Scapula Fracture Treatment & Management

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 treated 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 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.

Operative treatment for fractures of the 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.^{[17, 18, 19]}

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, as seen in 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.

Operative treatment of 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.^{[17, 18, 19]}

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, as seen in the image below. If the acromial process and distal clavicle also are severely comminuted, overhead olecranon pin traction may be considered.

Operative treatment of 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, as seen in the image below.^{[17, 18, 19]}

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 3 processes (ie, acromial, coracoid, glenoid), and the 3 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.

Posterior approach

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 opening the capsule 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.

Anterior approach

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 muscle 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. Take care to avoid injury to the nearby axillary nerve.

Superior approach

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. Take care 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 discontinuation 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.

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.

The most significant complications associated with scapular fractures are those that result from accompanying injuries to adjacent and distant osseous and soft-tissue structures. On average, there are 3.9 additional injuries, with the ipsilateral shoulder girdle, upper extremity, lung, and chest wall being affected most commonly. Pulmonary injuries, such as hemopneumothorax or pulmonary contusion, occur in 15-55% of cases. Cerebral contusions occur in 10-40% of cases, with central neurologic deficits in 5% of cases. Splenectomy is required in 8% of patients, and the mortality rate is 2%.

Complications related to the scapular fractures themselves are relatively uncommon. Nonunion is rare. Malunion can occur in a variety of forms, depending on the particular fracture type. Malunion of a scapular body fracture generally is well tolerated, although painful scapulothoracic crepitus has been described. Fractures of the glenoid cavity can result in symptomatic glenohumeral degenerative joint disease and instability. Angulated fractures of the glenoid neck can result in shoulder instability. Fractures of the glenoid neck with translational displacement can lead to altered mechanics of the surrounding soft tissues, giving rise to glenohumeral pain and dysfunction.

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.

Because of the low incidence of scapula fractures, little outcome data exists. Hardegger et al reported 79% good-to-excellent results associated with 5 displaced glenoid neck fractures treated surgically (6.5-year follow-up).^[1] Kavanaugh et al at the Mayo Clinic reviewed 10 displaced glenoid cavity fractures treated with ORIF and found it to be a useful and safe technique that can restore excellent function of the shoulder.^[12]

Nonoperative treatment can sometimes result in malunion, leading to poor range of motion, chronic pain, and poor cosmesis. Cole et al report that surgical reconstruction of malunited scapula neck or body fractures can yield good functional and cosmetic outcomes.^[20]

Until more data are available, it is reasonable to predict a good-to-excellent functional result if surgical management restores normal or near-normal anatomy, articular congruity, and glenohumeral stability; if surgery provides secure fixation; and if a well-structured and intensive rehabilitation program is implemented.^{[21, 22, 23]}

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. However, more data are needed to further define and support these recommendations. As surgical techniques advance, the indications for surgical intervention may expand.