Scapula fracture diagnosis and management

A brief review on scapula fractures diagnosis and management.

1. Scapula fracture diagnosis and management. SEMINAR. By: Dr Hemant Bansal MS ,DNB Orthopedics. AIIMS NEW DELHI,INDIA

2. Basic anatomy and its surgical importance. Mechanism of injury. # incidence and associated injuries. Diagnosis. Classification Treatment Complication . Recent literature.

3. Mechanism of injury Direct blunt trauma – most common. Indirect : Traction injuries by pull of muscles and ligaments around induces avulsion injuries of acromian and coracoid . Rarely seen during seizures/electric shock. Humeral head impaction- glenoid / scapular neck fracture.

4. Mode of injury: High energy trauma: road traffic accident- most common. Fall from height. Crush injuries. Sporting activities- boxing, horse riding, skiing,contact sport.

5. Associated injuries Very common- 61%-98%. More severe then scapula fracture which may delay diagnosis and treatment . Chest injuries-ribs #-most common. 8-54% Neurovasclar injuries- brachial plexus 5-13% Head injuries.20% Splenic and liver lacerations 3-5%. Mortality due to associated injuries- 2-15%.

6. Diagnosis Clinical : pain, crepitus ,tenderness, painful movements. Echymosis is less than expected due to thick muscular cover. Pseudo rupture of rotator cuff: due to intramuscular hematoma- resolves within week. Examination must include evaluation of chest ,head and neurovascular structure.

7. Radiological evaluation. Scapula trauma series. True shoulder AP view. Axillary view/trauma axillary view/ velpeau view. Lateral ‘Y’ view. CT scan.

8. Classification. Anatomic. MC-50% 25% 8,7% 10%

9. Zdravkovic and Damholt . Other similar: Thompson and colleagues,wilber and evans .

10. OTA/AO classification.

11. Glenoid – Ideberg classification.

12. Scapular neck fracture.(14 C1) GPA- 30-45* normal

13. Acromion # 14 A1- kuhn classification.

14. Coracoid # 14 A2- Ogawa. Disturbs scapulothoracic connection.

15. Operative indication: Glenoid # Ideberg I: >1 cm displacement, 25% ant rim,33% posterior rim # with glenohumeral instability. Tpe II,III,IV,V: > 5 mm displacement. Type VI: orif not indicated due to extensive comminution .

16. Scapula neck # >1 cm translation. > 40* angulation / GPA< 20* Associated displaced SSSC injury. Scapula body: non operative irrespective of no of fragments. heals with malunion .

17. Complications: With fracture: brachial plexus , supra scapular,axillary nerve injury. Rotator cuff injury. Conservative treatment: malunion , rarely non union, stiffness, arthritis,instability , Operative treatment: lantry 2008 injury hardware removal 7 % infection 4 % nerve injury 2% arhritis,rotator cuff dysfunction heterotrphic ossification. Rarely non union

18. Surgical approaches. Anterior – deltopectoral interval . Superior - between spinous process and clavicle. Posterior- classical judet approach. Modified judet approach. Ebraheim’s reverse judet incision approach. Brodsky’s and Jerosch’s vertical incision approach.

19. Anterior approach

20. Superior approach

21. Judet approach

22. A Modified Judet Approach to the Scapula William T. Obremskey , MD, MPH,* and Jeffrey R. Lyman, MD† ( J Orthop Trauma 2004;18:696–699)

23. Modified Judet approach

24. A Minimally Invasive Approach to Scapula Neck and Body Fractures Erich M. Gauger MD, Peter A. Cole MD Clin Orthop Relat Res (2011) 469:3390–3399

25. Minimal incision posterior approach

26. AO preferred approach

27. Brodsky ‘s vertical incision approach for Glenoid and Scapula neck #

28. Wirth’s posterior deltoid split approach.

29. Ebraheim’s reverse Judet skin incision appraoch .

30. Surgical Exposure and Fixation of Displaced Type IV, V, and VI Glenoid Fractures Sean E. Nork , MD, David P. Barei , MD, Michael J. Gardner, MD, Thomas A. Schildhauer , MD, Keith A. Mayo, MD, and Stephen K. Benirschke , MD J Orthop Trauma 2008;22:487–493 Both lateral and prone positioning may be used. Lateral positioning allows access to the coracoid process for manipulation of anterior or cephalad articular fracture fragments. However, intraoperative fluoroscopic maging is extremely difficult in this position. Prone positioning has the advantage of facilitating intraoperative fluoroscopic imaging, which may be helpful in particularly difficult fracture patterns. However, prone positioning has increased anesthetic risks and does not allow access to the coracoid process.

31. Operative treatment of scapular fractures: A systematic review Jacob M. Lantry a, Craig S. Roberts a,*, Peter V. Giannoudis Injury, Int. J. Care Injured ( 2008 ) 39, 271—283 The most common injuries treated with surgery were glenoid fossa fractures and scapular neck fractures. Approximately 25% of the cases had a concomitant injury to the clavicle or acromioclavicular ligaments. Internal fixation was most often achieved with a plate and screws through a posterior approach. The complication rate was low with infection, shoulder stiffness, and implant failure the most commonly reported problems. Good to excellent functional results were obtained in approximately 85% of the cases an average of 49.9 months postoperatively.

32. Recent literature on scapula fracture management…..

33. Take home message. Always search for associated injuries. Rule out chest trauma and neurological insult. Whenever suspicion in CXR, get scapula trauma series or CT done. Avoid delayed diagnosis in Polytrauma patients. Acceptable surgical indication: Fracture displacement >20mm Angulation >45* GPA < 20* Intra- articular step >4mm/>25% glenoid involved. Displaced double disruption of SSSC.

34. Delayed treatment .>3 weeks still give favorable results. Preferred implant : 3.5 mm recon locking plate/ tubular plates and ccs . Preferred approach: posterior minimal v/s modified judet depending on fracture pattern and extend. Avoid intra op injury to neurovascluar structure. Post op complication less. Avoid rotator cuff injury and stiffness.

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