- Email: [email protected]
Displaced scapular body fracture treated with operative closed reduction
Journal of Pediatric Surgery Case Reports 47 (2019) 101234
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Displaced scapular body fracture treated with operative closed reduction a,∗
a
Michael Ghassibi , Dhanunjay Sarma Boyalakuntla , Sheryl Handler-Matasar a b
T
b
Orthopedic Surgery, Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, 44501, USA Orthopedics, Akron Children's Hospital, 6505 Market St., Building A, Boardman, OH, 44512, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Case report Scapula Pediatric Closed reduction Scapular body fracture
Case: A majority of the pediatric scapula fractures sustained are scapular body fractures. There is a lack of literature concerning pediatric scapular body fractures and its management. We report the case of a scapular body fracture with significant angulation, our intraoperative closed reduction axillary fold approach under anesthesia, and the functional and radiologic outcomes post operatively. At 3 month and 2 year follow up, the patient was able to resume normal activities. Imaging demonstrated a completely healed, well aligned scapular body. Conclusions: We suggest closed reduction as an option in significantly angulated isolated scapular body fractures.
1. Introduction Scapular fractures in the pediatric population are rare making up only 1% of all fractures with less than 5% of pediatric fractures occurring at the shoulder [5,13]. Typically, patients are an average age of 35 years (range, 25–50 years) with up to 96% incidence of associated injuries [1]. The most common mechanism of injury for scapular fractures involve direct trauma. These fractures are associated with motor vehicle accidents (MVA) in 88% of cases. A majority of the pediatric scapular fractures sustained (82%) are scapular body fractures [13,14]. There is a paucity of literature concerning pediatric scapular body fractures and its management. We report the case of a scapular body fracture with significant displacement, our manipulation under anesthesia approach, and the functional and radiologic outcomes post operatively. 2. Case report A 14-year-old boy presented to the emergency room with right posterior shoulder pain and functional impairment. The injury occurred when he fell, striking his right shoulder on court while playing basketball. The patient did not sustain any other injuries. Physical exam demonstrated obvious winged deformity of the right scapular body with associated swelling. There was significantly decreased range of the shoulder motion globally due to pain and cradling of the arm. There was no evidence of neuromuscular compromise. Shoulder plain radiographs, shown in Fig. 1., revealed a transverse fracture through the body of the scapula with resultant significant apex
∗
anterior angulation of the scapula. CT scan of the shoulder and scapula and 3-D reconstruction were shown in Fig. 2., showed a mildly comminuted fracture of the mid body scapula with greater than 50° of dorsal angulation. The glenohumeral and acromioclavicular joints were not involved. There were no associated injuries to the shoulder girdle. The patient was discharged in a pediatric shoulder sling. Due functional impairment, pain, and deformity in addition to radiographs demonstrating greater than 50° dorsal scapula angulation, the option of closed reduction in the operative room was discussed versus non operative management with sling. The parents as well as the patient understood the limited literature and decided to proceed. The patient was taken to the operative room three days later for closed reduction under anesthesia. He was placed supine on the operating room table. After induction of general endotracheal anesthesia, the patient was positioned in the beach chair position on the operating table with his right shoulder and scapula off the edge of the OR table. The closed reduction maneuver was performed via an axillary fold approach using the technique described in the European Journal of Orthopedic Surgery and Traumatology in February 2009 [4]. The technique is as follows: The surgeon's left hand was grasped under the lower pole of the scapula through the patient's right axilla using the thumb as a fulcrum over which to flex and correct the deformity. The superior aspect of the scapula was stabilized by grasping around the clavicle onto the superior aspect of the scapula with the fingers of the right hand. Both of the fracture elements were then flexed forward using the left thumb as a fulcrum across the fracture site. The maneuver is shown in Fig. 3. After the closed reduction maneuver was performed, the large C-arm was then brought in to check scapular views which demonstrated significant
Corresponding author. E-mail address: [email protected] (M. Ghassibi).
https://doi.org/10.1016/j.epsc.2019.101234 Received 7 May 2019; Accepted 26 May 2019 Available online 01 June 2019 2213-5766/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 47 (2019) 101234
M. Ghassibi, et al.
Fig. 1. AP and scapular Y radiographs showing a dorsally angulated and displaced scapular body fracture.
Fig. 2. Shoulder sagittal CT scan and 3-D reconstruction demonstrating over 50° of dorsal angulation.
inherent location of the scapula enveloped in dense musculature as well as its thick periosteum which helps limit significant displacement and angulation [10]. The patient in this case review suffered a direct impact onto the scapula from standing height which is reported to be a common mechanism of injury for scapular body fractures [7]. Due to preoperative symptoms related to the displacement and deformity of the scapular body, the patient and family opted for closed reduction under anesthesia. The technique described by Caesar et al. was selected due to its applied anatomy of the scapula. Once disimpacted and reduced, the subscapularis, teres minor, and infraspinatus muscle origins are thought to pull in line with the scapula blade preventing displacement of the fracture in its reduced position. This allows for earlier recovery through early mobilization of the fracture without impairment due to deformity [4]. The consensus opinion in pediatric and adult orthopedic literature is that scapular fractures typically require no operative treatment [3]. Conservative treatment typically includes early passive and assisted active motion exercises to aid in recovering range of motion. Motion
improvement of alignment post reduction, as shown in Fig. 4. It was slightly difficult to tell the exact amount of residual angulation on these attempted scapular Y-views. Clinically, there was excellent correction of the deformity. The right shoulder was immobilized with instruction of non-weight bearing pendulum movements. After one-month post reduction, shoulder restrictions were discontinued and additional work on range of motion and strengthening shoulder exercises began. 3 months post operatively, patient's pain had resolved completely, and he was able to resume all normal activities. X-rays of the scapula demonstrated a well healing scapular body fracture. At 2 year follow up, X-ray images of the scapula demonstrated a completely healed scapular body fracture which was well-aligned, as shown in Fig. 5. 3. Discussion Scapular body fractures are uncommon with an incidence of concomitant injuries documented up to 96% [7]. This is likely due to the 2
Journal of Pediatric Surgery Case Reports 47 (2019) 101234
M. Ghassibi, et al.
early on also aids in muscle-induced self-reduction. Non-operative modalities have reported little functional losses with 86% excellent or good results. However, these prior studies used surgeon-based outcomes scores which may have been unable to document subtle deficits [7]. Literature has shown that expected non-operative outcome of most scapular fractures can do quite well. However, this is the first study in the United States to document a reduction of displacement in a closed setting without any complications or redisplacement. Nordqvist and Petersson indicated that radiographic displacement in adult scapular fractures went on to have symptoms and functional deficits related to the injury long term [11]. Thus, they advocated surgical treatment of significantly displaced fractures. Literature review has shown reports of scapular body nonunion cases which were complications of conservative management [6–8]. 3 patients involved in these studies required open reduction internal fixation with local bone graft because of symptoms of functional impairment and pain. The use of open operative management is rare for scapular fractures and with inherent risk. A systematic review of 520 scapular fractures in 22 case series was performed by Zlowodzki et al. which showed a 16.5% secondary surgical procedure rate for 140 adult scapular fractures including manipulation under anesthesia, hardware removal, irrigation and debridement, hematoma evacuation, revision fixation, and one arthrodesis of the glenohumeral joint. There were a total of 4 infections that required formal irrigation and debridement accounting for a total infection rate of 3.5% [12]. In regard to our patient, closed reduction under manipulation was thought to minimize the risk developing a non-union which may have necessitated an open surgical procedure. There are studies that describe open reduction and internal fixation of scapula fractures [2,9,12]. However, the patients in these studies are older than 18 years and the displacements involve the scapula neck and glenoid rim fractures. These procedures do not relate with a simple angulated scapula body fracture that was reduced closed as with the current case study submitted. To our knowledge, there have not been any publications on closed reduction of scapula body in children in the United States. The cited article is the only other case report published in European Journal of Orthopedic Surgery and Traumatology, involving a closed reduction of a pediatric scapula body [4].
Fig. 3. Intraoperative manipulation and reduction technique for scapular fracture.
4. Conclusion The isolated fracture of a pediatric scapular body with significant displacement is a rare injury, and it is a reasonable option to treat with closed reduction under anesthesia by using the axillary fold approach as described. Although this is the first study in the United States, we do concede that additional studies would yield a better consensus of treatment. We advocate it as an option in significantly displaced isolated scapular body fractures. Patient consent Consent to publish the case report was obtained from the mother and the patient. However, this report does not contain any personal information that could lead to the identification of the patient. Funding No funding or grant support.
Fig. 4. Intraoperative fluoroscopic shoulder x-ray showing improvement of alignment post reduction.
Authorship All authors attest that they meet the current ICMJE criteria for Authorship 3
Journal of Pediatric Surgery Case Reports 47 (2019) 101234
M. Ghassibi, et al.
Fig. 5. 2 year follow up radiographs scapula demonstrating completely healed scapular body fracture which was well-aligned.
Conflict of interest
0378-6. [5] Court-Brown CH, McQueen MM, Tornetta P. Trauma (shoulder girdle). Philadelphia, PA: Lippincott Williams & Wilkins; 2006. p. 68–88. [6] Ferraz IC, Papadimitriou NG, Sotereanos DG. Scapula body nonunion: a case report. J Shoulder Elb Surg 2002;11:98–100. https://doi.org/10.1067/mse.2002.118479. [7] Gosens T, Speigner B, Minekus J. Fracture of the scapula body: functional outcome after conservative treatment. J Shoulder Elbow Surg 2009;18:443–8. https://doi. org/10.1016/j.jse.2009.01.030. [8] Gupta R, Sher J, Williams GR, Iannotti JP. Non-union of the scapula body. A case report. J Bone Joint Surg Am 1998;80:428–30. [9] Leung KS, Lam TP. Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. JBJS 1993;75:1015–8. [10] Mencio GA, Swiontkowski MF. Green's skeletal trauma in children. fifth ed. Philadelphia, PA: Elsevier; 2014. [11] Nordqvist A, Petersson C. Fracture of the body, neck, or spine of the scapula. A long term follow-up study. Clin Orthop Relat Res 1992;283:139–44. [12] Schroder LK, Gauger E, Gilbertson Jeffrey A, Cole PA. Functional outcomes after operative management of extra-articular glenoid neck and scapular body fractures. JBJS 2016;98:1623–30. https://doi.org/10.1097/BOT.0000000000000710. [13] Shannon SF, Hernandez NM, Sems SA, Larson AN, Milbrandt TA. High-energy pediatric scapula fractures and their associated injures. J Pediatr Orthop 2017;0:1–4. https://doi.org/10.1097/BPO.0000000000000969. [14] Wilber MC, Evans EB. Fractures of the scapula: an analysis of 40 cases and a review of literature. J Bone Joint Surg Am 1977;59:358–62.
The following authors have no financial disclosures: MG, JD, SH Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.epsc.2019.101234. References [1] Ada JR, Miller ME. Scapular fractures. analysis of 113 cases. Clin Orthop Relat Res 1991;269:174–80. [2] Bauer G, Fleischmann W, Dubler E. Displaced scapular fractures: indication and long-term results of open reduction and internal fixation. Arch Orthop Trauma Surg 1995;114:215–9. [3] Butters K. Fractures of the scapula. sixth ed.Bucholz RW, Heckman JD, Court-Brown C, editors. Rockwood and Green's fractures in adults, vol. 2. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 1277 [chapter 33]. [4] Caesar BC, Qureshi AA, Hay SM. Locked and angulated fracture of the scapula blade in a 15-year-old rugby player: a closed manipulation technique for reduction. Eur J Orthop Surg Traumatol 2009;19:93–5. https://doi.org/10.1007/s00590-008-
4
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Displaced scapular body fracture treated with operative closed reduction a,∗
a
Michael Ghassibi , Dhanunjay Sarma Boyalakuntla , Sheryl Handler-Matasar a b
T
b
Orthopedic Surgery, Mercy Health St. Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, 44501, USA Orthopedics, Akron Children's Hospital, 6505 Market St., Building A, Boardman, OH, 44512, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Case report Scapula Pediatric Closed reduction Scapular body fracture
Case: A majority of the pediatric scapula fractures sustained are scapular body fractures. There is a lack of literature concerning pediatric scapular body fractures and its management. We report the case of a scapular body fracture with significant angulation, our intraoperative closed reduction axillary fold approach under anesthesia, and the functional and radiologic outcomes post operatively. At 3 month and 2 year follow up, the patient was able to resume normal activities. Imaging demonstrated a completely healed, well aligned scapular body. Conclusions: We suggest closed reduction as an option in significantly angulated isolated scapular body fractures.
1. Introduction Scapular fractures in the pediatric population are rare making up only 1% of all fractures with less than 5% of pediatric fractures occurring at the shoulder [5,13]. Typically, patients are an average age of 35 years (range, 25–50 years) with up to 96% incidence of associated injuries [1]. The most common mechanism of injury for scapular fractures involve direct trauma. These fractures are associated with motor vehicle accidents (MVA) in 88% of cases. A majority of the pediatric scapular fractures sustained (82%) are scapular body fractures [13,14]. There is a paucity of literature concerning pediatric scapular body fractures and its management. We report the case of a scapular body fracture with significant displacement, our manipulation under anesthesia approach, and the functional and radiologic outcomes post operatively. 2. Case report A 14-year-old boy presented to the emergency room with right posterior shoulder pain and functional impairment. The injury occurred when he fell, striking his right shoulder on court while playing basketball. The patient did not sustain any other injuries. Physical exam demonstrated obvious winged deformity of the right scapular body with associated swelling. There was significantly decreased range of the shoulder motion globally due to pain and cradling of the arm. There was no evidence of neuromuscular compromise. Shoulder plain radiographs, shown in Fig. 1., revealed a transverse fracture through the body of the scapula with resultant significant apex
∗
anterior angulation of the scapula. CT scan of the shoulder and scapula and 3-D reconstruction were shown in Fig. 2., showed a mildly comminuted fracture of the mid body scapula with greater than 50° of dorsal angulation. The glenohumeral and acromioclavicular joints were not involved. There were no associated injuries to the shoulder girdle. The patient was discharged in a pediatric shoulder sling. Due functional impairment, pain, and deformity in addition to radiographs demonstrating greater than 50° dorsal scapula angulation, the option of closed reduction in the operative room was discussed versus non operative management with sling. The parents as well as the patient understood the limited literature and decided to proceed. The patient was taken to the operative room three days later for closed reduction under anesthesia. He was placed supine on the operating room table. After induction of general endotracheal anesthesia, the patient was positioned in the beach chair position on the operating table with his right shoulder and scapula off the edge of the OR table. The closed reduction maneuver was performed via an axillary fold approach using the technique described in the European Journal of Orthopedic Surgery and Traumatology in February 2009 [4]. The technique is as follows: The surgeon's left hand was grasped under the lower pole of the scapula through the patient's right axilla using the thumb as a fulcrum over which to flex and correct the deformity. The superior aspect of the scapula was stabilized by grasping around the clavicle onto the superior aspect of the scapula with the fingers of the right hand. Both of the fracture elements were then flexed forward using the left thumb as a fulcrum across the fracture site. The maneuver is shown in Fig. 3. After the closed reduction maneuver was performed, the large C-arm was then brought in to check scapular views which demonstrated significant
Corresponding author. E-mail address: [email protected] (M. Ghassibi).
https://doi.org/10.1016/j.epsc.2019.101234 Received 7 May 2019; Accepted 26 May 2019 Available online 01 June 2019 2213-5766/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 47 (2019) 101234
M. Ghassibi, et al.
Fig. 1. AP and scapular Y radiographs showing a dorsally angulated and displaced scapular body fracture.
Fig. 2. Shoulder sagittal CT scan and 3-D reconstruction demonstrating over 50° of dorsal angulation.
inherent location of the scapula enveloped in dense musculature as well as its thick periosteum which helps limit significant displacement and angulation [10]. The patient in this case review suffered a direct impact onto the scapula from standing height which is reported to be a common mechanism of injury for scapular body fractures [7]. Due to preoperative symptoms related to the displacement and deformity of the scapular body, the patient and family opted for closed reduction under anesthesia. The technique described by Caesar et al. was selected due to its applied anatomy of the scapula. Once disimpacted and reduced, the subscapularis, teres minor, and infraspinatus muscle origins are thought to pull in line with the scapula blade preventing displacement of the fracture in its reduced position. This allows for earlier recovery through early mobilization of the fracture without impairment due to deformity [4]. The consensus opinion in pediatric and adult orthopedic literature is that scapular fractures typically require no operative treatment [3]. Conservative treatment typically includes early passive and assisted active motion exercises to aid in recovering range of motion. Motion
improvement of alignment post reduction, as shown in Fig. 4. It was slightly difficult to tell the exact amount of residual angulation on these attempted scapular Y-views. Clinically, there was excellent correction of the deformity. The right shoulder was immobilized with instruction of non-weight bearing pendulum movements. After one-month post reduction, shoulder restrictions were discontinued and additional work on range of motion and strengthening shoulder exercises began. 3 months post operatively, patient's pain had resolved completely, and he was able to resume all normal activities. X-rays of the scapula demonstrated a well healing scapular body fracture. At 2 year follow up, X-ray images of the scapula demonstrated a completely healed scapular body fracture which was well-aligned, as shown in Fig. 5. 3. Discussion Scapular body fractures are uncommon with an incidence of concomitant injuries documented up to 96% [7]. This is likely due to the 2
Journal of Pediatric Surgery Case Reports 47 (2019) 101234
M. Ghassibi, et al.
early on also aids in muscle-induced self-reduction. Non-operative modalities have reported little functional losses with 86% excellent or good results. However, these prior studies used surgeon-based outcomes scores which may have been unable to document subtle deficits [7]. Literature has shown that expected non-operative outcome of most scapular fractures can do quite well. However, this is the first study in the United States to document a reduction of displacement in a closed setting without any complications or redisplacement. Nordqvist and Petersson indicated that radiographic displacement in adult scapular fractures went on to have symptoms and functional deficits related to the injury long term [11]. Thus, they advocated surgical treatment of significantly displaced fractures. Literature review has shown reports of scapular body nonunion cases which were complications of conservative management [6–8]. 3 patients involved in these studies required open reduction internal fixation with local bone graft because of symptoms of functional impairment and pain. The use of open operative management is rare for scapular fractures and with inherent risk. A systematic review of 520 scapular fractures in 22 case series was performed by Zlowodzki et al. which showed a 16.5% secondary surgical procedure rate for 140 adult scapular fractures including manipulation under anesthesia, hardware removal, irrigation and debridement, hematoma evacuation, revision fixation, and one arthrodesis of the glenohumeral joint. There were a total of 4 infections that required formal irrigation and debridement accounting for a total infection rate of 3.5% [12]. In regard to our patient, closed reduction under manipulation was thought to minimize the risk developing a non-union which may have necessitated an open surgical procedure. There are studies that describe open reduction and internal fixation of scapula fractures [2,9,12]. However, the patients in these studies are older than 18 years and the displacements involve the scapula neck and glenoid rim fractures. These procedures do not relate with a simple angulated scapula body fracture that was reduced closed as with the current case study submitted. To our knowledge, there have not been any publications on closed reduction of scapula body in children in the United States. The cited article is the only other case report published in European Journal of Orthopedic Surgery and Traumatology, involving a closed reduction of a pediatric scapula body [4].
Fig. 3. Intraoperative manipulation and reduction technique for scapular fracture.
4. Conclusion The isolated fracture of a pediatric scapular body with significant displacement is a rare injury, and it is a reasonable option to treat with closed reduction under anesthesia by using the axillary fold approach as described. Although this is the first study in the United States, we do concede that additional studies would yield a better consensus of treatment. We advocate it as an option in significantly displaced isolated scapular body fractures. Patient consent Consent to publish the case report was obtained from the mother and the patient. However, this report does not contain any personal information that could lead to the identification of the patient. Funding No funding or grant support.
Fig. 4. Intraoperative fluoroscopic shoulder x-ray showing improvement of alignment post reduction.
Authorship All authors attest that they meet the current ICMJE criteria for Authorship 3
Journal of Pediatric Surgery Case Reports 47 (2019) 101234
M. Ghassibi, et al.
Fig. 5. 2 year follow up radiographs scapula demonstrating completely healed scapular body fracture which was well-aligned.
Conflict of interest
0378-6. [5] Court-Brown CH, McQueen MM, Tornetta P. Trauma (shoulder girdle). Philadelphia, PA: Lippincott Williams & Wilkins; 2006. p. 68–88. [6] Ferraz IC, Papadimitriou NG, Sotereanos DG. Scapula body nonunion: a case report. J Shoulder Elb Surg 2002;11:98–100. https://doi.org/10.1067/mse.2002.118479. [7] Gosens T, Speigner B, Minekus J. Fracture of the scapula body: functional outcome after conservative treatment. J Shoulder Elbow Surg 2009;18:443–8. https://doi. org/10.1016/j.jse.2009.01.030. [8] Gupta R, Sher J, Williams GR, Iannotti JP. Non-union of the scapula body. A case report. J Bone Joint Surg Am 1998;80:428–30. [9] Leung KS, Lam TP. Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. JBJS 1993;75:1015–8. [10] Mencio GA, Swiontkowski MF. Green's skeletal trauma in children. fifth ed. Philadelphia, PA: Elsevier; 2014. [11] Nordqvist A, Petersson C. Fracture of the body, neck, or spine of the scapula. A long term follow-up study. Clin Orthop Relat Res 1992;283:139–44. [12] Schroder LK, Gauger E, Gilbertson Jeffrey A, Cole PA. Functional outcomes after operative management of extra-articular glenoid neck and scapular body fractures. JBJS 2016;98:1623–30. https://doi.org/10.1097/BOT.0000000000000710. [13] Shannon SF, Hernandez NM, Sems SA, Larson AN, Milbrandt TA. High-energy pediatric scapula fractures and their associated injures. J Pediatr Orthop 2017;0:1–4. https://doi.org/10.1097/BPO.0000000000000969. [14] Wilber MC, Evans EB. Fractures of the scapula: an analysis of 40 cases and a review of literature. J Bone Joint Surg Am 1977;59:358–62.
The following authors have no financial disclosures: MG, JD, SH Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.epsc.2019.101234. References [1] Ada JR, Miller ME. Scapular fractures. analysis of 113 cases. Clin Orthop Relat Res 1991;269:174–80. [2] Bauer G, Fleischmann W, Dubler E. Displaced scapular fractures: indication and long-term results of open reduction and internal fixation. Arch Orthop Trauma Surg 1995;114:215–9. [3] Butters K. Fractures of the scapula. sixth ed.Bucholz RW, Heckman JD, Court-Brown C, editors. Rockwood and Green's fractures in adults, vol. 2. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 1277 [chapter 33]. [4] Caesar BC, Qureshi AA, Hay SM. Locked and angulated fracture of the scapula blade in a 15-year-old rugby player: a closed manipulation technique for reduction. Eur J Orthop Surg Traumatol 2009;19:93–5. https://doi.org/10.1007/s00590-008-
4