Scapula Fracture Treatment & Management
- Author: Thomas P Goss, MD; Chief Editor: S Ashfaq Hasan, MD more...
Most scapula fractures can be managed effectively with closed treatment. Some injuries with significant displacement have poor long-term outcomes for the shoulder and the upper extremity as a whole if treated with closed techniques.
Because scapula fractures often are associated with other, sometimes life-threatening injuries, delay surgery until the patient is medically stabilized. Absolute contraindications for surgery are few. In the case of a major vascular injury, such as an axillary or brachial artery tear, repair the vessel first, then follow with fracture fixation.
Recognizing the exact indications for operative treatment of scapula fractures is a major issue for the future. The authors have presented guidelines for when to consider surgery (see Indications for Surgical Management). However, more data are needed to further define and support these recommendations. As surgical techniques advance, the indications for surgical intervention may expand.
Medical therapy for patients with scapula fractures generally is the same as that for any trauma patient. Perform fluid resuscitation, stabilize the cardiopulmonary system, and treat life-threatening injuries prior to operative fixation of scapula fractures.
Most scapula fractures can be managed with closed treatment. More than 90% of scapula fractures have minimal displacement, primarily because of the thick, strong support provided by the surrounding soft tissues. Treatment is symptomatic. Short-term immobilization in a sling and swathe bandage is provided for comfort. Early progressive range-of-motion (ROM) exercises and use of the shoulder out of the sling (within clearly defined limits) are initiated as pain subsides. In some cases, such as intra-articular fractures, close radiographic follow-up is necessary to ensure that unacceptable displacement does not occur.
Most scapular fractures heal completely by 6 weeks, and all external support is discontinued at this time. Progressive use of the upper extremity is encouraged. Continue ROM exercises until full shoulder mobility is recovered. As motion improves, add progressive strengthening exercises. Full functional recovery takes several months. Ultimately, the prognosis for these fractures is excellent.
Indications for Surgical Management
Whereas most scapula fractures can be managed with closed treatment, surgical management should be considered for significantly displaced fractures.[14, 15] The following injuries occur with enough frequency to merit discussion of operative treatment:
Significantly displaced fractures of the glenoid cavity (glenoid rim and fossa)
Significantly displaced fractures of the glenoid neck
Double disruptions of the superior shoulder suspensory complex (SSSC) in which one or more elements of the scapula are significantly displaced
Approximately 50% of scapula fractures involve the scapular body and spine. Avulsion fractures caused by indirect forces and injuries caused by direct trauma have been described. The latter may be severely comminuted and displaced. Despite sporadic reports describing operative management, there seems to be little enthusiasm for surgical treatment, for the following two reasons:
There is little substantial bone stock for internal fixation, aside from the scapular spine and lateral scapular border
These fractures seem to heal reliably with a good functional result without surgical treatment
If painful scapulothoracic impingement occurs at a later date, bone prominences over the ventral scapular surface can be removed surgically.
Significantly displaced fractures of glenoid cavity (rim and fossa)
Fewer than 10% of glenoid cavity fractures are significantly displaced. Ideberg reviewed over 300 such injuries and proposed the first detailed classification scheme. This classification subsequently was expanded by Goss (see the image below). Type I injuries involve the glenoid rim (IA=anterior rim, IB=posterior rim). Types II-V include fractures of the glenoid fossa. Type VI fractures include all comminuted injuries (ie, more than two glenoid cavity fragments).
In 2012, the AO Foundation and Orthopaedic Trauma Association introduced a new comprehensive and reliable scapula classification involving glenoid fracture patterns.[19, 20]
Fractures of the glenoid rim occur when the humeral head is driven against the glenoid margin. Surgical management is indicated if the fracture results in persistent subluxation of the humeral head, defined as failure of the humeral head to lie concentrically within the glenoid fossa, or if the reduction is unstable. DePalma has stated that instability can be anticipated if the fracture is displaced 10 mm or more and if at least one fourth of the anterior aspect of the glenoid cavity or one third of the posterior aspect of the glenoid cavity is involved.
Fractures of the glenoid fossa occur when a laterally applied force drives the humeral head directly into the glenoid cavity. Soslowsky et al found the maximum depth of glenoid articular cartilage to measure 5 mm. Consequently, with displacement more than 5 mm, subchondral bone is exposed, making posttraumatic arthritis more likely.
Kavanagh et al reported on open reduction and internal fixation (ORIF) of glenoid fossa fractures in which displacement ranged from 4 to 8 mm. They found ORIF to be a useful and safe technique for the treatment of selected displaced fractures of the glenoid fossa. On the basis of these and other studies, it seems reasonable to conclude that an articular step-off of 5 mm should warrant consideration for ORIF and that a 10-mm step-off is a definite indication for surgery.
Other indications for surgical management of these fractures include the following:
Glenoid fossa fractures that result in significant displacement of the humeral head such that it fails to lie in the center of the glenoid cavity, thereby resulting in glenohumeral instability
Fractures of the glenoid fossa with such severe separation of the fracture fragments that nonunion is likely to occur
Significantly displaced fractures of glenoid neck
Glenoid neck fractures (see the image below) that cause significant translational or angulatory displacement of the glenoid fragment can interfere with normal shoulder mechanics and/or cause glenohumeral instability. Nordqvist and Petersson evaluated 37 glenoid neck fractures treated nonoperatively and found the functional results at 10- to 20-year follow-up to be fair or poor in 32% of cases. Hardegger et al noted that displaced glenoid neck fractures result in a functional imbalance because the relationship of the glenohumeral joint with the acromion and nearby muscle origins is altered.
Overall, there is literature to suggest that surgery should be considered for fractures with translational displacement greater than or equal to 1 cm and/or angulatory displacement greater than or equal to 40° in either the transverse or coronal plane.
Double disruptions of superior shoulder suspensory complex
The SSSC is a bone/soft-tissue ring at the end of a superior and inferior bony strut (see the image below). The ring consists of the glenoid process, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the acromioclavicular (AC) joint, and the acromial process. The superior strut is the middle third of the clavicle. The inferior strut is the lateral scapular body and spine.
Traumatic disruptions of one of the components of the SSSC are common. If the force is sufficient, the ring may fail in two or more places (double disruption), a situation in which significant displacement at one or both of the individual sites and of the SSSC as a whole frequently occurs. Similarly, a disruption of one portion of the ring, combined with a fracture of one of the struts or fractures of both struts, also creates a potentially unstable anatomic situation.
Adverse consequences include delayed union, malunion, and nonunion. Subacromial impingement, decreased strength and muscle fatigue, discomfort due to altered shoulder mechanics, neurovascular compromise due to a drooping shoulder, and glenohumeral degenerative joint disease also can occur.
If unacceptable displacement is present, surgical reduction and stabilization at the injury sites is necessary. Frequently, operative management of one of the injury sites satisfactorily reduces and stabilizes the second disruption indirectly.
Herscovici et al reported results in nine patients with ipsilateral clavicular and glenoid neck fractures. Seven patients were treated surgically with plate fixation of the clavicular fracture and achieved excellent results. Two patients were treated without surgery and were found to have decreased ROM, as well as drooping of the involved shoulder. The authors strongly recommended ORIF of the clavicle to prevent glenoid neck malunion.
Combined fractures of the distal clavicle and the superior aspect of the glenoid cavity is another potentially unstable situation. Each disruption may lead to displacement at the other fracture site. If displacement of the clavicular fracture site is unacceptable, surgical reduction and stabilization is indicated, usually with a Kirschner-wire (K-wire) tension-band fixation construct. Because the proximal clavicular segment is attached to the superior glenoid-coracoid process fragment by means of the coracoclavicular ligaments, this may indirectly reduce and stabilize the glenoid cavity fracture satisfactorily. If not, the glenoid fracture may also require surgical management using the surgical techniques described.
Fracture of the coracoid or the acromion process with a second disruption of the SSSC is another potentially unstable situation. If displacement at either or both sites is unacceptable, surgical management is indicated. For double disruptions consisting of both an acromion and a coracoid fracture, ORIF of the acromion may be all that is required (see the image below).
Determination of operative approach
Fractures of glenoid cavity
The approach to glenoid cavity fractures depends on the type of fracture. Anterior rim (type IA) fractures are approached anteriorly with the patient in the beach-chair position. Posterior rim (type IB) fractures and all glenoid fossa disruptions are approached at least in part posteriorly. The fragment or fragments are reduced and held rigidly with either an interfragmentary compression screw or a contoured reconstruction plate. A superior approach may be added if a large, displaced superior glenoid fragment (type III) or glenoscapular fragment (type IV) is present.[26, 27, 28]
Basic orthopedic and shoulder instruments should be available, and fixation devices should include 3.5-mm and 4.0-mm cannulated screws and 3.5-mm malleable reconstruction plates. K-wires can be used for temporary or definitive fixation of glenoid fragments (see the image below). In patients with anterior rim, posterior rim, and type II glenoid cavity fractures, prepare and drape the iliac crest in case the fragment is comminuted, requiring replacement with a tricortical graft to restore glenohumeral stability.
Type II glenoid neck fractures
For type II glenoid neck fractures, the posterior approach is utilized, developing the interval between the infraspinatus and the teres minor. A superior approach may be added if the glenoid fragment is difficult to control.[26, 27, 28, 29]
Temporary fixation can be obtained with K-wires or interfragmentary screws. Definitive fixation of the reduced fragment generally is achieved with a 3.5-mm reconstruction plate contoured along the posterior aspect of the glenoid fragment and the lateral scapular border. In some type II fractures, severe comminution of the scapular body or spine may preclude plate fixation. In these cases, K-wire or interfragmentary screw fixation can be used. The reduced glenoid fragment is secured to the adjacent osseous structures, including the acromial process and the distal clavicle (see the image below). If the acromial process and distal clavicle also are severely comminuted, overhead olecranon pin traction may be considered.
Coracoid and acromion fractures
For coracoid fractures that require ORIF, an anterior deltoid-splitting approach is utilized. The rotator interval is opened as needed for optimal exposure of the fracture site. Cannulated 3.5-mm and 4.0-mm compression screws are useful for fixation of large fragments. If the fragment is significantly comminuted, treatment is excision and suture fixation of the conjoined tendon to the remaining coracoid process (see the image below).[26, 27, 28] A deltopectoral approach could also be utilized as an alternative to a deltoid-splitting approach.
If surgical reduction and stabilization of an acromion fracture is necessary, a tension-band construct usually is chosen for distal disruptions in which the acromial process is quite thin, whereas 3.5-mm malleable reconstruction plates usually are chosen for more proximal injuries.
In addition to defining the fracture type and pattern, preoperative evaluation should include identification of associated injuries and a thorough neurovascular examination of the involved extremity. Radiographic evaluation must visualize the scapular body and spine, the three processes (ie, acromial, coracoid, glenoid), and the three articulations (ie, scapulothoracic, glenohumeral, acromioclavicular).
General anesthesia is advised for patients undergoing fixation of scapula fractures. Nerve block techniques are available but generally are used only as supplements because of awkward positioning, extensive dissection and manipulation, and, often, prolonged operating time. With the exception of type IA fractures of the glenoid cavity (anterior rim injuries) that require an anterior exposure, the primary surgical approach is posterior. Occasionally, a superior exposure is useful.
For the posterior approach, the patient is placed in the lateral decubitus position, operative side up, and the torso is stabilized with a beanbag. The upper extremity and shoulder complex are prepared and draped free. Bony landmarks are outlined with a marking pen. An incision is made over the lateral one third of the scapular spine along the posterior aspect of the acromion to its lateral tip and then distally in the midlateral line for 2.5 cm. Skin flaps are developed.
The deltoid is dissected sharply off of the scapular spine and the acromion, and then split in the line of its fibers for a distance of up to 5 cm, starting at the lateral tip of the acromion. The deltoid is separated off of the underlying infraspinatus and teres minor musculotendinous units and retracted down to, but not below, the inferior margin of the teres minor.
The infraspinatus tendon is incised 2.5 cm medial to the greater tuberosity and along its superior and inferior borders. It then is dissected off of the underlying posterior glenohumeral capsule and turned back medially. After the capsule is opened in a similar fashion, a Fukuda retractor is inserted into the joint. With the retractor holding the humeral head out of the way, the entire glenoid cavity can be inspected, and the surgeon has ready access to its posterior rim and the glenoid neck.
The interval between the infraspinatus and teres minor muscles can be developed further, and the long head of the triceps is detached to gain access to the inferior aspect of the glenoid process and the lateral border of the scapular body. Take particular care to protect and avoid injury to the nearby suprascapular and axillary nerves.
For the anterior approach, the patient is placed on the operating room table in the beach-chair position. An anterior incision is made in Langer lines, centered over the glenohumeral joint and running from the superior to the inferior margin of the humeral head.
The deltoid muscle is exposed and split in the line of its fibers directly over the coracoid process. The conjoined tendon is retracted medially, whereas the deltoid is retracted laterally. The subacromial bursa is removed, exposing the subscapularis tendon. The tendon is incised 2.5 cm medial to the medial border of the biceps groove and along its superior and inferior borders. The subscapularis tendon then is dissected off of the underlying anterior glenohumeral capsule-glenoid neck periosteum and turned back medially. The anterior glenohumeral capsule is incised in the same fashion (5 mm medial to the anatomic neck) and also is turned back medially.
With a humeral head retractor inserted into the glenohumeral joint and holding the humeral head out of the way, the entire glenoid cavity can be inspected, and the surgeon has ready access to its anterior rim. Care must be taken to avoid injury to the nearby axillary nerve.
The superior approach can be added to the anterior or posterior exposure if a displaced, difficult to control or stabilize superior glenoid fragment, or a glenoid process fragment is present. Either incision is extended over the superior aspect of the shoulder.
Soft-tissue flaps are developed and retracted, exposing the superior aspect of the distal clavicle, the AC joint, the acromion, and the trapezius muscle. In the interval between the clavicle and the acromion, the trapezius muscle and the underlying supraspinatus tendon are split in the line of their fibers, bringing one down upon the superior aspect of the glenoid process. Care must be taken to protect and avoid injury to the suprascapular nerve and vessels that lie medial to the coracoid process.
Postoperative management partially depends on the degree of stability achieved at surgery. Complete immobilization in a sling and swathe is used for the first 24-48 hours. After that, progressive ROM exercises and functional use of the shoulder out of the sling (within clearly defined limits) are initiated if fixation is satisfactory. If surgical fixation was not rigid, immobilization in a sling and swathe, abduction brace, or overhead olecranon pin traction may be required for 7-14 days.
Radiographs are taken every 2 weeks to ensure maintained reduction. By 6 weeks, healing usually is sufficient to permit discontinuance of the sling and to allow progressive functional use of the extremity.
Physical therapy is continued until ROM and strength are maximized. Initial emphasis is on regaining ROM. As ROM progresses, strengthening exercises are added. Light use of the shoulder is encouraged through postoperative week 12. Heavy physical use of the shoulder, such as athletic activity, is prohibited for 4-6 months. Patients are encouraged to work diligently on their rehabilitation programs, as final motion and strength may not be achieved for 6 months to 1 year.
Complications can result directly from surgical management. Neurovascular injury, infection (superficial and deep), and loss of fixation all can result from poor surgical technique. An improper physical therapy rehabilitation program may lead to unnecessary postoperative shoulder stiffness. Finally, poor patient compliance can contribute to shoulder stiffness and possible hardware failure.
After discharge from the hospital, patients should be seen for follow-up every 2 weeks for the first 6 weeks. Radiographs are taken to ensure maintained reduction. Evaluate the patient's ROM and update his/her rehabilitation program as needed. Patients should be seen at 12 weeks for evaluation of motion and progression of functional use of the shoulder. Final motion and strength may not be achieved until 6 months to 1 year.
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