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.

12. 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 /

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

14. 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%.

15. 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.

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

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

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

19. OTA/AO classification.

20. Glenoid – Ideberg classification.

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

22. Acromion # 14 A1- kuhn
classification.

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

24. 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.

25.  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.

26. 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

27. 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.

28. Anterior approach

29. Superior approach

30. Judet approach

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

32. Modified Judet approach

35. 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

36. Minimal incision posterior approach

37. AO preferred
approach

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

39. Wirth’s posterior deltoid split
approach.

40. Ebraheim’s reverse Judet skin
incision appraoch.

41. 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.

42. 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.

43. Recent literature on scapula fracture
management…..

44. 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.

45.  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.

46. PRESENTATION IS THE BEST WAY TO
improve KNOWLEDGE.