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Fractures of the glenoid
J. Shoulder Elbow Surg. Volume 5, Number 2, Part 2
142
143
FRACTURES OF THE GLENOID CAVITY, T.P. GOSS, M.D. DEPARTMENT OF ORTHOPEDICS, UNIVERSITY OF MASS MEDICAL CTR. WORCESTER, MASSACHUSETTS The purpose of this paper is to understand and to classify fractures of the glenoid cavity as well as to provide a guide to evaluation and treatment. Glenoid fractures are uncommon (i/i000 fractures) and significantly displaced glenoid fractures are rare (i/i0,000 fractures). Consequently, they have received little attention in the literature. They are, however, intraarticular injuries involving a major joint and can lead to considerable morbidity (instability and degenerative disease). Therefore, they deserve more consideration than they have received in the past and should be accorded appropriate respect and effort. The paper will present basic information regarding fractures of the scapula in general and list situations in which operative intervention is a consideration. The entire literature with respect to fractures of the glenoid cavity will be reviewed. A comprehensive classification scheme is proposed which includes two "rim" (anterior and posterior), and five "fossa" fractures (minimally displaced, significantly displaced, and comminuted varieties). The various mechanisms of injury will be described and the reasons why most fossa fractures begin as a transverse disruption will be discussed. The diagnostic evaluation is detailed and a logical therapeutic approach is offered for each fracture type. ~rom a surgical standpoint, operative indications will be proposed and surgical approaches (anterior, posterior, and superior) will be described. Areas of adequate scapula bone stock and available fixation techniques will be shown. Finally, follow-up care and rehabilitation will be described.
ARTHROSCOPICALLY ASSISTED REDUCTION AND FIXATION OF DISPLACED INTRA-ARTICULAR FRACTURES OF THE GLENOID FOSSA. P.R. Lozman, M.D., K.S. Hechtman, M.D., E.W. Tjin-A-Tsoi, M.D., L.A. Vargas, M.D., J.W. Uribe, M.D., Division
of Sports Medicine, Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, Miami, FL Significant intra-articularfractures of the glenoid are rare injuries comprising approximately five percent of fractures of the shoulder girdle and less than one percent of all fractures. The indication for open reduction and intemal fixation of intra-articular glenoid fractures is limited and includes fractures involving one fourth of the glenoid fossa that are associated with shoulder instability. Traditional methods of fixation for displaced intra-ar~icular fractures of the glenoid fossa include open reduction and internal fixation through a posterior operative approach. In this paper we describe the technique of anhmscopic management of displaced intra-articular fractures of the glenoid fossa and report the results of three patients that were treated with arthmscopicallyassisted reduction and internal fixation. All patients were available for evaluation at an average of thirty months after operation. None of the patients had significant symptoms at the time of follow-up, and all patients had a full range of motion and strength. There were no complications. At the time of follow-up all fractures appeared well reduced on radiographs without evidence of post-traumatic arthritis. Arthroscopic reduction and internal fixation is a safe and effective method of treating displaced intra-articularfractures of the glenoid fossa.
Abstracts
144
145
$51
A NEW CLASSIFICATION FOP, SCAPULAP, NECK FRACTURES DEPENDING ON THE GLENOPOLAR ANGLE. J. Romero, P. Schai, & A.B. ]mhoff, Dep. of Orthop. Surg., Univ. of Zurich, Switzerland Scapular neck fractures are considered to he unstable, if an ipsilaleral clavicular fracture or ac-joint dislocation is associated. However, we saw in our series severe dislocations of the glenoidal fragment without a disruption of the shoulder girdle. Therefore, we conducted a retrospective study to analyze the impact of a shoulder girdle injury on the degree of dislocation using the glenopolar angle (GPA) and the value of the GPA in prediciting the clinical outcome. 19 patients, who sustained a scapular neck fracture at a mean age of 42 years (21-61 ys.) were assigned into two groups according to their GPA a mean of 6 years (0.5-23.0 ys.) after the injury. The GPA is the angle between the craniocaudal diameter of the glenoidal cavity and a line drawn from the upper end of the glenoidal cavity to the lower tip of the scapular body (range 30~ We considered a GPA <20* (group II) as a severe displacement of the glenoidal fragment. Associated shoulder girdle injuries were found in two patients from group I and in 3 patients from group I1.7 patients complained of persistend pain at follow-up. 5 of them had a GPA <20% Among the 5 patients who had severe disability for activities of daily living (ADL), 4 had a GPA <20 ~ Only 2 patients had a severe impaired range of motion. Both had a GPA <20 ~ The data for pain and ADL were statistically significant (Fisher's exact). A non-union or shoulder instability did not occurr. One patient developed mild osteoarthritis. Our data suggest that a severe glenoidal fragment displacement (GPA <20 ~ is responsible for an unfavorable outcome. A scapular neck fracture without associated shoulder girdle injury may in our new classification only be considered stable with a GPA >20 ~ (type la), but becomes unstable with an associated shoulder girdle injury (Ib). The glenoidal fragment is always unstable with a GPA <20 ~ regardless of an associated shoulder girdle injury (type Ila without; type lib with).
INTERNAL FIXATION OF UNUN1TED OS ACROMIALE. Sonnabend, DH and Hughes, J.S. Sydney Shoulder & Elbow Association, Sydney, 2031, Australia. Ununited os acromiale is recognised as a cause of subacromial impingement. Some doubt has existed regarding the role of fixation of the os as opposed to decompression without fixation in the treatment of impingement. Twenty-two patients underwent O.R.I.F. of ununited os acromiale and coraco-acromial ligament excision. Ten underwent simultaneous repair of rotator cuff tears, whilst 5 had irreparable tears. Fixation techniques included malleolar screws with tension band wire or suture (16), 2 K-wires with tension band wire (3) and one screw and one wire with tension band suture (3). Removal of fixation was required in 6 patients (2/16 patients had screws removed, 4/6 patients had K-wires or tension band wires removed). All 6 of those patients obtained relief of their residual symptoms with removal of their fixation. Time to bony union was variable (6 weeks to 6 months, average four months). One patient had ongoing pain of unknown cause. Another patient who suffered an acromial fracture gained partial pain relief. Satisfactory results with good relief of pain were achieved in 20 patients (91%).Complications included 2 fractures of the os. The segment involved was lateral to the most lateral wire or screw. The use of 2 A t malleolar screws and a tension band wire or suture was the technique of choice. Division of the coraco-acromial ligament allows elevation of the os and adequate decompression. Retention of the acromio-clavicular capsule and lateral clavicle up.pears to aid stability when internally fixing the os. The use of Kwxres is not recommended, because of the incidence of wire loosening, requiring subsequent removal. The authors believe that O.R.I.F. of a sizeable os acromiale, together with corano-acromial ligament excision, is preferabIe to ligament excision and debulking of the os acromiale.
142
143
FRACTURES OF THE GLENOID CAVITY, T.P. GOSS, M.D. DEPARTMENT OF ORTHOPEDICS, UNIVERSITY OF MASS MEDICAL CTR. WORCESTER, MASSACHUSETTS The purpose of this paper is to understand and to classify fractures of the glenoid cavity as well as to provide a guide to evaluation and treatment. Glenoid fractures are uncommon (i/i000 fractures) and significantly displaced glenoid fractures are rare (i/i0,000 fractures). Consequently, they have received little attention in the literature. They are, however, intraarticular injuries involving a major joint and can lead to considerable morbidity (instability and degenerative disease). Therefore, they deserve more consideration than they have received in the past and should be accorded appropriate respect and effort. The paper will present basic information regarding fractures of the scapula in general and list situations in which operative intervention is a consideration. The entire literature with respect to fractures of the glenoid cavity will be reviewed. A comprehensive classification scheme is proposed which includes two "rim" (anterior and posterior), and five "fossa" fractures (minimally displaced, significantly displaced, and comminuted varieties). The various mechanisms of injury will be described and the reasons why most fossa fractures begin as a transverse disruption will be discussed. The diagnostic evaluation is detailed and a logical therapeutic approach is offered for each fracture type. ~rom a surgical standpoint, operative indications will be proposed and surgical approaches (anterior, posterior, and superior) will be described. Areas of adequate scapula bone stock and available fixation techniques will be shown. Finally, follow-up care and rehabilitation will be described.
ARTHROSCOPICALLY ASSISTED REDUCTION AND FIXATION OF DISPLACED INTRA-ARTICULAR FRACTURES OF THE GLENOID FOSSA. P.R. Lozman, M.D., K.S. Hechtman, M.D., E.W. Tjin-A-Tsoi, M.D., L.A. Vargas, M.D., J.W. Uribe, M.D., Division
of Sports Medicine, Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, Miami, FL Significant intra-articularfractures of the glenoid are rare injuries comprising approximately five percent of fractures of the shoulder girdle and less than one percent of all fractures. The indication for open reduction and intemal fixation of intra-articular glenoid fractures is limited and includes fractures involving one fourth of the glenoid fossa that are associated with shoulder instability. Traditional methods of fixation for displaced intra-ar~icular fractures of the glenoid fossa include open reduction and internal fixation through a posterior operative approach. In this paper we describe the technique of anhmscopic management of displaced intra-articular fractures of the glenoid fossa and report the results of three patients that were treated with arthmscopicallyassisted reduction and internal fixation. All patients were available for evaluation at an average of thirty months after operation. None of the patients had significant symptoms at the time of follow-up, and all patients had a full range of motion and strength. There were no complications. At the time of follow-up all fractures appeared well reduced on radiographs without evidence of post-traumatic arthritis. Arthroscopic reduction and internal fixation is a safe and effective method of treating displaced intra-articularfractures of the glenoid fossa.
Abstracts
144
145
$51
A NEW CLASSIFICATION FOP, SCAPULAP, NECK FRACTURES DEPENDING ON THE GLENOPOLAR ANGLE. J. Romero, P. Schai, & A.B. ]mhoff, Dep. of Orthop. Surg., Univ. of Zurich, Switzerland Scapular neck fractures are considered to he unstable, if an ipsilaleral clavicular fracture or ac-joint dislocation is associated. However, we saw in our series severe dislocations of the glenoidal fragment without a disruption of the shoulder girdle. Therefore, we conducted a retrospective study to analyze the impact of a shoulder girdle injury on the degree of dislocation using the glenopolar angle (GPA) and the value of the GPA in prediciting the clinical outcome. 19 patients, who sustained a scapular neck fracture at a mean age of 42 years (21-61 ys.) were assigned into two groups according to their GPA a mean of 6 years (0.5-23.0 ys.) after the injury. The GPA is the angle between the craniocaudal diameter of the glenoidal cavity and a line drawn from the upper end of the glenoidal cavity to the lower tip of the scapular body (range 30~ We considered a GPA <20* (group II) as a severe displacement of the glenoidal fragment. Associated shoulder girdle injuries were found in two patients from group I and in 3 patients from group I1.7 patients complained of persistend pain at follow-up. 5 of them had a GPA <20% Among the 5 patients who had severe disability for activities of daily living (ADL), 4 had a GPA <20 ~ Only 2 patients had a severe impaired range of motion. Both had a GPA <20 ~ The data for pain and ADL were statistically significant (Fisher's exact). A non-union or shoulder instability did not occurr. One patient developed mild osteoarthritis. Our data suggest that a severe glenoidal fragment displacement (GPA <20 ~ is responsible for an unfavorable outcome. A scapular neck fracture without associated shoulder girdle injury may in our new classification only be considered stable with a GPA >20 ~ (type la), but becomes unstable with an associated shoulder girdle injury (Ib). The glenoidal fragment is always unstable with a GPA <20 ~ regardless of an associated shoulder girdle injury (type Ila without; type lib with).
INTERNAL FIXATION OF UNUN1TED OS ACROMIALE. Sonnabend, DH and Hughes, J.S. Sydney Shoulder & Elbow Association, Sydney, 2031, Australia. Ununited os acromiale is recognised as a cause of subacromial impingement. Some doubt has existed regarding the role of fixation of the os as opposed to decompression without fixation in the treatment of impingement. Twenty-two patients underwent O.R.I.F. of ununited os acromiale and coraco-acromial ligament excision. Ten underwent simultaneous repair of rotator cuff tears, whilst 5 had irreparable tears. Fixation techniques included malleolar screws with tension band wire or suture (16), 2 K-wires with tension band wire (3) and one screw and one wire with tension band suture (3). Removal of fixation was required in 6 patients (2/16 patients had screws removed, 4/6 patients had K-wires or tension band wires removed). All 6 of those patients obtained relief of their residual symptoms with removal of their fixation. Time to bony union was variable (6 weeks to 6 months, average four months). One patient had ongoing pain of unknown cause. Another patient who suffered an acromial fracture gained partial pain relief. Satisfactory results with good relief of pain were achieved in 20 patients (91%).Complications included 2 fractures of the os. The segment involved was lateral to the most lateral wire or screw. The use of 2 A t malleolar screws and a tension band wire or suture was the technique of choice. Division of the coraco-acromial ligament allows elevation of the os and adequate decompression. Retention of the acromio-clavicular capsule and lateral clavicle up.pears to aid stability when internally fixing the os. The use of Kwxres is not recommended, because of the incidence of wire loosening, requiring subsequent removal. The authors believe that O.R.I.F. of a sizeable os acromiale, together with corano-acromial ligament excision, is preferabIe to ligament excision and debulking of the os acromiale.