- Email: [email protected]
Dorsal Plate Fixation of Scapular Fracture
SURGICAL TECHNIQUE
Dorsal Plate Fixation of Scapular Fracture Takashi Noguchi, MD, PhD,* James F. Mautner, MD,† Scott F. M. Duncan, MD, MPH*
Scapular fractures are uncommon injuries. When they occur, they are usually treated nonsurgically. However, certain indications remain for operative intervention for the treatment of these injuries. In this article, we review some operative indications as well as the surgical technique. We present a case to demonstrate the indications and surgical technique of treatment. As with most surgical approaches, technique is critical to minimize morbidity and maximize functional outcome. Using these techniques, operative management of scapular fractures can be successful. (J Hand Surg Am. 2017;-(-):1.e1-e5. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Glenoid fracture, plate fixation, posterior approach, scapular fracture, suprascapular nerve.
S
CAPULAR FRACTURES ARE UNCOMMON, with an incidence of 0.5% to 1.0% of all fractures.1,2 High-energy trauma is the usual mechanism that leads to such fractures. Mortality in patients with scapular fractures is reported to range from 10% to 15% because they frequently have other concomitant injuries involving the pulmonary system, cervical spine, or cranial region.3e5 Most scapular fractures do not require operative treatment to achieve a satisfactory outcome.6,7 Scapular fractures frequently heal well without surgery because the scapula is encased by multiple muscles providing a rich vascular supply to the bone. However, Nordqvist and Petersson8 reported that the outcome of nonsurgical treatment showed reduced shoulder function from factors such as arthrosis, rotator cuff dysfunction, scapulothoracic dyskinesis, and impingement pain. Furthermore, it was reported that operative treatment
From the *Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA; and the †Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA. Received for publication February 7, 2017; accepted in revised form July 24, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Scott F. M. Duncan, MD, MPH, Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, 850 Harrison Avenue, Dowling 2 North, Boston, MA 02118; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.07.022
for scapular fractures demonstrated superior functional recovery and improved outcomes.9 More than 90% of scapular fractures involve the body and neck.10,11 Therefore, the posterior or dorsal surgical approach is more commonly used for this fracture pattern. We describe our strategy for treating scapular fractures to restore shoulder function. INDICATIONS Patients with scapular fractures occasionally experience polytrauma. The operative criteria are controversial. However, current treatment standards recommend at least one of the following for surgical intervention: 1. Intra-articular stepoff of the glenoid surface greater than 4 mm on computed tomography (CT) imaging 2. Fracture line crossing the scapular body, spine, and neck 3. Angular deformity greater than 40 on the scapular-Y view 4. Displacement or shortening greater than 20 mm on CT or anteroposterior radiograph 5. Glenopolar angle smaller than 10 on CT imaging 6. Floating shoulder (concomitant fracture of clavicle, acromion, or coronoid process with displacement greater than 10 mm or acromioclavicular dislocation)
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
DORSAL FIXATION OF SCAPULAR FRACTURE
CONTRADICTIONS Patients with polytrauma and unstable vital signs should have surgery postponed until they are medically stable: 1. Large bone or soft tissue defect in the shoulder girdle 2. Markedly comminuted fracture of the scapula 3. Concomitant traumatic brain injury or cervical spinal cord injury above C5 SURGICAL ANATOMY For optimal surgery, it is essential to have thorough knowledge of scapula anatomy. The scapula is divided into 3 major parts when viewed posteriorly: the spine with acromial process, glenoid, and body. The base of the scapula forms by membranous ossification. It is a thinner bone than are the other bones that form by cartilaginous ossification. However, the lateral and medial borders of the scapular body have a markedly thicker bone in which drilling and screw fixation are possible. There are several muscles originating from or inserting onto the scapula, covering the scapula entirely in muscle. These are the supraspinatus and infraspinatus muscles innervated by the suprascapular nerve, the deltoid and teres minor muscles innervated by the axillary nerve, and the subscapularis muscle innervated by the subscapular nerve.12 The scapula has a complex vascular network that contains the circumflex scapular artery along with the scapular and subscapular arteries located next to the suprascapular nerve. The suprascapular nerve wraps around the lateral base of the scapular spine, defined as the spinoglenoid notch from superior to inferior. After exiting the notch, the nerve divides into 3 branches and courses just underneath the infraspinatus muscle where the nerve ends. The potential location of the nerve spreads inferiorly and medially like a fan, with a radius of 40 mm around the scapular notch where it is reported to be the 4-7-8 triangle in the cadaver study by Wijdicks et al.13 Almost all scapular fractures involve the body and the neck. Because of this, there are 3 common radiographic classification systems for scapula fractures: AO/Orthopaedic Trauma Association,14 Goss,2 and Ada and Miller.11 Armitage et al15 focused on fracture patterns and traced various patterns of actual fractures of the scapular body and neck treated operatively using a CT mapping technique. Accordingly, 3 main patterns were codified as inferior glenoid neck, spinoglenoid notch, and glenoid articular surface, respectively. They demonstrated that 68% of J Hand Surg Am.
FIGURE 1: Illustration of incision line.
fractures involved an inferior aspect of the glenoid neck, and 71% of fractures traversed the scapular body inferior to the medial extent of the scapular spine. Furthermore, 17% of fractures had an articular fragment and 22% were cracked beyond the spinoglenoid notch. SURGICAL TECHNIQUE Surgery is performed under general anesthesia. The patient is positioned laterally with a slight lean anteriorly. This position allows easy manipulation of the arm during surgery. It is important to make sure that there is enough space to move an image intensifier in and out. A modified Judet approach is recommended to expose the scapular fracture, place hardware adequately, and minimize morbidity and maximize function.16 The incision line is placed as an L shape ascending from the inferior angle of the scapula to the base of the lateral scapular spine through the medial edge of the scapular spine along the medial border of the scapula body and the ridge of the scapular spine (Fig. 1). A fasciocutaneous flap is raised laterally along the incision line. Consequently, the posterior part of the deltoid muscle is exposed. It is incised sharply from the scapular spine and then bluntly dissected from the infraspinatus muscle moving laterally until reaching the lateral border of the scapula. The infraspinatus muscle is detached from its origin and raised toward the lateral side off the scapular surface. This is done to avoid suprascapular r
Vol. -, - 2017
DORSAL FIXATION OF SCAPULAR FRACTURE
1.e3
FIGURE 2: Fracture lines are present on the scapular body, glenoid, and glenoid neck. Three-dimensional CT shows 7-mm glenoid displacement. Inferior scapular body fragment was displaced 14 mm. A Posterior view; B glenoid view.
other long bones. When performing plate fixation, the initial fixation should be performed laterally first, with medial fixation performed last. An essential point of focus is avoiding unnecessary dissection between the subscapularis muscle and the scapula. This is crucial because the subscapularis supplies blood flow into the scapular bone in addition to the vascular circuit created by the circumflex scapular artery and suprascapular artery. In wound closure, the infraspinatus should be sutured to the rhomboid fascia, and the deltoid should be sutured directly to the scapular spine. The subcutaneous tissue should be closed firmly to relieve tension on the skin, thus minimizing hypertrophic scar formation. A drain tube is inserted underneath the subcutaneous layer and removed within 48 hours after the procedure.
nerve injury while being attentive to the vulnerable area described previously. It is unnecessary to expose the neurovascular bundle. When adequate exposure of the scapula is achieved, the flap and muscles are retracted with suitable instruments; however, the surgeon must be careful not to place excess retraction on the soft tissue flap that contains the neurovascular bundle, or rotator cuff dysfunction may result. While elevating the infraspinatus, the ascending branch of the circumflex scapular artery is exposed in the surgical site. The artery is cauterized as necessary. To reduce fracture fragments, Schantz pins (Synthes, Paoli, PA) and small external fixators can be used. Moreover, reduction of an extra-articular glenoid neck fragment connecting to the articular surface can result indirectly in the reduction of glenoid congruity without intra-articular exposure. Provisional fixation is implemented with instruments such as wires and clamps; then it is followed by definitive plate fixation. If the glenoid fragment is small and isolated from the extra-articular fragment, an approach between the teres minor and the infraspinatus muscle may be required to reduce and repair the fragment.17 Multiple screws or pins may be required to repair the fragment successfully. Anatomically designed locking plates for the scapula are helpful. In some cases, a combination of anatomically designed locking plates, reconplates, and plates designed for other types of fractures are used to achieve stable fixation. Furthermore, support with double plates and multiple screws may be necessary because the scapula is much thinner than J Hand Surg Am.
Postoperative care The upper arm and shoulder are immobilized using a sling for 3 weeks after surgery. However, the fingers, wrist, and elbow should not be immobilized and should be moved as soon as pain subsides. Passive motion of the shoulder can be allowed 2 weeks after the operation and continued for 6 weeks. Active range of motion and strengthening exercises may begin 6 weeks after surgery. Normal daily use of the affected shoulder is encouraged at least 8 weeks later. Three months after the procedure, patients may resume regular work and activities. The discontinuation of physical therapy depends on pain resolution, range of motion, and the strength of the shoulder. r
Vol. -, - 2017
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DORSAL FIXATION OF SCAPULAR FRACTURE
FIGURE 3: Intraoperative photos. A The deltoid muscle and infraspinatus muscle containing the suprascapular neurovascular bundle are elevated laterally. Scapular body and glenoid neck are exposed without exposure of the glenoid articular surface. A Schantz pin was inserted into glenoid neck fragment. B Double anatomic locking plates are placed properly to fix the fragments. L, lateral; M, medial; P, pin; S, superior.
FIGURE 4: Postoperative radiograph (4 months). Fixation is maintained. No reduction loss or screw loosening is seen in either view. A Anteroposterior view; B lateral view.
CASE PRESENTATION A 63-year-old, right hand-dominant man was injured in a motorcycle accident and brought to the emergency unit. He had a right scapular fracture and no other injuries except for minor abrasions. Radiographs and CT scans showed displaced scapular fragments with an unacceptable glenoid stepoff connecting to a glenoid J Hand Surg Am.
neck fragment and a displaced scapular body fragment (AO/OTA 14-C3) (Fig. 2). Seven days after the injury, he underwent surgery for the scapular fractures. Using a modified Judet approach in the left lateral position under general anesthesia, the deltoid with its fascia was elevated laterally. Next, the infrasupinatus muscle was carefully
r
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DORSAL FIXATION OF SCAPULAR FRACTURE
elevated laterally from the origin off the medial edge of the scapula. The fracture sites were fully exposed with adequate retraction (Fig. 3A). There were 2 large fracture lines on the body of the scapula as well as the base of the scapular spine and neck. They were reduced using the Schantz pin and clamps followed by insertion of 2 anatomical plates (Acumed, Beaverton, OR) (Fig. 3B). The infraspinatus and deltoid muscles were carefully repaired and closed layer on layer with a drain inserted subcutaneously. Postoperative therapy began the following day. No postsurgical complications occurred. Four months later, the fractures were healing radiographically (Fig. 4) and there was no loss of the screw or plate fixation. The patient was able to return to work without pain. He had regained full range of shoulder motion by that time.
3. Intraoperative iatrogenic fracture 4. Inappropriate placement of the plates (too medial or central) 5. Insertion of screws with excessive length, which can interrupt shoulder movement and injure structures adjacent to the scapula REFERENCES 1. Collins J. Chest wall trauma. J Thorac Imaging. 2000;(15): 112e119. 2. Goss TP. Scapular fractures and dislocations: diagnosis and treatment. J Am Acad Orthop Surg. 1995;(3):22e33. 3. Armstrong CP, Van der Spuy J. The fractured scapula: importance and management based on a series of 62 patients. Injury. 1984;(15): 324e329. 4. Stephens NG, Morgan AS, Corvo P, Bernstein BA. Significance of scapular fracture in the blunt-trauma patient. Ann Emerg Med. 1995;(26):439e442. 5. Thompson DA, Flynn TC, Miller PW, Fischer RP. The significance of scapular fractures. J Trauma. 1985;(25):974e977. 6. Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006;(20):230e233. 7. Gosens T, Speigner B, Minekus J. Fracture of the scapular body: functional outcome after conservative treatment. J Shoulder Elbow Surg. 2009;(18):443e448. 8. 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):139e144. 9. Cole PA, Talbot M, Schroder LK, Anavian J. Extra-articular malunions of the scapula: a comparison of functional outcome before and after reconstruction. J Orthop Trauma. 2011;(25): 649e656. 10. McGahan JP, Rab GT, Dublin A. Fractures of the scapula. J Trauma. 1980;(20):880e883. 11. Ada JR, Miller. ME Scapular fractures: analysis of 113 cases. Clin Orthop Relat Res. 1991;(269):174e180. 12. Cole PA, Dubin JR, Freeman G. Operative techniques in the management of scapular fractures. Orthop Clin North Am. 2013;(44): 331e343, viii. 13. Wijdicks CA, Armitage BM, Anavian J, Schroder LK, Cole PA. Vulnerable neurovasculature with a posterior approach to the scapula. Clin Orthop Relat Res. 2009;(467):2011e2017. 14. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendiume2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;(21):S1eS133. 15. Armitage BM, Wijdicks CA, Tarkin IS, et al. Mapping of scapular fractures with three-dimensional computed tomography. J Bone Joint Surg Am. 2009;(91):2222e2228. 16. Jones CB, Cornelius JP, Sietsema DL, Ringler JR, Endres TJ. Modified Judet approach and minifragment fixation of scapular body and glenoid neck fractures. J Orthop Trauma. 2009;(23): 558e564. 17. Gauger EM, Cole PA. Surgical technique: a minimally invasive approach to scapula neck and body fractures. Clin Orthop Relat Res. 2011;(469):3390e3399.
COMPLICATIONS Complications related to surgery using the modified Judet approach are rare. Suprascapular nerve injury can result in decreased shoulder function. Nonunion and malunion can lead to persistent pain during shoulder movement. Infection, wound dehiscence, scarring, seroma formation, or hematoma are all possible. Postoperative patient problems of numbness and hypesthesia along the incision site are rare. Occasionally, shoulder manipulation may be required to treat residual joint stiffness (about 10%).16 PEARLS AND PITFALLS Pearls 1. Take care to protect the suprascapular nerve and the circumflex scapular artery and be aware of their location. 2. Carefully dissect along the fracture line and gently retract in the vicinity of the suprascapular nerve and the circumflex scapular artery. 3. Place each plate along the scapular border where the bone is thickest. 4. In the case of a concomitant clavicle fracture, the clavicle should be fixed first. Pitfalls 1. Incorrect indications 2. Over-retraction of muscles surrounding the scapula
J Hand Surg Am.
1.e5
r
Vol. -, - 2017
Dorsal Plate Fixation of Scapular Fracture Takashi Noguchi, MD, PhD,* James F. Mautner, MD,† Scott F. M. Duncan, MD, MPH*
Scapular fractures are uncommon injuries. When they occur, they are usually treated nonsurgically. However, certain indications remain for operative intervention for the treatment of these injuries. In this article, we review some operative indications as well as the surgical technique. We present a case to demonstrate the indications and surgical technique of treatment. As with most surgical approaches, technique is critical to minimize morbidity and maximize functional outcome. Using these techniques, operative management of scapular fractures can be successful. (J Hand Surg Am. 2017;-(-):1.e1-e5. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Glenoid fracture, plate fixation, posterior approach, scapular fracture, suprascapular nerve.
S
CAPULAR FRACTURES ARE UNCOMMON, with an incidence of 0.5% to 1.0% of all fractures.1,2 High-energy trauma is the usual mechanism that leads to such fractures. Mortality in patients with scapular fractures is reported to range from 10% to 15% because they frequently have other concomitant injuries involving the pulmonary system, cervical spine, or cranial region.3e5 Most scapular fractures do not require operative treatment to achieve a satisfactory outcome.6,7 Scapular fractures frequently heal well without surgery because the scapula is encased by multiple muscles providing a rich vascular supply to the bone. However, Nordqvist and Petersson8 reported that the outcome of nonsurgical treatment showed reduced shoulder function from factors such as arthrosis, rotator cuff dysfunction, scapulothoracic dyskinesis, and impingement pain. Furthermore, it was reported that operative treatment
From the *Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA; and the †Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA. Received for publication February 7, 2017; accepted in revised form July 24, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Scott F. M. Duncan, MD, MPH, Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, 850 Harrison Avenue, Dowling 2 North, Boston, MA 02118; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.07.022
for scapular fractures demonstrated superior functional recovery and improved outcomes.9 More than 90% of scapular fractures involve the body and neck.10,11 Therefore, the posterior or dorsal surgical approach is more commonly used for this fracture pattern. We describe our strategy for treating scapular fractures to restore shoulder function. INDICATIONS Patients with scapular fractures occasionally experience polytrauma. The operative criteria are controversial. However, current treatment standards recommend at least one of the following for surgical intervention: 1. Intra-articular stepoff of the glenoid surface greater than 4 mm on computed tomography (CT) imaging 2. Fracture line crossing the scapular body, spine, and neck 3. Angular deformity greater than 40 on the scapular-Y view 4. Displacement or shortening greater than 20 mm on CT or anteroposterior radiograph 5. Glenopolar angle smaller than 10 on CT imaging 6. Floating shoulder (concomitant fracture of clavicle, acromion, or coronoid process with displacement greater than 10 mm or acromioclavicular dislocation)
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
DORSAL FIXATION OF SCAPULAR FRACTURE
CONTRADICTIONS Patients with polytrauma and unstable vital signs should have surgery postponed until they are medically stable: 1. Large bone or soft tissue defect in the shoulder girdle 2. Markedly comminuted fracture of the scapula 3. Concomitant traumatic brain injury or cervical spinal cord injury above C5 SURGICAL ANATOMY For optimal surgery, it is essential to have thorough knowledge of scapula anatomy. The scapula is divided into 3 major parts when viewed posteriorly: the spine with acromial process, glenoid, and body. The base of the scapula forms by membranous ossification. It is a thinner bone than are the other bones that form by cartilaginous ossification. However, the lateral and medial borders of the scapular body have a markedly thicker bone in which drilling and screw fixation are possible. There are several muscles originating from or inserting onto the scapula, covering the scapula entirely in muscle. These are the supraspinatus and infraspinatus muscles innervated by the suprascapular nerve, the deltoid and teres minor muscles innervated by the axillary nerve, and the subscapularis muscle innervated by the subscapular nerve.12 The scapula has a complex vascular network that contains the circumflex scapular artery along with the scapular and subscapular arteries located next to the suprascapular nerve. The suprascapular nerve wraps around the lateral base of the scapular spine, defined as the spinoglenoid notch from superior to inferior. After exiting the notch, the nerve divides into 3 branches and courses just underneath the infraspinatus muscle where the nerve ends. The potential location of the nerve spreads inferiorly and medially like a fan, with a radius of 40 mm around the scapular notch where it is reported to be the 4-7-8 triangle in the cadaver study by Wijdicks et al.13 Almost all scapular fractures involve the body and the neck. Because of this, there are 3 common radiographic classification systems for scapula fractures: AO/Orthopaedic Trauma Association,14 Goss,2 and Ada and Miller.11 Armitage et al15 focused on fracture patterns and traced various patterns of actual fractures of the scapular body and neck treated operatively using a CT mapping technique. Accordingly, 3 main patterns were codified as inferior glenoid neck, spinoglenoid notch, and glenoid articular surface, respectively. They demonstrated that 68% of J Hand Surg Am.
FIGURE 1: Illustration of incision line.
fractures involved an inferior aspect of the glenoid neck, and 71% of fractures traversed the scapular body inferior to the medial extent of the scapular spine. Furthermore, 17% of fractures had an articular fragment and 22% were cracked beyond the spinoglenoid notch. SURGICAL TECHNIQUE Surgery is performed under general anesthesia. The patient is positioned laterally with a slight lean anteriorly. This position allows easy manipulation of the arm during surgery. It is important to make sure that there is enough space to move an image intensifier in and out. A modified Judet approach is recommended to expose the scapular fracture, place hardware adequately, and minimize morbidity and maximize function.16 The incision line is placed as an L shape ascending from the inferior angle of the scapula to the base of the lateral scapular spine through the medial edge of the scapular spine along the medial border of the scapula body and the ridge of the scapular spine (Fig. 1). A fasciocutaneous flap is raised laterally along the incision line. Consequently, the posterior part of the deltoid muscle is exposed. It is incised sharply from the scapular spine and then bluntly dissected from the infraspinatus muscle moving laterally until reaching the lateral border of the scapula. The infraspinatus muscle is detached from its origin and raised toward the lateral side off the scapular surface. This is done to avoid suprascapular r
Vol. -, - 2017
DORSAL FIXATION OF SCAPULAR FRACTURE
1.e3
FIGURE 2: Fracture lines are present on the scapular body, glenoid, and glenoid neck. Three-dimensional CT shows 7-mm glenoid displacement. Inferior scapular body fragment was displaced 14 mm. A Posterior view; B glenoid view.
other long bones. When performing plate fixation, the initial fixation should be performed laterally first, with medial fixation performed last. An essential point of focus is avoiding unnecessary dissection between the subscapularis muscle and the scapula. This is crucial because the subscapularis supplies blood flow into the scapular bone in addition to the vascular circuit created by the circumflex scapular artery and suprascapular artery. In wound closure, the infraspinatus should be sutured to the rhomboid fascia, and the deltoid should be sutured directly to the scapular spine. The subcutaneous tissue should be closed firmly to relieve tension on the skin, thus minimizing hypertrophic scar formation. A drain tube is inserted underneath the subcutaneous layer and removed within 48 hours after the procedure.
nerve injury while being attentive to the vulnerable area described previously. It is unnecessary to expose the neurovascular bundle. When adequate exposure of the scapula is achieved, the flap and muscles are retracted with suitable instruments; however, the surgeon must be careful not to place excess retraction on the soft tissue flap that contains the neurovascular bundle, or rotator cuff dysfunction may result. While elevating the infraspinatus, the ascending branch of the circumflex scapular artery is exposed in the surgical site. The artery is cauterized as necessary. To reduce fracture fragments, Schantz pins (Synthes, Paoli, PA) and small external fixators can be used. Moreover, reduction of an extra-articular glenoid neck fragment connecting to the articular surface can result indirectly in the reduction of glenoid congruity without intra-articular exposure. Provisional fixation is implemented with instruments such as wires and clamps; then it is followed by definitive plate fixation. If the glenoid fragment is small and isolated from the extra-articular fragment, an approach between the teres minor and the infraspinatus muscle may be required to reduce and repair the fragment.17 Multiple screws or pins may be required to repair the fragment successfully. Anatomically designed locking plates for the scapula are helpful. In some cases, a combination of anatomically designed locking plates, reconplates, and plates designed for other types of fractures are used to achieve stable fixation. Furthermore, support with double plates and multiple screws may be necessary because the scapula is much thinner than J Hand Surg Am.
Postoperative care The upper arm and shoulder are immobilized using a sling for 3 weeks after surgery. However, the fingers, wrist, and elbow should not be immobilized and should be moved as soon as pain subsides. Passive motion of the shoulder can be allowed 2 weeks after the operation and continued for 6 weeks. Active range of motion and strengthening exercises may begin 6 weeks after surgery. Normal daily use of the affected shoulder is encouraged at least 8 weeks later. Three months after the procedure, patients may resume regular work and activities. The discontinuation of physical therapy depends on pain resolution, range of motion, and the strength of the shoulder. r
Vol. -, - 2017
1.e4
DORSAL FIXATION OF SCAPULAR FRACTURE
FIGURE 3: Intraoperative photos. A The deltoid muscle and infraspinatus muscle containing the suprascapular neurovascular bundle are elevated laterally. Scapular body and glenoid neck are exposed without exposure of the glenoid articular surface. A Schantz pin was inserted into glenoid neck fragment. B Double anatomic locking plates are placed properly to fix the fragments. L, lateral; M, medial; P, pin; S, superior.
FIGURE 4: Postoperative radiograph (4 months). Fixation is maintained. No reduction loss or screw loosening is seen in either view. A Anteroposterior view; B lateral view.
CASE PRESENTATION A 63-year-old, right hand-dominant man was injured in a motorcycle accident and brought to the emergency unit. He had a right scapular fracture and no other injuries except for minor abrasions. Radiographs and CT scans showed displaced scapular fragments with an unacceptable glenoid stepoff connecting to a glenoid J Hand Surg Am.
neck fragment and a displaced scapular body fragment (AO/OTA 14-C3) (Fig. 2). Seven days after the injury, he underwent surgery for the scapular fractures. Using a modified Judet approach in the left lateral position under general anesthesia, the deltoid with its fascia was elevated laterally. Next, the infrasupinatus muscle was carefully
r
Vol. -, - 2017
DORSAL FIXATION OF SCAPULAR FRACTURE
elevated laterally from the origin off the medial edge of the scapula. The fracture sites were fully exposed with adequate retraction (Fig. 3A). There were 2 large fracture lines on the body of the scapula as well as the base of the scapular spine and neck. They were reduced using the Schantz pin and clamps followed by insertion of 2 anatomical plates (Acumed, Beaverton, OR) (Fig. 3B). The infraspinatus and deltoid muscles were carefully repaired and closed layer on layer with a drain inserted subcutaneously. Postoperative therapy began the following day. No postsurgical complications occurred. Four months later, the fractures were healing radiographically (Fig. 4) and there was no loss of the screw or plate fixation. The patient was able to return to work without pain. He had regained full range of shoulder motion by that time.
3. Intraoperative iatrogenic fracture 4. Inappropriate placement of the plates (too medial or central) 5. Insertion of screws with excessive length, which can interrupt shoulder movement and injure structures adjacent to the scapula REFERENCES 1. Collins J. Chest wall trauma. J Thorac Imaging. 2000;(15): 112e119. 2. Goss TP. Scapular fractures and dislocations: diagnosis and treatment. J Am Acad Orthop Surg. 1995;(3):22e33. 3. Armstrong CP, Van der Spuy J. The fractured scapula: importance and management based on a series of 62 patients. Injury. 1984;(15): 324e329. 4. Stephens NG, Morgan AS, Corvo P, Bernstein BA. Significance of scapular fracture in the blunt-trauma patient. Ann Emerg Med. 1995;(26):439e442. 5. Thompson DA, Flynn TC, Miller PW, Fischer RP. The significance of scapular fractures. J Trauma. 1985;(25):974e977. 6. Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006;(20):230e233. 7. Gosens T, Speigner B, Minekus J. Fracture of the scapular body: functional outcome after conservative treatment. J Shoulder Elbow Surg. 2009;(18):443e448. 8. 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):139e144. 9. Cole PA, Talbot M, Schroder LK, Anavian J. Extra-articular malunions of the scapula: a comparison of functional outcome before and after reconstruction. J Orthop Trauma. 2011;(25): 649e656. 10. McGahan JP, Rab GT, Dublin A. Fractures of the scapula. J Trauma. 1980;(20):880e883. 11. Ada JR, Miller. ME Scapular fractures: analysis of 113 cases. Clin Orthop Relat Res. 1991;(269):174e180. 12. Cole PA, Dubin JR, Freeman G. Operative techniques in the management of scapular fractures. Orthop Clin North Am. 2013;(44): 331e343, viii. 13. Wijdicks CA, Armitage BM, Anavian J, Schroder LK, Cole PA. Vulnerable neurovasculature with a posterior approach to the scapula. Clin Orthop Relat Res. 2009;(467):2011e2017. 14. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendiume2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;(21):S1eS133. 15. Armitage BM, Wijdicks CA, Tarkin IS, et al. Mapping of scapular fractures with three-dimensional computed tomography. J Bone Joint Surg Am. 2009;(91):2222e2228. 16. Jones CB, Cornelius JP, Sietsema DL, Ringler JR, Endres TJ. Modified Judet approach and minifragment fixation of scapular body and glenoid neck fractures. J Orthop Trauma. 2009;(23): 558e564. 17. Gauger EM, Cole PA. Surgical technique: a minimally invasive approach to scapula neck and body fractures. Clin Orthop Relat Res. 2011;(469):3390e3399.
COMPLICATIONS Complications related to surgery using the modified Judet approach are rare. Suprascapular nerve injury can result in decreased shoulder function. Nonunion and malunion can lead to persistent pain during shoulder movement. Infection, wound dehiscence, scarring, seroma formation, or hematoma are all possible. Postoperative patient problems of numbness and hypesthesia along the incision site are rare. Occasionally, shoulder manipulation may be required to treat residual joint stiffness (about 10%).16 PEARLS AND PITFALLS Pearls 1. Take care to protect the suprascapular nerve and the circumflex scapular artery and be aware of their location. 2. Carefully dissect along the fracture line and gently retract in the vicinity of the suprascapular nerve and the circumflex scapular artery. 3. Place each plate along the scapular border where the bone is thickest. 4. In the case of a concomitant clavicle fracture, the clavicle should be fixed first. Pitfalls 1. Incorrect indications 2. Over-retraction of muscles surrounding the scapula
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