction advantages. Compared to RP, it provides improved stability and more reliable fixation.

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.

Mapping of Orthopaedic Fractures for Optimal Surgical Guidance

Orthopaedic fractures may be difficult to treat surgically if accurate information on the fracture propagation and its exit points are not known. Even with two-dimensional (2D) radiographic images, it is difficult to be completely certain of the exact location of the fracture site, the fracture propagation pattern and the exit points of the fracture. Three-dimensional (3D) computerised tomographic models are better in providing surgeons with the extent of bone fractures, but they may still not be sufficient to allow surgeons to plan open reduction and internal fixation (ORIF) surgery.Fracture patterns and fracture maps are developed to be visual tools in 2D and 3D. These tools can be developed using fractured bones either before or after fracture reduction. Aside from being beneficial to surgeons during pre-surgical planning, these maps aid bioengineers who design fracture fixation plates and implants for these fractures, as well as represent fracture classifications.Fracture maps can be either created ex silico or in silico. Ex silico models are created using 3D printed bone models, onto which fracture patterns are marked. In silico fracture models are created by tracing the fracture lines from a fractured bone to a healthy bone template on a computer. The points of interest in both of these representations are the path of fracture propagation on the bone's surface and exit zones, which eventually determine the surgeon's choice of plate and fracture reduction. Both ex silico and in silico fracture maps are used for pre-surgical planning by the surgeons where they can plan the best way to reduce the fracture as well as template various implants in a low-risk environment before performing the surgery.Recently, fracture maps have been further digitised into heat maps. These heat maps provide visual representations of critical regions of fractures propagating through the bone and identify the weaker zones in the bone structure. These heat maps can allow engineers to develop optimal surgical plates to fix an array of fracture patterns propagating through the bone. Correlation of fractured regions with the mechanisms of injury, age, gender, etc. may improve fracture predictability in the future and optimise the intervention, along with making sure that surgeons do not miss fractures of the bone that may otherwise be hidden from plain sight.

A comparative analysis of titanium anatomic plate and titanium reconstructive plate for treatment of extra-articular fractures of the scapula (Miller types IIb, IIc, and IV)

BACKGROUND

Because of the irregular shape of the scapula and the different types of fractures, a standard internal fixation device is lacking in clinical practice, even though there are many options available. This study aimed to compare the therapeutic efficacy of titanium anatomic and reconstructive plates for extra-articular fractures of the scapula (Miller types IIb, IIc, and IV).

METHODS

A retrospective study of 41 patients who underwent treatment for extra-articular fractures of the scapula between March 2017 and March 2020 was conducted. Patients were divided into 2 groups based on the fixation device: titanium anatomic plate group (20 patients) and titanium reconstructive plate group (21 patients). After follow-up for 12-18 months, the general characteristics, perioperative characteristics, postoperative follow-up findings, and imaging data of the 2 groups were compared.

RESULTS

The surgical procedures were uneventful in both groups. The anatomic plate group significantly outperformed the reconstructive plate group with respect to surgical duration and intraoperative blood loss (P < .001). At 3-month postoperative follow-up, the Constant-Murley score (P = .026), shoulder flexion range of motion, and shoulder abduction range of motion in the anatomic plate group were all significantly better than those in the reconstructive plate group (P < .001). The postoperative Western Ontario Shoulder Instability scores of the 2 groups were similar. Imaging showed functional recovery and stable and reliable fixation in both groups. Time to bone union was similar in both groups (9.10 ± 1.25 weeks in anatomic plate group and 9.24 ± 1.41 weeks in reconstructive plate group, P = .742). No complications occurred in any patient, such as fixation failure, instability, or bone nonunion.

CONCLUSION

Surgeons should favorably consider titanium anatomic plates for the treatment of extra-articular scapular fractures owing to their clear efficacy associated with a shorter surgical time, less intraoperative blood loss, better fixation, and rapid short-term functional recovery.

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.

Functional Outcome of Open Reduction and Internal Fixation of Displaced Extra-Articular Scapula Fractures

BACKGROUND

Scapular fractures are uncommon injuries of upper extremity resulting mostly from high-energy trauma. Extra-articular fractures form the majority of them. Un-displaced fractures can be managed conservatively with good results. But displaced fracture does not yield satisfactory results and needs surgical fixation. In this case series, we report our experience about such fractures.

METHODS

This was a retrospective study of 12 patients with displaced scapular body and neck fractures treated between 2015 and 2018. Scapular fractures were exposed by modified Judet approach and fixed with either 3.5 mm T buttress or recon locking plate and screws. One case had associated clavicle fracture which was fixed along with scapula. Patients were put on structured rehabilitation and followed up regularly. Functional outcome and range of motion were analyzed.

RESULTS

The patients included 10 males and two females. Mean age was 42 years. Average follow-up was 33 months. Average constant and Murley score was 80. Excellent results were seen in four patients, good results in seven patients and one patient has got fair result. The mean post-operative range of motion of the shoulder at the time of final follow-up was 140° of forward flexion, 136° of abduction, and 34° of external rotation.

CONCLUSION

Displaced extra-articular scapular fractures managed by internal fixation using T buttress locking plates and reconstruction plates give good functional outcome.

Can displaced extra-articular fractures of the scapula be stabilized through a direct lateral-column approach

BACKGROUND

Displaced extraarticular fractures of the scapula are uncommon, and rarely require operative fixation. When managed operatively, a posterior Judet approach with detachment of the deltoid muscle from the scapular spine and elevation of the infraspinatus from its fossa, is often performed. This approach is invasive and involves extensive soft tissue dissection. This paper describes the utility of single-column fixation with a direct lateral column approach, with mobilisation of the deltoid, and elevation of the interval between the infraspinatus and teres minor. Our aim is to assess the functional and radiological outcomes of this alternative approach.

METHODS

We performed a retrospective cohort study of all patients who underwent operative fixation of their extra-articular scapula fracture (with at least 12 months follow up), using the direct lateral-column approach. Operative indications included patients with an extra articular scapular neck or body fracture, with medial/lateral displacement of ≥20 mm, angulation ≥45°, double disruption of the shoulder suspensory complex, and glenopolar angle (GPA) ≤ 22°. Functional outcomes were assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Subjective Shoulder Value (SSV), pain score & return to work. Radiological assessment was done by 2 independent assessors.

RESULTS

Between January 2014 and December 2016, 12 patients (11 males and 1 female) underwent fixation of their scapula fracture using this approach. Eleven patients (91.7%) returned their questionnaire at an average of 15.6 months (12-28 months). All fractures had healed at the time of the final follow-up. The scapular neck angulation was corrected from 38.7° pre-operatively (0-74°) to 3.6° post-operatively (0-20°). The mean post-operative GPA was 35.4° (30.2°-42.0°). None of the patients had superficial or deep infections, or post-operative neurovascular injuries. Two patients underwent elective removal of their clavicle hook plates. The mean SSV was 88.9 (70-100) and mean pain score was 1.5 (0-8). The mean DASH score was 11.4 (0-51.6). Ten patients returned back to their pre-injury work, with an average return to work of 3.3 months (2 weeks-8 months). Only one patient had a poor DASH score. He had associated ipsilateral segmental fracture of the humerus, fracture of the lateral clavicle and brachial plexus injury.

CONCLUSIONS

The direct lateral-column approach is an alternative technique for fixation of the extra-articular neck and body scapular fracture. Plating of the lateral column of the scapula through this single approach is associated with correction of scapular angular deformity, no complications and good clinical results at more than 12 months' follow-up.