Scapula Fractures Thomas P. Goss, MD Robert V. Cantu, MD University of Massachusetts Medical Center Scapulothoracic Di

1. Scapula Fractures Thomas P. Goss, MDRobert V. Cantu, MDUniversity of Massachusetts Medical CenterScapulothoracic Dissociation Andrew H. Schmidt, MDCreated March 2004

2. Outline 1. Incidence and Mechanisms 2. Diagnosis and Nonoperative Treatment 3. Fractures of the Glenoid Process 4. Isolated Fractures of the Coracoid Process

3. Outline Continued 5. Isolated Fractures of the Acromial Process 6. Double Disruptions of the Superior Shoulder Suspensory Complex 7. Scapulothoracic Dissociation 8. Complications

4. Incidence of Scapula Fractures 1% of all fractures 3% of injuries to shoulder girdle 5% of shoulder fractures

5. Location of Scapula Fractures

6. Diagnosis History typically high energy injury (80-95% incidence other injury) Mechanism often direct but can be indirect Diagnosis ultimately radiographic

7. Radiographs �Scapula trauma series�: AP and Lat of scapula, true glenohumeral axillary view CT scanning for complex injuries with 3D reconstructions Stress AP projection if injury to the clavicular-scapular linkage suspected

8. Nonoperative Treatment >90% scapular fractures minimally displaced Treatment in sling and swathe with gradual increase of functional use for first 6 weeks x-rays at 2 week intervals until 6 weeks

9. Nonoperative Tx Continued At 6 weeks osseous union usually present and sling/swathe discontinued Full recovery may take 6 months to 1 year

10. Operative Indications 1. Significantly displaced (5-10mm) fractures of glenoid cavity (rim and fossa) 2. Significantly displaced (10mm or 40 degrees rotation) fractures of the glenoid neck 3. Double Disruptions of the superior suspensory shoulder complex with displacement of one or more elements

11. Glenoid Process Glenoid process includes glenoid cavity (rim and fossa) and glenoid neck

12. Fractures of the Glenoid Cavity (Rim and Fossa) 10% of scapula fractures of which no more than 10% are significantly displaced

13. Classification Glenoid Cavity Fractures Ia= anterior rim fracture Ib=posterior rim fracture

14. Classification Glenoid Cavity Fractures II= fracture line through glenoid fossa exiting at lateral border of scapula

15. Classification Glenoid Cavity Fractures III= fracture line through glenoid fossa exiting at superior border of the scapula

16. Classification Glenoid Cavity Fractures IV= fracture line through glenoid fossa exiting at the medial border of the scapula

17. Classification Glenoid Cavity Fractures Va= combination types II and IV Vb= combination types III and IV Vc= combination types II,III, and IV

18. Classification Glenoid Cavity Fractures VI= comminuted fracture

19. Glenoid Rim Fractures Instability anticipated if fracture displaced 10mm and involves one fourth anterior aspect or one third posterior aspect glenoid cavity Fractures of anterior rim approached anteriorly and posterior rim posteriorly

20. Fractures of the Glenoid Fossa Surgery if articular step-off 5-10mm or displacement causes subluxation humeral head out of glenoid cavity All glenoid fossa fractures approached posteriorly

21. Glenoid Neck Fractures 25% of scapula fractures of which 10% or less are significantly displaced Mechanism can be direct blow, fall on outstretched arm, or fall on superior aspect shoulder

22. Classification Glenoid Neck Fractures Type I: non and minimally displaced (<10mm) Type II: translational displacement 1cm or more or angulatory displacement 40 degrees or more

23. Glenoid Neck Fractures Continued Surgery for type II fractures Posterior approach between infraspinatus and teres minor Fixation with 3.5mm recon plate, and possibly k-wires or interfragmentary screws

24. Isolated Fractures of the Coracoid Process Fracture can be at base of coracoid, between CA and CC ligaments, or at tip (avulsion) Diagnosis often on plain films but CT scan may be needed to better define fracture Fractures at tip of coracoid typically treated non-operatively (athletes and manual laborers may be exceptions)

25. Coracoid Fractures Con�t Surgical options include ORIF (cannulated 3.5 or 4.0mm screw) or excision fragment and suture fixation conjoined tendon to remaining coracoid process Fractures between CA and CC ligaments can often be treated non-operatively unless high physical demand patient Fractures at base coracoid generally minimally displaced and treated non-operatively. Fibrous union may occur but rarely source discomfort

26. Isolated Fractures of the Acromial Process Scapula series detects most acromial fractures Os acromionale may complicate evaluation Most are nondisplaced or minimally displaced and treated symptomatically

27. Fixation of Acromial Fractures If ORIF undertaken tension band construct for fractures at distal portion and 3.5mm recon plate for more proximal fractures

28. Double Disruptions of the Superior Suspensory Shoulder Complex (SSSC) SSSC is a bone-soft tissue ring at the end of a superior and inferior bone strut Ring includes glenoid process, coracoid process, CC ligaments, distal clavicle, AC joint, acromial process Superior strut is middle third clavicle Inferior strut is lateral scapular body and spine

29. Superior Shoulder Suspensory Complex

30. Double Disruption of SSSC Traumatic disruption 2 or more components SSSC usually secondary to high energy injury and frequently require surgical management Frequently described as �Floating Shoulder� Potential long term consequences non-operative treatment include: nonunion, malunion, impingement, altered shoulder mechanics, DJD, neurovascular compromise

31. Floating Shoulder Operative management recommended because of potential instability, displacement of glenoid Recent series of floating shoulders treated nonoperatively shows good results with conservative care.

32. Nonoperative Management of Ipsilateral Fractures of the Scapula and Clavicle Retrospective review of 20 cases 11 of 20 clavicle fx�s displaced > 10 mm 5 of 20 scapular fx�s displaced > 5 mm Treated with sling or immobilizer Evaluated by 3 different shoulder scores, strength compared to uninjured shoulder.

33. Results 1 clavicle nonunion (segmental bone loss at injury) Strength = to opposite arm in all Constant score 96, Rowe score 95 17-18 patients excellent results depending on evaluation system

34. Summary - Floating Shoulder Nonoperative treatment sufficient for many of these injuries. Each component of the injury should be separately evaluated for indications for surgery, but the combination itself does not mandate operative intervention

35. Scapulothoracic Dissociation Traumatic disruption of scapula from posterior chest wall Neurovascular injury common

36. Scapulothoracic Dissociation=Closed Forequarter Amputation

37. Scapulothoracic Dissociation Left scapulothoracic dissociation with brachial artery disruption

38. Scapulothoracic Dissociation Rare, life-threatening injury First described in 1984 (Oreck, JBJS 66A:758). Hallmark: Severe neurovascular injury to the upper extremity, associated with lateral displacement of the scapula. Sometimes associated with obvious fracture or dislocation about the shoulder Sometimes without obvious bone injury

39. Scapulothoracic Dissociation Caused by Blunt Trauma Review of 4 personal cases and 54 described in the literature Broad spectrum of injuries: Neurologic injuries in 94% Vascular injuries in 88% Poor Outcome Flail extremity in 52% Early amputation in 21% Death in 10%, 8% due to this injury

40. Musculoskeletal Injuries

41. Brachial Plexus Injury Complete brachial plexopathy: 81% Partial plexopathy: 13% None: 6%

42. Neurologic Injury in Scapulothoracic Dissociation If deficit present EMG done at 3 weeks to determine extent and assess recovery if any Cervical myelography can be performed at 6 weeks Nerve root avulsions and complete deficits have a poor prognosis Partial plexus injuries have good prognosis and functional use extremity often regained

43. Vascular Injury Subclavian or axillary artery: 88% None: 12%

44. Diagnosis Massive swelling of shoulder region Pulseless arm Complete or partial neurologic deficit Lateral displacement of scapula on a non-rotated chest radiograph is diagnostic

45. 37 year old male, found lying on ground, intoxicated. Paramedics noted broken branches above. Patient later found to have fallen from 2nd story balcony

47. Chest Radiography

48. CT Scan

49. Arteriogram

50. Classification Type I: Musculoskeletal injury alone Type IIA: Musculoskeletal injury with vascular disruption Type IIB: Musculoskeletal injury with neurologic impairment Type III: Musculoskeletal injury with both neurologic and vascular injury

51. Initial Treatment Patients often polytraumatized ATLS protocols must be followed. Angiography of limb. Vascular repair, with exploration of brachial plexus.

52. Case Example To OR immediately Revascularization of Left Arm with Goretex graft. Musculocutaneous nerve avulsion ???

53. What can the orthopedist do? Stabilize associated bone or joint injury Clavicle fractures are most common.

54. Benefits of Skeletal Stabilization Avoid delayed or nonunion Stabilize shoulder girdle Protect vascular and/or neurologic repairs

55. ORIF Clavicle

56. Complications of Revascularization Graft thrombosis Compartment syndrome Hyperkalemia Rhabdomyolysis, myoglobinuria

57. Case Example CPK levels: 9579 IU/L just after admission Hb: 13.7 @admission to 8.1 4 hrs later Treated with iv fluids and alkalinization of urine, no renal failure seen.

58. Deep Vein Thrombosis Severe swelling of arm 2 weeks later DVT L cephalic and brachial veins

59. Later Treatment 3 weeks: EMG 6 weeks: cervical myelography Shoulder arthrodesis and/or above-elbow amputation may be necessary if the limb is flail.

60. Prognosis Nerve avulsion or complete neurologic deficit: poor Partial neurologic deficit: good

61. Case Example Cervical myelogram: no root avulsion EMG 4 months: severe, widespread brachial plexopathy, complete denervation. Repeat EMG 7 months: no change. To OR for exploration, neurolysis. 2.5 years, arm remains paralyzed.

62. Limb Salvage If initial exploration of the brachial plexus reveals a severe injury, primary above-elbow amputation should be considered . If cervical myelography reveals 3 or more pseudomeningoceles, the prognosis is similarly poor.

63. Summary - Scapulothoracic Dissociation Scapulothoracic dissociation may be a life or limb-threatening injury If revascularization is necessary, try to explore the brachial plexus at the same time - if it is �shredded� amputation may be considered Orthopedic stabilization of any skeletal injury is warranted - although the outcome remains poor in most cases.

64. Intrathoracic Dislocation of the Scapula Extremely rare Inferior angle scapula locked in intercostal space Chest CT may be needed to confirm diagnosis

65. Intrathoracic Dislocation of the Scapula Continued Treatment is closed reduction and immobilization with sling and swathe and tape for 2 weeks followed by progressive functional use of shoulder and arm

66. Complications of Scapula Fractures Nonunion (rare) Malunion more common DJD glenohumeral joint Shoulder instability Glenohumeral pain and dysfunction Infection, neurovascular injury, loss of fixation