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Scapular Fractures

Incidence

  • most common scapular fractures in order
    • body
    • neck 60%
    • glenoid 10%
    • acromion

Associated Injuries

  • seen in upto 80-90% of patients
    • pulmonary injuries & pneumothorax (23%)
    • clavicle fractures (23%), which represents floating shoulder injury
    • shoulder dislocation either anterior or posterior
    • brachial plexus injuries
    • rib fractures
    • flail chest/tension pneumothorax
    • vascular injuries

Classification

According to Anatomical Region

Classification of Scapula Fractures
Type Description
Type I Apophyseal fractures
IA Acromion process
IB Scapular spine
IC Coracoid process
Type II Glenoid neck fractures
IIA Vertical, lateral to base of spine
IIB Vertical, involving base of spine
IIC Transverse fracture
Type III Fracture of glenoid articular surface
Type IV Fracture of the scapular body

 

Scapular Neck

Classification of Scapula Neck Fractures
Type Description
I nonangulated, nondisplaced
IIA shortened / displaced > 1 cm
IIIB Angulated > 40 deg

Glenoid Lip

Glenoid Fossa

Ideberg Classification of Glenoid Fossa Fractures
Type Description
I Anterior avulsion fractures
II Transverse, inferior glenoid
III Transverse, superior glenoid
IV Transverse, through body
V Combo of types II & IV

Pathology

  • body
  • neck
    • usually these fractures are impacted & extra-articular
  • glenoid lip
    • usually involve either anterior or posterior lip of glenoid & are oriented vertically (& exit inferiorly)
    • large lip fractures of glenoid are usually associated with subluxation or partial dislocation of head of humerus
  • glenoid fossa
    • typically present with transverse fracture thru glenoid
    • some fractures will extend medially across scapula & exit just medial tocoracoid or will exit at medial aspect of scapula

Investigations

Xrays

  • AP of Shoulder
    • essential to rule out articular involvement with high quality AP view in which there is no overlap of humerus over glenoid
    • ideally, view should be purely tangential to glenoid
  • 45 deg cephalic tilt allows evaluation of coracoid fractures
  • Apical Oblique View

CT scanning

  • particulary helpful in evaluation of intra articular glenoid fractures
  • allows more accurate assesment of articular step off, as well as displacement & angulation of glenoid neck
  • Systematic Review
    • need to carefully assess entire scapular body & spine, acromion, coracoid, & glenoid
    • need to asses each articulation: glenohumeral, AC joint, & scapulo-thoracic

Treatment

Nonoperative

  • vast majority of scapula fractures may be treated non operatively
  • closed reduction of these fractures is usually not possible
  • treatment consists of support of sling & early motion
  • most fractures will heal by 6 weeks

Operative

Indications

  • Body
    • rare
  • Neck
    • > 10mm medial displacement
    • > 40 deg angulation
    • Combined Neck + Acromion / Coracoid fractures / Clavicle
      • especially if AC separation is present
  • Glenoid Rim
    • > 10 mm displacement
    • > 25% of joint surface & displaced
    • (due to likelihood of instability)
  • Glenoid fossa
    • subluxation & instability of humeral head
    • displaced more than 5 mm require fixation
  • Acromion
    • depressed acromion fractures that encroach on subacromial space & interfere with rotator cuff function

Surgical Approach

    • anterior rim fractures are approached anteriorly & posterior rim fractures are approach posteriorly
    • transverse glenoid fractures may be directly reduced through anterior approach & have fixation via percutaneously inserted screws from above (thru deltoid)
  • Anterior Approach in Fractures of Glenoid
    • for fractures of anterior & inferior margins of glenoid, deltopectoral approach may be chosen
    • reduction of inferior glenoid fractures can be difficult due to proximity of axillary nerve
    • osteotomy of coracoid may be necessary for improved exposure
    • reattach coracoid with 4.5 mm cortex screw & absorbable washer to avoid splitting of coracoid tip
  • Implants:
    • 3.5mm cortex screws or 4.0mm cancellous screws as lag screws
    • 1/3 tubular plate may be applied below glenoid to lateral border of scapula as butress

Extra-articular Scapular Fractures

  • Treatment Considerations
    • with glenoid neck fractures, (articular surface in intact) fractures extends from suprascpular notch area across neck to lateral border of scapula
    • glenoid neck fractures is often displaced but intact clavicle & AC joint will limit displacement & provide stability
    • implant of choice is often contoured 3.5 pelvic reconstruction plate which is applied to posterior border of glenoid & lateral
    • border of scapula
  • Implants
    • 1/3 tubular plate, 3.5 mm DCP, or LC-DCP for fixation of Clavicle
    • 3.5 mm DCP or LC-DCP
    • contoured 3.5 pelvic reconstruction plate
    • 4.0 mm cancellous bone screws as lag screws

Prognosis

  • body
    • good prognosis for healing
  • neck
    • good prognosis for healing
  • if "operative scapular fractures" is treated non operatively
    • patient may develop abductor weakness & subacromial impingement
  • outcomes:
    • Scapular neck fracture influence of permanent malalignment of glenoid neck on clinical outcome
    • J. Romero. Archives of Orthopaedic & Trauma Surgery. 1434-3916 Volume 121 Issue 6 (2001) pp 313-316
      • authors analyzed effect of associated shoulder girdle injury on glenoid displacement & influence of glenoid malalignment on clinical outcome
      • 19 patients with scapular neck fractures were reviewed clinically & radiologically at mean of 8 years after injury
      • none of them has developed nonunion of scapular neck, & only one showed radiological signs of mild degenerative joint disease
      • glenopolar angle (GPA), which assesses rotational malalignment of glenoid about anteroposterior
      • axis perpendicular to scapular plane on plain X-rays was measured less than 20° in six patients
      • 3 of them had sustained associated clavicular fracture or AC joint dislocation
      • other 3 patients had permanent severe malalignment of glenoid neck in absence of associated shoulder girdle injury
      • 5 patients with GPA less than 20° complained of moderate or severe pain
      • 13 patients with mild or no glenoid rotational displacement or medial displacement alone
      • 11 patients had no or mild pain, & only 2 had moderate or severe pain
      • 5 patients presented with reduced activities of daily living, 4 of them had severe glenoid rotational displacement
      • loss of motion was found in only 2 patients, & both had severely displaced glenoid neck