Shoulder and Elbow

Treating Glenoid Fractures

The Problem

Previously, scapula fractures were thought to be a rare condition but recent epidemiologic studies indicate that they occur with approximately the same frequency as calcaneus and distal femur fractures. There has been a widespread belief that all scapula fractures healed and eventually had good outcomes. Recently published research and educational material has made clinicians more aware of the importance of scapula fractures, and specifically the dysfunction which results from malunion. In fact, there is a significant subset of patients who should be considered for surgery.

However, scapula fractures are challenging injuries to treat particularly in the light of the lack of training and education regarding surgical approaches and techniques for fixation. Resources are beginning to emerge for addressing this very issue and hopefully some of the pearls and techniques described in this essay will be useful to that end.

Clinical Presentation

Glenoid fractures typically result from blunt trauma with a force transmitted to the lateral or superior shoulder girdle. These fractures often occur in young adults involved in motor vehicle accidents or other crush injuries to the shoulder. Operative high energy scapula fractures occur with other associated injuries in approximately 80-90%of cases based on published surgical series. This means that the diagnostic workup must include a rigorous exam of the entire body. Specifically, it is estimated that 15% of patients have cervical spine injuries, 15% traumatic brain injuries, 50% ipsilateral upper extremity injuries, and approximately 10-15% have brachial plexus or peripheral nerve injury.

Diagnostic Workup

The diagnostic workup should focus on all aspects of the patient’s presentation so as not to lose perspective of the patient’s medical and orthopaedic priorities, especially with regard to the high prevalence of associated injuries.

Physical Exam

The classic physical exam findings would include a slumped or depressed shoulder and often with a medialized appearance in the upright patient (Figure 1). This is often apparent to the patient when they look in the mirror and is caused by the anterior rotation of the scapula around the thoracic cage when the restraints of an intact clavicle or glenoid neck are not present. It is important to look for other bodily warning flags as well. Skin lesions should be documented immediately as abrasions affect timing of surgery (Figure 2). Chest wall crepitation or tenderness are concerning for rib fractures and subcutaneous emphysema can occur in the setting of a pneumothorax.

Figure 1.

This is a clinical photograph of a patient who presented with a right shoulder droop and scapular fracture. Note his right shoulder is medialized and the lateral aspect of his right shoulder lies more inferior when compared with his left shoulder.

Figure 2.

This is a clinical photograph of a patient with a scapular fracture who also sustained a skin abrasion over his shoulder. Skin abrasions should be documented on initial presentation and this should delay operative treatment until the area has healed.

A critical neurologic exam for C5 to T1 will help detect the common nerve injuries. Specifically, the suprascapular nerve and axillary nerve are the most commonly injured, but only the axillary nerve can be detected by a sensory exam. The suprascapular nerve often is un-examinable in the initial setting because the patient cannot externally rotate or even move their shoulder due to pain. Severe brachial plexus lesions should have myelography or MRI to ascertain the level of the nerve lesions and to check for nerve root avulsions. Suspicion for vascular injury from asymmetric pulses also warrant a MRI and/or an angiogram.

Imaging

Scapular fractures that present in the trauma setting may be identified on chest x-ray and computed tomography (CT) scans during the initial patient evaluation. All patients with a suspected or known scapula fracture should receive dedicated scapular radiographs consisting of anteroposterior (AP) shoulder, scapular Y, and axillary views (Figure 3). This scapula radiographic trauma series is a useful screening tool to identify a fracture, determine the relationship of its fragments, and the position of the humeral head relative to the glenoid.

Figure 3.

These radiographs are preoperative shoulder AP and scapular Y views from a 47-year-old male involved in a car accident. The AP view reveals a comminuted glenoid neck fracture that extends into the glenoid articular surface. The Y view also reveals an angular deformity of the scapular body.

Proper positioning of patients for radiographs is often difficult in the trauma setting but imperative to accurately assess radiographic measurements that will guide treatment. A 3D-CT scan with reconstructions from 1 to 2 mm cuts in coronal, sagittal, and axial planes is the preferred modality for determining displacement and angulation since the images can be rotated to perfect position for accurate measurement of angulation and displacement (Figure 4). Three-dimensional-CT scans have also been found to be superior to radiographs in assessing displacement as well as having good reliability in measuring the glenopolar angle and angulation. In general a 3D-CT scan should be ordered for accurate measurements if greater than 1 cm of displacement is detected on plain films, because this approaches the displacement (20 mm) of surgical indications. A 2D-CT scan may also be useful in evaluating intra-articular glenoid fractures for step-off and gaps, and location and percentage of articular involvement.

Figure 4.

This is a three-dimensional CT scan with a posterior coronal, transcapular Y, and anterior coronal view of the same patient from the previous figure. The CT scan revealed a displaced glenoid neck fracture involving the posterior and inferior aspect of the glenoid surface. The fracture extends into the infraspinous fossa and traverses the base of the acromion.

Special Diagnostic Tests

Electromyography

Electromyography (EMG) is useful in scapula fractures that are at an increased risk of suprascapular nerve injury, namely fractures involving the spinoglenoid notch, sometimes referred to as anatomical neck fractures. An EMG will not hold diagnostic value until at least 2 weeks after the initial injury when Wallerian degeneration is complete. Otherwise the EMG will be falsely negative in a high percentage of cases. For this reason EMG is most useful in patients with a delayed presentation from their initial injury. We recommend it for any patient delayed from surgery for more than 2 weeks because of the high positivity rate. Positive results can help guide surgery and prognosis.

Non-Operative Management

Non-operative glenoid fractures should be treated with a 2 week period of immobility in a sling. Casting or braces have not been proven effective. Active wrist and elbow range of motion (ROM) is helpful to decrease swelling during this period. After 2 weeks, passive shoulder ROM including pendulum exercises should be initiated and progress to full ROM as tolerated. Active ROM should begin at 4 weeks with strengthening exercises starting at 3 weeks. Weight-bearing restrictions may be lifted completely at 3 months depending on symptoms as there will be no risk of displacement or refracture. A physical therapist can be helpful to guide motion and strength, and they often teach helpful adjunctive modalities for home exercise prognosis.

Indications for Surgery

Surgical indications for the management of glenoid fossa fractures include an assessment of articular step-off, gap, and percentage of joint involvement. In general, open reduction and internal fixation(ORIF) for glenoid fractures is recommended with the following:

  • > 4 mm of articular step-off or fracture gap

  • > 20% of glenoid surface involvement

Open reduction internal fixation is also recommended for scapular neck and body fractures that meet the following criteria (Figure 5):

Figure 5.

The radiographs and 3D-CT images in this figure outline how to determine the imaging measurements used in evaluating whether a scapula fracture meets operative indications. Lateral border offset is measured by drawing a perpendicular line from the lateral most extent of the inferior fragment and another perpendicular line from where it originally was located on the superior fragment. The distance between these two lines is the lateral border offset and is often referred to as medialization. The glenopolar angle is calculated by drawing a line from the inferior to the superior pole of the glenoid fossa and another line from the superior pole to the apex of the scapula body's inferior angle. Angular deformity is determined using the scapular Y view and the angle is formed by the intersection of a line running parallel to the proximal fragment and a line running parallel to the distal fragment borders. Additional operative indications include simultaneous lateral border offset of > 15 mm and 30° of angulation, as well as double disruptions to the subscapularis with both lesions having > 10 mm displacement.

  • ≥ 20 mm lateral border offset (medialization)

  • ≥ 22° glenopolar angle

  • ≥ 45° angulation

  • ≥ 15 mm medialization and ≥30° angulation

  • Double lesions of the superior shoulder suspensory complex in which each lesion is displaced ≥ 10mm. For instance, a clavicle fracture with 10 mm of displacement (or complete acromioclavicular dislocation) and a scapula neck fracture with10 mm of displacement.

  • Process fracture

    • ≥ 10 mm displacement or caudal tilting of the acromion

    • ≥ 10 mm displacement of the coracoid

These operative indications should always take into consideration a patient’s activity level, physiologic status, functional needs, and hand dominance with a lower threshold for surgery in younger, highly active patients. Lastly, some articular fracture patterns which involve the superior glenoid are more accepting of displacement due to the relative stability. For instance, Ideberg type II fracture patterns are more stable and will tolerate a larger degree of step-off relative to anterior or posterior glenoid fractures.

The Mayo version of the Ideberg classification system of glenoid fractures is also useful in directing surgical planning. Types I through III do not involve the scapula body.

  • Type I:An isolated fracture of the anteroinferior glenoid and may involve complete dislocation.

  • Type II:Fractures through the superior surface of the glenoid that extend in a transverse plane along theglenoid neck to under the base of the coracoid.

  • Type III:Fractures involving the inferior or inferoposterior surface of the glenoid along with a portion of the lateral scapular border

  • Type IV:A fracture pattern that consists of an inferior fracture through the articular surface that extends in a stellate pattern to involve the scapular body. These fractures may be associated with spine fractures.

  • Type V:This fracture type is defined as a Type IV fracture pattern with an additional fracture through the coracoid, acromion, or superior articular component.

Surgical Technique

Determining Surgical Approach

Glenoid fractures can be surgically treated by either the anterior deltopectoral approach or a variation of the posterior approach of Judet. Other posterior approaches including the straight and minimally invasive approaches have been described, and spare soft tissue insult and reduce surgical morbidity. In general, transverse fractures involving the superior glenoid such as in the Ideberg type II are best managed through the deltopectoral surgical approach in order to visualize the articular displacement, access the coracoid, and render internal fixation. A posterior approach is indicated for posterior glenoid fractures and those involving the scapula neck and body. Combined anterior and posterior approaches are rarely indicated, but maybe necessary in transverse or highly comminuted glenoid fractures with a significant scapular body or neck fracture and those body and neck fractures which also have associated coracoid fractures. In these cases it is best to first try indirectly reducing the glenoid fracture through a posterior incision before proceeding to the anterior approach. Separate incisions may be needed to treat clavicle, acromion, or coracoid fractures.

Necessary Equipment/Instrumentation

  • Minifragment implant from 2.0 to 2.7 mm screws and plates

  • Reduction tools including shoulder hooks, dental picks, and 4 mm schantz pins

  • At least two small pointed bone reduction forceps

  • Various sized retractors from Langenbecks to Israels, Richardsons, and Deavers

  • An extra assistant is necessary for adequate visualization for either an anterior or posterior approach

Anterior approach

For anterior glenoid fractures or Ideberg II superior glenoid fractures and coracoid fractures.

Positioning

The patient should be positioned in a beach chair with their upper extremity supported by an arm board. The ipsilateral shoulder is thrust forward slightly by placing a rolled-up single towel bump behind it. The patient’s complete upper extremity, ipsilateral upper quadrant, and neck should be prepped and draped to allow for full shoulder motion. Intraoperative fluoroscopy should not be needed as this approach will provide direct visualization of the glenoid.

Exposure

The anterior approach is made from the coracoid following the deltopectoral groove to the lateral aspect of the axillary fold. If more exposure is needed, the incision can be extended proximally to the clavicle and distally to the deltoid’s humeral insertion.

As the incision is developed down to the deltopectoral interval, attention should be given to identifying the cephalic vein. Once the vein is found, it should be preserved and retracted laterally. The interval should then be further developed down to the clavipectoral fascia which is then opened to visualize the coracobrachialis and subscapularis tendons. The anterior humeral circumflex vessels run just inferior to the subscapularis tendon and will need to be ligated or cauterized. Exercise caution as the axillary nerve is just inferior to these vessels and is at risk if the dissection is carried further distally.

Holding the humerus in a neutral position, incise the subscapularis tendon about 0.75 cm away from its insertion on the lesser tuberosity. The remaining cuff of tissue will be used to facilitate repair at the end of the surgery. Stay sutures placed on each side of the subscapularis tendon will help identify it for repair and prevent medial retraction. The subscapularis is frequently adherent to the joint capsule and will need to be dissected away to gain exposure to the capsule. A more accurate closure is often achieved by discriminating between the two layers, but this is often difficult and the later repair can be achieved jointly.

The joint capsule is now visualized and an arthrotomy can be performed for intra-articular evaluation. The joint capsule is incised in a longitudinal fashion just off the glenoid rim. A Fukuda retractor placed into the joint and along the posterior aspect of the glenoid that levers the humerus laterally will provide optimal exposure of the joint. The arthrotomy is mandatory if there is articular comminution, but it can be avoided when indirect articular reduction is achieved through reducing the one large articular fragment which keys in anatomically.

Reduction and Implants

Reduction can be achieved with a dental pick or shoulder hook followed by provisional Kirschner wire. Screw sizes range from 2.0 to 3.5 mm depending on fragment size and comminution. A small 2.0 or 2.4 mm buttress plate along the anteroinferior edge of the glenoid is helpful in comminuted glenoid fractures.

Closure

Following fixation, the joint should be irrigated, repaired, and the subscapularis reattached. The senior author prefers fascia closure with absorbable braided sutures and an absorbable subcuticular stitch for the skin.

Posterior Approach

Positioning

Place the patient in the lateral decubitus position on a beanbag with the body falling slightly forward. A soft wedge such as a BoneFoam positioner (BoneFoam Inc., Plymouth, MN) between both arms will protect the lower arm and provide a useful work space (Figure 6). The patient’s neck, vertebral column, and complete upper extremity should be prepped and draped to allow for complete motion of the glenohumeral joint during the operation.

Figure 6.

This preoperative image shows the positioning for a posterior surgical approach. The patient is in a lateral decubitus position with the injured arm draped free to assess range of motion intraoperatively and aid in reduction.

Exposure with a Posterior Judet Incision

Prior to incision, the bony landmarks should be outlined with a sterile pen, including the acromion, scapular spine, and scapular borders. Protracting and retracting the scapula will allow for palpation of the vertebral border. The posterior Judet incision is made 1 cm inferior to the acromion spine and directed medially. The incision then curves caudally at the base of the spine so that it continues 1 cm parallel and lateral to the vertebral border until it reaches the inferior angle. This will allow a flap that will be retracted laterally to provide necessary exposure and adequate coverage of implants following closure.

Extensile Judet

In an extensile Judet approach the infraspinatus fossa musculature is mobilized on the suprascapular neurovascular pedicle with a Cobb elevator as a fasciocutaneous flap to allow for full visualization of the posterior scapula. The scapula’s blood supply is not disrupted due to preservation of the subscapularis anteriorly, and the rotator cuff muscles posteriorly on its pedicle. Careful dissection is required caudal to the acromion to respect the suprascapular neurovascular bundle as it enters the infraspinatus muscle. In this approach the glenoid surface cannot be visualized because of the large flap which interferes with the appropriate site line and vector for instrumentation. This approach should be reserved for body and neck fractures, or for uncomplicated glenoid fractures, which can be reduced and fixed from an extra-articular position.

Limited Judet

Unlike the extensile approach only the skin and subcutaneous layer is retracted laterally to expose the scapular musculature. The deltoid fascia is then incised at its inferior border and the deltoid is retracted cephalad. Next the infraspinatus fascia is incised to expose the teres and infraspinatus interval which is often distinguished by a stripe of fat (Figure 7). Two intermuscular windows are then created to reduce specific fracture locations. These intervals are recommended to obtain reduction and render fixation, and they avoid injury to the suprascapular neurovascular bundle, axillary nerve, and posterior humeral circumflex vessels. Sparing the deltoid of detachment from its origin helps expedite rehabilitation.

Figure 7.

The limited Judet approach utilizes the muscular interval between the infraspinatus and teres minor to expose the lateral aspect of the scapula. An infraspinatus tenotomy would enhance exposure of the glenoid. The suprascapular neurovascular bundle is susceptible to injury if excessive retraction is applied to the infraspinatus.

  1. Lateral border window: An intermuscular interval is developed between the infraspinatus and teres minor. This allows access to the glenoid, scapular neck, and lateral border fracture. Often, the main goal is to reduce the lateral border. A capsulotomy can then be performed to visualize the glenohumeral joint, because there is not the need for retraction and working around the large flap developed in the extensile approach.

  2. Vertebral border window: This window is established by elevating the deltoid and the infraspinatus off the base of the spine or the upper vertebral border. The rhomboids are left intact at their attachment and sufficient exposure for fracture assessment and reduction is accomplished.

Exposure with Less Invasive Posterior Incisions

The minimally invasive and straight approaches both utilize an incision directly over the posterior glenoid. The minimally invasive approach uses an additional incision over the scapula’s vertebral border to reduce scapula body fractures.

Direct Posterior Approach

The straight posterior approach involves a direct incision over the posterior glenohumeral joint. Dissection is carried down to the inferior deltoid margin, where it is retracted superiorly to expose the external rotators. The joint is then accessed between the infraspinatus and teres minor in a similar manner to the lateral border window used in a limited posterior Judet approach. This approach is beneficial by allowing for a smaller incision than the large Judet incision and is best for isolated posterior fractures of the glenoid or anatomic scapular neck fractures which exit the spinoglenoid notch.

Minimally Invasive Approach

The minimally invasive approach is identical to the direct posterior approach with the addition of a second incision medially that provides access to the vertebral border window. The incision is placed directly over the fracture exiting the perimeter. It may be oriented along the spine, or angle, or vertebral border depending on the pattern. Dissection is taken down to the periosteum of the vertebral border to access medial fracture lines. This approach provides adequate exposure for plate application of most common scapular fracture patterns and minimizes soft tissue disruption.

Reduction

Manual reduction is best accomplished using Schanz pins (4 mm) and T-handled chucks inserted into the superior fracture fragments at the level of the neck. These external fixation pins can then be manipulated to joystick fragments but they must be placed to avoid interference with plate placement. A shoulder hook placed into a pilot hole in the distal lateral border can be used to joystick the caudal fragment. Small pointed bone clamps are then needed to maintain reduction. When this clamp is impossible due to comminution, a temporary 2.0 mm plate and screws medially to reduce the lateral border while not interfering with definitive plate fixation can be used. Highly comminuted body and neck variants will require multiple clamps along the acromion and lateral and medial borders to achieve reduction.

Implants

The senior author recommends a contoured 2.7 mm locking plate for the medial border because of its contourability and fixation potential in thin bone, and a 2.7 dynamic compression plate for the lateral border, which may also be a locking plate (Figure 8). Smaller plates are easier to contour and provide more points of fixation. Larger 3.5 mm plates are also difficult to fit through intermuscular intervals and too bulky for the acromial and vertebral border with minimal soft-tissue coverage.

Figure 8.

These are postoperative AP and scapular Y radiographs of the same patient from Figure 3 and 4 showing anatomic reduction. A single 2.7 mm screw was placed along the inferior glenoid and extended along the glenoid neck. A plate was placed over the posterior glenoid to serve as a buttress. Another 2.7 screw was placed across and perpendicular to the glenoid fracture line. A 2.7 recon plate was placed across the acromion fracture and the lateral border was fixed with a 7-hole 2.7 mm DC plate.

The lateral border locking plate should be applied straight with only gradual contouring as it approaches the posterior glenoid. Simple fractures should only require 4 screws distally and 2 in the glenoid neck. The vertebral border plates will require more contouring and in multiple dimensions around the superomedial border. Two small Kocher clamps will be helpful in contouring this plate. Considering the short screw length, six screws should be placed on the vertebral side of the fracture when possible and 3-4 at the base of the spine and along the spine.

Closure

Judet Incisions

Prior to closure, the shoulder should be manipulated to release any adhesions; this is especially important in patients delayed to surgery, such as greater than 10 days post-injury. The senior author routinely uses a suction drain under the extensile Judet flap and reattaches the rotator cuff to its origin using non-absorbable heavy braided suture through several drill holes along the scapular spine and vertebral border. Absorbable subcutaneous sutures are preferred for skin closure. In the limited approaches, there is no need to reattach the musculature through drill holes.

Pearls and Pitfalls of Technique

Increased Exposure with the Anterior Approach

A coracoid osteotomy may be helpful by providing more exposure in comminuted glenoid fractures approached anteriorly and treated with a buttress plate. The osteotomy is best accomplished by using an osteotome or micro-oscillating saw approximately midway (2 cm) down its stalk. The coracoid with the attached conjoined tendon is then reflected medially and distally to expose the scapular neck and anterior glenoid. Beware of the musculocutaneous nerve during retraction as it pierces the coracobrachialis about 5 cm distal to its insertion on the coracoid. The coracoid can be fixed with one lag screw and one derotational screw of either 2.7 or 3.5 mm diameter depending on its size.

Choosing a Posterior Approach

Patients with scapula fractures involving the body and neck regardless of whether there is an intra-articular fracture are generally managed through a Judet incision. However, a decision needs to be made whether to elevate the subcutaneous flap and work in between muscle planes or manage the fracture through an extensile Judet approach by elevating the infraspinatus and teres minor off the infraspinatus fossa. A complete extensile approach is generally preferred if the surgery is delayed by more than 10 days or in cases of extremely complex fracture patterns with four exit points around the scapula perimeter. The limited Judet approach working through muscle intervals is preferred when possible because muscle dissection is minimized. A minimally invasive posterior approach utilizing two incisions over the lateral and verterbral borders can be used in simple fractures extending from the lateral to medial border with minimal comminution. Indications for the limited approaches can be expanded as the surgeon develops greater familiarity with the techniques. This approach requires a keen understanding of deforming forces of the musculature on their resective fragments.

Patient Positioning for Posterior Approaches

Positioning for the posterior approach varies slightly depending on whether there is extra-articular involvement. In intra-articular fractures the patient should be positioned in the lateral decubitus position with the torso upright at 90 degrees to the table to help approach the anteverted orientation of the scapula. However, in isolated extra-articular fractures, the patient should be tilted slightly forward so the scapular body faces the surgeon.

Increased Glenoid Exposure with a Posterior Approach

The glenoid can be further exposed through an optional infraspinatus tenotomy. This is performed by incising the infraspinatus tendon 1 cm off of its insertion at the lesser tuberosity and later repairing it with heavy non-absorbable sutures. The tenotomy is useful in muscular patients with comminuted glenoid fractures but will require protection against external rotation for 6 weeks.

Superior Medial Angle Fixation

Fractures involving the superior medial angle of the scapula are best fixed with 20-30 mm long screws directed towards the base of the scapular spine. This area has adequate bone stock and will help enhance purchase. The proper vector for screw placement can be appreciated by palpating under the levator scapulae origin. The contour of plates at this location is very tricky, and the senior author has found that two baby Kocher clamps placed through holes in the plate can be used to make the contour in multiple planes parallel to this angle.

Vertebral Border Reduction

The vertebral border is best reduced by placing vertically-orientated, small pointed bone reduction forceps in small drill holes through the posteromedial aspect of the scapula body. It is helpful to reduce the lateral border first, because there is not a strong fix hold for clamp reduction due to thin bone.

Surgical Planning with Associated Injuries

Over 20% of scapula fractures are associated with a cervical or thoracic spine injury that can complicate operative positioning and draping. Spinal fixation should be performed first when feasible; however, if this is not an option, intra-operative inline halo traction is preferred over working around a cervical collar. Also, in cases of ipsilateral clavicle fractures our recommendation is open reduction and internal fixation in addition to the scapula. This provides patients with a quicker rehabilitation and quicker pain relief and reduces the risk of deformity and dysfunction from clavicle malunion.

Potential Complications

Patients experience good outcomes following ORIF of glenoid fractures according to the literature, but like any operative intervention there is always a risk of nerve injury, implant failure, infection, nonunion, and shoulder stiffness. Fortunately, these risks are rare and more likely to be seen in patients with delayed treatment or highly displaced and comminuted fractures. Nonunions are almost a reportable event as the scapula has a robust blood supply and infections occur in less than 1% of cases.

Shoulder Stiffness

Shoulder stiffness is the most common complication following glenoid fractures and often develops after extended immobilization either pre- or post-operation. Manipulating the shoulder following fixation and while the patient is still under anesthesia reduces this complication by releasing any contractures. The 6-week post-operative clinic visit is also a key time-point to evaluate patients for stiffness. Several cases have been reported to benefit from manipulation under anaesthesia from 6-12 weeks due to the formation of adhesions. An intra-articular steroid injection during the procedure will also prevent the reoccurrence of intra-articular tissue.

Nerve and Arterial Injury

The suprascapular nerve, circumflex scapular artery, musculocutaneous, and axillary nerve are at risk depending on the surgical approach, but can also be damaged during the fracture mechanism. It is often difficult to determine whether a nerve injury is iatrogenic or injury-related. The suprascapular nerve is most at risk during the extensile posterior approach as the teres minor is elevated from the scapular body. Careful dissection, avoiding excessive retraction, and a clear knowledge of anatomy can prevent its injury. Anterior exposure risks damaging the axillary and musculocutaneous nerve. Avoiding distal dissection past the anterior humeral circumflex vessels during an anterior deltopectoral approach and limiting retraction of the coracobrachialis will protect the axillary and musculocutaneous nerve respectively.

Implant Failure

There is a very low rate of implant failure in scapular fractures treated with plates and screws. Hardware failure can be prevented by reducing stress on a single implant through the use of both vertebral and lateral border fixation. Locking plates also reduce the possibility of screw pullout, and allow for the use of shorter plates and smaller incisions.

Post-operative Rehabilitation

Post-operative care and rehabilitation is similar for both anterior and posterior approaches. A sling may be worn for comfort, but passive range of motion with no restriction is started by a therapist on the first post-operative day to prevent shoulder stiffness. A regional anesthetic block consisting of an indwelling interscalene catheter for the first 48 to 72 hours will help control pain and encourage early range of motion. Once the patient’s pain subsides active-assisted ROM is added (often in the first couple of post-operative days) with the goal of regaining full passive and active shoulder ROM by 4 weeks. Therapy should continue following discharge with the use of a home exercise plan consisting of pulleys and supine-assisted motion with push-pull sticks.

In patients with an anterior surgical approach, external rotation needs to be protected against forced motion past neutral and internal rotation against resistance for 6 weeks to protect the subscapularis tenotomy repair. Weight-bearing should be delayed at least 4 weeks and often longer. However, patients are encouraged to use 3 to 5 pound weights on a supported elbow to prevent muscular atrophy during this time. Strengthening exercises can begin at 4weeks with the addition of weights and by 8 weeks advanced to full resistance. At 3 months postoperatively all restrictions can be lifted. Endurance activities are begun at this stage.

Outcomes/Evidence in the Literature

Anavian, J, Gauger, EM, Schroder, LK, Wijdicks, CA, Cole, PA. "Surgical and functional outcomes after operative management of complex and displaced intra-articular glenoid fractures". J Bone Joint Surg Am. vol. 94. 2012. pp. 645-53.

(The authors determined that all of their 33 patients with displaced intra-articular fractures of the glenoid had a radiographic union and 90% returned to their pre-injury level of work and activity following ORIF.)

Mayo, KA, Benirschke, SK, Mast, JW. "Displaced fractures of the glenoid fossa. Results of open reduction and internal fixation". Clin Orthop Relat Res. 1998. pp. 122-30.

(In a series of 27 cases of displaced glenoid fractures the authors found that anatomicre construction can be achieved in a high percentage of patients while complications are uncommon and often related to associated injuries or poor rehabilitation effort.)

Schandelmaier, P, Blauth, M, Schneider, C, Kretteck, C. "Fractures of the glenoid treated by operation A 5 to 23-year follow-up of 22 cases". J Bone Joint Surg Br. vol. 84. 2002. pp. 173-7.

(After reviewing 22 consecutive displaced glenoid fractures at a mean follow-up of 10 years, the authors concluded that ORIF provides excellent outcomes and the Ideberg classification is helpful in surgical planning.)

Cole, PA, Gauger, EM, Herrera, DA, Anavian, J, Tarkin, IS. "Radiographic follow-up of 84 operatively treated scapula neck and body fractures". Injury. vol. 43. 2012. pp. 327-33.

(A retrospective review of 74 patients who underwent ORIF for a scapula body or neck fracture found all patients achieved radiographic union with only 3malunions. The authors concluded that ORIF for displaced scapula fractures is a safe and effective procedure for restoring anatomy of scapula neck and body fractures.)

Judet, R. "Surgical treatment of scapular fractures". Acta Orthop Belg. vol. 30. 1964. pp. 673-8.

(Judet described the extensile posterior approach and advocated for operative treatment for displaced scapula fractures.)

Nordqvist, A, Petersson, C. "Fracture of the body neck, or spine of the scapula. Along-term follow-up study". Clin Orthop Relat Res. 1992. pp. 139-44.

(This study followed-up 68 patients after non-operative treatment of scapula body, neck, and spine fractures and found many patients had symptomatic moderate to severe deformities of their scapula. In some cases, operative treatment could have improved long-term results.)

Bozkurt, M, Can, F, Kirdemir, V, Erden, Z, Demirkale, I, Basbozkurt, M. "Conservative treatment of scapular neck fracture: the effect of stability and glenopolar angle on clinical outcome". Injury. vol. 36. 2005. pp. 1176-81.

(The authors determined that a decreased glenopolar angle was more reliable in predicting degree of instability than the fracture type. Patient age and associated injuries were also found as effective determinants of the functional outcome.)

Armitage, BM, Wijdicks, CA, Tarkin, IS, Schroder, LK, Mark, DJ, Zlowodzki, M, Cole, PA. "Mapping of scapular fractures with three-dimensional computed tomography". J Bone Joint Surg Am. vol. 91. 2009. pp. 2222-8.

(This study prospectively reviewed imaging of 90 patients with operative scapula fractures and reported common fracture locations and patterns. Overall the study found scapular fractures follow common patterns and the greatest variation was among fractures of the glenoid’s articular surface.)

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. vol. 25. 2011. pp. 649-56.

(The authors reviewed the outcome of 5 patients with symptomatic malunions following non-operative treatment of a scapula neck and/or body fracture who went on to have surgical revision. The results revealed good functional outcomes, with all patients achieving union and a pain-free status in regard to their shoulder.)

Anavian, J, Conflitti, JM, Khanna, G, Guthrie, ST, Cole, PA. "A reliable radiographic measurement technique for extra-articular scapular fractures". Clin Orthop Relat Res. vol. 469. 2011. pp. 3371-8.

(This study compared injury radiographs and 3D-CT scans of 45 patients with extra-articular scapular fractures and found 3D-CT scans were more reliable than plain radiographs in assessing angulation and the glenopolar angle.)

Summary

One of the key axioms in orthopaedic trauma is that function follows form and we believe there is no reason that the scapula fracture should be treated by any other principle. Specifically, the principles of restoring length, alignment, rotation, and stability equally apply to this important part of the shoulder girdle on which eighteen muscles insert or originate. Appropriate diagnostic workup and knowledge of measurement of deformity are critical to understanding the indications for surgery to select those patients who would benefit greatest. As long as these key principles are used to guide management, gexcellent outcomes can be achieved following open reduction and internal fixation of scapula fractures with only a minimal risk of complications.

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