Scapula Fracture 

Updated: Jun 15, 2018
Author: Thomas P Goss, MD; Chief Editor: S Ashfaq Hasan, MD 

Overview

Background

Traumatic injuries of the scapula have received little attention in the literature because they are uncommon. Scapula fractures account for approximately 1% of all fractures. Historically, these fractures have been treated by closed means. One of the earliest descriptions of treating scapula fractures was published in 1805 in Desault's treatise on fractures. Hardegger et al reported that if significant displacement occurs, conservative treatment alone cannot restore congruence, and stiffness and pain may result, thereby indicating open reduction and stabilization.[1]

Their relative infrequency notwithstanding, scapula fractures have a high association with other injuries.[2, 3] Research shows that 80-95% of scapula fractures are accompanied by associated injuries, which may be multiple, life-threatening, or both. As a result, diagnosis and treatment of scapular injuries may be delayed or suboptimal. Long-term functional impairment may occur. As more focus is placed on the proper management of scapular injuries, functional outcomes should improve.[4]

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. This article reviews closed management of scapula fractures, discusses open treatment, and provides guidelines for injuries that require operative intervention.

Anatomy

The scapula serves as the attachment site for 18 muscles, which link it to the thorax, spine, and upper extremity. (See the image below.) The subscapularis covers the anterior surface, and the serratus anterior attaches to the inferior angle along the anterior medial border. The supraspinatus and the infraspinatus lie on the posterior border of the scapula. Overlying them is the trapezius, which inserts on the spine and the clavicle. The deltoid originates from the scapular spine, acromion, and anterior clavicle. Many other muscles attach to the scapular margins.

(Click Image to enlarge.) Scapular anatomy. Muscle (Click Image to enlarge.) Scapular anatomy. Muscle origin and insertion.

The coracoid process projects from the superior border of the scapula. The coracobrachialis and the short head of the biceps originate from the coracoid, and the pectoralis minor inserts on the coracoid. The brachial plexus and the axillary artery run posterior to the pectoralis minor tendon. The scapular notch lies just medial to the coracoid base and is covered by the transverse scapular ligament. The suprascapular nerve runs under the ligament, and the suprascapular artery passes over it.

The acromion is the lateral projection from the spine of the scapula. The spinoglenoid notch is the gap between the acromion and the glenoid neck of the scapula. The suprascapular nerve and vessels pass through the notch en route to the infraspinatus.

Etiology

Typically, scapula fractures result from high-energy trauma.[5] Direct forces are most common, but indirect mechanisms can also be responsible. An example of an indirect force is a fall on an outstretched arm that causes the humeral head to impact on the glenoid cavity.

Scapula fracture has been reported as a potential complication of reverse total shoulder arthroplasty for rotator cuff tear arthropathy.[6]

Epidemiology

Scapula fractures account for 1% of all fractures, 3% of shoulder girdle injuries, and 5% of all shoulder fractures. Approximately 50% of scapula fractures involve the body and spine. Fractures of the glenoid neck constitute about 25% of all scapula fractures, whereas fractures of the glenoid cavity (glenoid rim and fossa) make up approximately 10% of scapula fractures. The acromial and coracoid processes account for 8% and 7%, respectively.

Prognosis

Because of the low incidence of scapula fractures, little in the way of outcome data exists. Hardegger et al reported 79% good-to-excellent results associated with five 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 open reduction and internal fixation (ORIF) and found this to be a useful and safe technique that can restore excellent function of the shoulder.[7]

Nonoperative treatment can sometimes result in malunion, leading to poor range of motion (ROM), 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.[8]

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.[9, 10, 11, 12, 13]

 

Presentation

History and Physical Examination

Most patients with scapula fractures present after high-energy trauma. Associated injuries are common and may delay the diagnosis. Associated injury patterns commonly involve the ipsilateral upper extremity and thorax. Frequencies of associated injuries are as follows:

Typically, physical examination reveals swelling, tenderness, crepitus, and ecchymosis over the scapular region. Perform a careful neurovascular examination to rule out arterial injury or brachial plexopathy.

Complications

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 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, though 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.

 

Workup

Laboratory Studies

Laboratory evaluation for patients with a scapula fracture that results from a high-energy mechanism generally is the same as that of a trauma patient. The following studies are warranted:

  • Complete blood count (CBC)
  • Electrolytes
  • Blood urea nitrogen (BUN)/creatinine
  • Urinalysis
  • Prothrombin time (PT)/activated partial thromboplastin time (aPTT)
  • Type and cross-match

Imaging Studies

Radiography

Obtain plain radiographs for the shoulder trauma series, including anteroposterior (AP), lateral, and axillary views of the shoulder/scapula. If an injury to the scapuloclavicular linkage is suspected, obtain a stress AP projection with weights. Occasionally, oblique views may be helpful.

In patients with a pulseless upper extremity, perform emergency arteriography to define the vascular injury.

Computed tomography

Most displaced scapula fractures should be evaluated by means of computed tomography (CT), especially if operative intervention is planned. CT helps visualize the complex osseous anatomy of the scapula. Reconstruction views also help define the anatomy (three-dimensional [3D] CT is useful for the most complex injuries).[14]  Dugarte et al found 3D fracture mapping strategies to be superior to two-dimensional (2D) strategies for 3D CT reconstructions of scapula neck and body fractures.[15]

Other Tests

Electromyography (EMG) can be performed 3 weeks after injury in patients with a scapula fracture and brachial plexus injury. EMG is useful for assessing the extent of the injury and potential for recovery, if any.

Cervical myelography can be performed at 6 weeks in patients with a neurologic deficit due to a scapular injury.

Classification

Fractures involving the glenoid cavity may be classified into the following types (see the image below):

  • Type IA - Anterior rim fracture
  • Type IB - Posterior rim fracture
  • Type II - Fracture line through the glenoid fossa exiting at the lateral border of the scapula
  • Type III - Fracture line through the glenoid fossa exiting at the superior border of the scapula
  • Type IV - Fracture line through the glenoid fossa exiting at the medial border of the scapula
  • Type VA - Combination of types II and IV
  • Type VB - Combination of types III and IV
  • Type VC - Combination of types II, III, and IV
  • Type VI - Comminuted fracture
(Click Image to enlarge.) Classification of glenoi (Click Image to enlarge.) Classification of glenoid cavity fractures: IA - Anterior rim fracture; IB - Posterior rim fracture; II - Fracture line through the glenoid fossa exiting at the lateral border of the scapula; III - Fracture line through the glenoid fossa exiting at the superior border of the scapula; IV - Fracture line through the glenoid fossa exiting at the medial border of the scapula; VA - Combination of types II and IV; VB - Combination of types III and IV; VC - Combination of types II, III, and IV; VI - Comminuted fracture

Fractures of the glenoid neck may be classified into the following two types:

  • Type I - Includes all nondisplaced or minimally displaced fractures
  • Type II - Includes all significantly displaced fractures (translational displacement equal to or greater than 1 cm or angulatory displacement equal to or greater than 40°)

Bartonicek et al described a clinically oriented classification of scapular body fractures based on involvement of the pillars of the scapular body as seen on 3D CT, as follows[16] :

  • Fracture of spinal pillar
  • Fracture of lateral pillar (two-part, three-part, comminuted)
  • Fracture of both pillars (medial, central)
 

Treatment

Approach Considerations

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 injuries, which are sometimes life-threatening, surgery should be delayed 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 of the vessel should be carried out first, followed by 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

Medical therapy for a patient with a scapula fracture 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.[17, 18] 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.[19] 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.[20] This classification subsequently was expanded by Goss (see the image below).[18, 21] 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).

(Click Image to enlarge.) Classification of glenoi (Click Image to enlarge.) Classification of glenoid cavity fractures: IA - Anterior rim fracture; IB - Posterior rim fracture; II - Fracture line through the glenoid fossa exiting at the lateral border of the scapula; III - Fracture line through the glenoid fossa exiting at the superior border of the scapula; IV - Fracture line through the glenoid fossa exiting at the medial border of the scapula; VA - Combination of types II and IV; VB - Combination of types III and IV; VC - Combination of types II, III, and IV; VI - Comminuted fracture

In 2013, the AO Foundation and Orthopaedic Trauma Association published a comprehensive and reliable scapula classification involving glenoid fracture patterns.[22, 23, 24]

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 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.[25]

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.[26] 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.[7] 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 stepoff of 5 mm should warrant consideration for ORIF and that a 10-mm stepoff 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 or cause glenohumeral instability. Nordqvist et al 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.[27] Hardegger et al noted that displaced glenoid neck fractures result in a functional imbalance because the relation of the glenohumeral joint to the acromion and nearby muscle origins is altered.[1]

Classification of glenoid neck fractures. Type I i Classification of glenoid neck fractures. Type I includes all minimally displaced fractures. Type II includes all significantly displaced fractures (translational displacement greater than or equal to 1 cm; angulatory displacement greater than or equal to 40°)

Overall, there is support in the literature for the view 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.

Superior shoulder suspensory complex. (A) anteropo Superior shoulder suspensory complex. (A) anteroposterior view of the bony/soft tissue ring and the superior and inferior bony struts; and (B) lateral view of the bony/soft tissue ring.

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.[28]

Herscovici et al reported results in nine patients with ipsilateral clavicular and glenoid neck fractures.[29] 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).

Fixation of acromion fractures. (A) tension band c Fixation of acromion fractures. (A) tension band construct; and (B) plate-screw fixation (most appropriate for proximal fractures).

Surgical Therapy

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.[30, 31, 32]

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.

Illustrations depicting fixation techniques availa Illustrations depicting fixation techniques available for stabilization of fractures of the glenoid cavity. (1) interfragmentary compression screw; (2) Kirschner wires; (3) construct using Kirschner wires and cerclage wires or Kirschner wires and cerclage sutures; (4) cerclage wire or suture; (5) staple; and (6) 3.5-mm malleable reconstruction plate.

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.[30, 31, 32, 33]

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.

Fixation of glenoid neck fractures. (A) stabilizat Fixation of glenoid neck fractures. (A) stabilization with a 3.5-mm malleable reconstruction plate (note the Kirschner wire running from the acromial process to the glenoid process that can be used for either temporary or permanent fixation); (B) stabilization with 3.5-mm cannulated interfragmentary screws; and (C) stabilization with Kirschner wires (in this case, Kirschner wires passed from the acromion and clavicle into the glenoid process).

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).[30, 31, 32]  A deltopectoral approach could also be utilized as an alternative to a deltoid-splitting approach.

Illustrations showing techniques for managing cora Illustrations showing techniques for managing coracoid fractures. (A) interfragmentary screw fixation (if the fragment is sufficiently large and noncomminuted), and (B) excision of the distal fragment (if small and/or comminuted) and suture fixation of the conjoined tendon to the remaining coracoid process.

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.

Fixation of acromion fractures. (A) tension band c Fixation of acromion fractures. (A) tension band construct; and (B) plate-screw fixation (most appropriate for proximal fractures).

Operative details

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.

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 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.[34]

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 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.

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. Care must be taken to protect and avoid injury to the suprascapular nerve and vessels that lie medial to the coracoid process.

Postoperative Care

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

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.

Long-Term Monitoring

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.