Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

379. Open Reduction and Internal Fixation of Intra-articular Scapular Fractures

Brett D. Owens, Joanna G. Branstetter, and Thomas P. Goss

DEFINITION

images Intra-articular scapular fractures include fractures of the glenoid cavity, which includes the glenoid rim and the glenoid fossa. They account for 10% of scapular fractures.6 Most scapular fractures are extra-articular, and 50% involve the body and spine.

images Over 90% of fractures of the glenoid cavity are insignificantly displaced and are managed nonoperatively.3

images Significant displacement requires evaluation for surgical intervention to achieve the best possible outcome.

ANATOMY

images The scapula is a flat triangular bone with three processes: the glenoid process, the acromial process, and the coracoid process.

images The glenoid process consists of the glenoid cavity (the glenoid rim and glenoid fossa) and the glenoid neck.

images The glenoid cavity provides a firm concave surface with which the convex humeral head articulates. The average depth of the articular cartilage is 5 mm.

images Glenoid cavity fractures are classified according to whether they involve the glenoid rim or the glenoid fossa and the direction of the fracture line (FIG 1).

PATHOGENESIS

images Scapular fractures usually are the result of high-energy trauma and have a high rate (90%) of associated bony and soft tissue injuries, both local and distant.5

images Fractures of the glenoid rim occur when the humeral head strikes the periphery of the glenoid cavity. They are true fractures, not avulsion injuries caused by indirect forces applied to the periarticular soft tissues by the humeral head.

images Fractures of the glenoid fossa occur when the humeral head is driven into the center of the concavity. The fracture then promulgates in a number of different directions, depending on the characteristics of the humeral head force.

NATURAL HISTORY

images The results of nonoperative treatment of intra-articular scapular fractures usually are good if the fracture displacement is minimal and the humeral head lies concentrically within the glenoid cavity.

images Significant displacement can result in posttraumatic degenerative joint disease, glenohumeral instability, and even nonunion.2

PATIENT HISTORY AND PHYSICAL FINDINGS

images In addition to the specifics of the injury, it is helpful to obtain an understanding of the functional demands on the extremity. Hand dominance, occupation, and sports participation are all relevant.

images A thorough neurovascular examination must be performed. Deficits are evaluated with angiography and electromyography, as necessary.

images A thorough soft tissue examination also is warranted. Wounds may represent an open fracture and warrant exploration. Blisters or swelling may delay surgery.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Intra-articular scapular fractures initially are evaluated with a routine scapula trauma radiographic series (a true anteroposterior view of the shoulder with the arm in neutral rotation, a true axillary view of the glenohumeral joint, and a true lateral scapular view; FIG 2A).

images CT scans and three-dimensional studies with reconstructions can be helpful in evaluating articular congruity and fracture displacement (FIG 2BD). In addition, the bony relationships should be evaluated for evidence of ligamentous disruption(s) or instability.

DIFFERENTIAL DIAGNOSIS

images Intra-articular scapular fractures

images Nonarticular scapular fractures

images Scapulothoracic dissociation

images Double disruptions of the superior shoulder suspensory complex, including a floating shoulder (a glenoid neck fracture with an ipsilateral middle third clavicle fracture)

NONOPERATIVE MANAGEMENT

images Most (over 90%) intra-articular scapular fractures are insignificantly displaced and are managed nonoperatively.

images Significantly displaced glenoid fossa and glenoid rim fractures require operative management.

SURGICAL MANAGEMENT

images Surgical indications are as follows:

images Rim fractures: 25% or more of the glenoid cavity anteriorly or 33% or more of the glenoid cavity posteriorly and displacement of the fragment 10 mm or more

images Fossa fractures: an articular step-off of 5 mm or more, significant separation of the fracture fragments, or failure of the humeral head to lie in the center of the glenoid cavity

Preoperative Planning

images Imaging studies should be reviewed before the surgery and should be available for reference in the operating room. A draped fluoroscopy unit and a competent technician should be available. An examination for instability can be performed while under anesthesia.

Positioning

images Open reduction with internal fixation (ORIF) of intraarticular scapular fractures requires wide access to the entire shoulder girdle. Depending on the particular fracture, the patient is placed in either the lateral decubitus position (FIG 3A) or the beach chair position (FIG 3B).

images

FIG 1  Goss-Ideberg classification of glenoid cavity fractures. Ia, anterior rim; Ib, posterior rim; II, inferior glenoid; III, superior glenoid; IV, transverse through the body; V; combination II-IV; VI, comminuted.

images

images

FIG 2  A. The AP radiograph shows a type Vc glenoid cavity fracture. B. Axillary CT image shows a large anterosuperior glenoid cavity fragment including the coracoid process. C. Axillary CT image shows the lateral aspect of the scapular body lying between the two glenoid cavity fragments and abutting the humeral head. D. Axillary CT image shows a large posteroinferior cavity fragment. (From Goss TP, Owens BD. Fractures of the scapula: Diagnosis and treatment. In: Iannotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007:793–840.)

images

FIG 3  Patient position: lateral decubitus (A) and beach chair (B).

images Care must be taken to allow adequate exposure of the entire scapula and clavicle. The shoulder girdle is prepped and draped widely, and the entire upper extremity is prepped and draped “free.”

images In some cases, a staged procedure may be necessary using separate positions, sterile preparations, and exposures.10

Approach

images The posterior approach is used for fractures of the posterior glenoid rim and most fractures of the glenoid fossa.

images The superior approach is used, in conjunction with a posterior approach, for fractures of the glenoid fossa with a difficultto-control superior fragment.

images The anterior approach is used for fractures of the anterior glenoid rim and some fractures involving the superior aspect of the glenoid fossa.

TECHNIQUES

POSTERIOR APPROACH TO THE GLENOID CAVITY

images  Bony landmarks are outlined with a marking pen.

images  An incision is made along the scapular spine and acromion and down the midlateral aspect of the shoulder, as needed (TECH FIG 1A).

images  Origins of the posterior and middle heads of the deltoid muscle are sharply detached from the scapular spine– acromial process, and the deltoid muscle is split in the line of its fibers for 2.5 cm in the midlateral line. It is then retracted distally (TECH FIG 1B).

images  The interval between infraspinatus and teres minor is developed (TECH FIG 1C). To gain access to the glenoid fossa, the infraspinatus tendon and underlying posterior glenohumeral joint capsule are incised 2 cm lateral to their insertion on the greater tuberosity and reflected posteriorly (TECH FIG 1D).

images  Subperiosteal mobilization of the teres minor muscle allows access to the lateral scapular border.

images

TECH FIG 1  A. Posterior approach using a skin incision along the scapular spine and acromion. B. The posterior and posteromedial heads of the deltoid are detached from the scapular spine and acromial process. C.Interval developed between the infraspinatus and teres minor. D. The infraspinatus tendon and underlying posterior glenohumeral capsule are incised 2 cm from insertion on the greater tuberosity to allow access to the glenohumeral joint. (From Goss TP. Glenoid fractures: open reduction and internal fixation. In Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia: Lippincott–Raven, 1998.)

SUPERIOR APPROACH TO THE GLENOID CAVITY

images  The superior approach to the glenoid cavity is made by extending the posterior incision superiorly.

images  The trapezius and underlying supraspinatus muscles are split in the line of their fibers (TECH FIG 2).

images

TECH FIG 2  Superior approach. The trapezius and underlying supraspinatus muscles are split in line with their fibers. (From Goss TP. Glenoid fractures: open reduction and internal fixation. In Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia: Lippincott–Raven, 1998.)

ANTERIOR APPROACH TO THE GLENOID CAVITY

images  The incision is made in Langer’s lines and centered over the glenohumeral joint from the superior to inferior level of the humeral head (TECH FIG 3A).

images  The deltoid muscle is split in the line of its fibers over the palpable coracoid process and retracted medially and laterally.

images  The conjoined tendon is retracted medially after division of the overlying fascia along its medial border (TECH FIG 3B).

images  Care must be taken to protect all neurovascular structures from injury.

images  Incise the subscapularis tendon vertically 2.5 cm medial to its insertion on the lesser tuberosity and along its superior and inferior borders.

images Dissect it off the underlying anterior glenohumeral capsule.

images  Tag the corners of the subscapularis unit and turn it back medially (TECH FIG 3C).

images  Incise the anterior glenohumeral capsule in the same fashion, tag its corners, and turn it back medially to gain access to the glenohumeral joint.

images

TECH FIG 3  A. Anterior approach using a skin incision made in Langer’s lines and centered over the glenohumeral joint. B. The conjoined tendon is retracted medially. C. Incise the subscapularis tendon 2 cm from its insertion on the lesser tuberosity, dissect it off the glenohumeral capsule, incise the capsule similarly, and turn both of them back medially to gain access to the glenohumeral joint. (From Goss TP. Open reduction and internal fixation of glenoid fractures. In: Craig EV, ed. Master Techniques in Orthopaedic Surgery: The Shoulder, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2004.)

FIXATION TECHNIQUES

images  The fracture is reduced as anatomically as possible.

images  Temporary fixation may be obtained with K-wires.

images  Rigid fixation may be obtained with a contoured reconstruction plate and 3.5-mm cortical screws or with cannulated interfragmentary compression screws, depending on the characteristics of the fracture.

images  Care must be taken to avoid violating the glenoid fossa with any screws placed in the glenoid fragment (TECH FIG 4A,B).

images  If severe comminution is present, an iliac crest tricortical bone graft is an option (TECH FIG 4C).

images  All soft tissues divided to gain access to the fracture site must be meticulously repaired. With posterior approaches, the deltoid must be securely reattached to the acromion and scapular spine with permanent sutures through drill holes.

images

images

TECH FIG 4  A. Postoperative AP image of the patient shown in Tech Fig 1. B. Axillary radiograph showing the glenoid cavity fragments secured together with cannulated screws and the glenoid unit secured to the scapular body with a malleable reconstruction plate (the acromial fracture was reduced and stabilized with a tension band construct). C. If severe comminution is present, an iliac crest tricortical bone graft is an option. (A,B: From Goss TP, Owens BD. Fractures of the scapula: diagnosis and treatment. In: Iannotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007:793–840.)

PEARLS AND PITFALLS

images

POSTOPERATIVE CARE

images The aggressiveness of the rehabilitation program following ORIF of intra-articular scapular fractures is determined by the rigidity of the fixation construct and the adequacy of the soft tissue repair.4

images Patients are immobilized in a sling and swathe binder and started on gentle pendulum exercises during the first 2 weeks.

images Progressive passive and active-assisted range-of-motion exercises emphasizing forward flexion and internal–external rotation are prescribed during weeks 2 through 6 postoperatively.

images All protection is discontinued at 6 weeks postoperatively.

images Strengthening is begun after 6 weeks postoperatively and when range of motion is satisfactory.

images Return to sports or physical labor is restricted until 3 to 6 months postoperatively.

images Close outpatient follow-up with radiographs, especially early in recovery, and a well-defined, closely monitored physical therapy program are extremely important.

OUTCOMES

images Good results have been reported for the operative management of glenoid rim fractures.9,12

images Bauer et al1 reviewed six patients treated surgically for glenoid cavity fractures. Four patients with an anatomic reduction had good results; two patients with nonanatomic reductions developed arthritic changes.

images Kavanaugh and colleagues7 presented their experience at the Mayo Clinic in which 10 displaced intra-articular fractures of the glenoid cavity were treated with ORIF. They found ORIF to be “a useful and safe technique” that “can restore excellent function of the shoulder.” In their series, the major articular fragments were displaced 4 to 8 mm.

images Schandelmaier and coauthors11 reported a series of 22 fractures of the glenoid fossa treated with ORIF with good results.

images Leung and colleagues8 reviewed 14 displaced intra-articular fractures of the glenoid treated with ORIF (30.5-year average follow-up) and reported 9 excellent and 5 good results.

images On the basis of these reports, it seems reasonable to conclude that there is a definite role for surgical management in the treatment of glenoid cavity fractures.

COMPLICATIONS

images Neurologic complications most commonly are caused by overly aggressive retraction or misdirected dissection.

images The musculocutaneous and axillary nerves are vulnerable in the anterior approach.

images The suprascapular nerve is at risk in the superior approach, and the axillary and suprascapular nerves are vulnerable in the posterior approach.10

images A variety of other complications can occur as a result of poor surgical technique, inadequately directed or managed rehabilitation, and poor patient compliance.

REFERENCES

· 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;14:215.

· DePalma AF. Surgery of the Shoulder, 3rd ed. Philadelphia: JB Lippincott, 1983.

· Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg Am 1992; 74:299–305.

· Goss TP. Glenoid fractures—open reduction and internal fixation. In Wiss DA, ed: Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia: Lippincott-Raven, 1998.

· Goss TP. Scapular fractures and dislocation: diagnosis and treatment. J Am Acad Orthop Surg 1995;25:106.

· Goss TP, Owens BD. Fractures of the scapula: Diagnosis and treatment. In: Iannotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007:793–840.

· Kavanagh BF, Bradway JK, Cofield RH. Open reduction of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75A:479.

· Leung KS, Lam TB, Poon KM. Operative treatment of displaced intra-articular glenoid fractures. Injury 1993;24:324.

· Niggebrugge AHP, van Heusden HA, Bode PJ, van Vugt AB. Dislocated intra-articular fracture of the anterior rim of glenoid treated by open reduction and internal fixation. Injury 1993;24:130.

· Owens BD, Goss TP. Surgical approaches for glenoid fractures. Tech Shoulder Elbow Surg 2004;5:103–115.

· Schandelmaier P, Blauth M, Schneider C, Krethek C. Fractures of the glenoid treated by operation. A 5to 23-year follow-up of 22 cases. J Bone Joint Surg Br 2002;84B:173–177.

· Sinha J, Miller AJ. Fixation of fractures of the glenoid rim. Injury 1992;23:418.



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