^DEFINITION

^{Nonarticular scapular fractures include fractures of the glenoid neck, scapular spine and body, acromial process, and coracoid process. They account for 90% of scapular fractures.6}

^{Most nonarticular scapular fractures can be treated nonoperatively, including all isolated scapular body-spine fractures.}

^{Significant displacement at one or more of these sites, alone or in conjunction with ligamentous disruptions of the superior shoulder suspensory complex, require evaluation for surgical intervention.1, 9}

 

 

^ANATOMY

 

^{The scapula is a flat triangular bone with three processes laterally: the glenoid process, the acromial process, and the coracoid process.}

 

^{The glenoid process consists of the glenoid fossa, the glenoid rim, and the glenoid neck.}

 

^{The superior shoulder suspensory complex is a bone and soft tissue ring at the end of a superior and an inferior bony strut (FIG 1). This ring is composed of the glenoid process, the coracoid process, the coracoclavicular ligament, the distal clavicle, the acromioclavicular joint, and the acromial process. The superior strut is the middle third of the clavicle, whereas the inferior strut is the junction of the most lateral}

^{portion of the scapular body and the most medial portion of the glenoid neck.1}

 

 

 

^{FIG 1 • Superior shoulder suspensory complex.}

 

^PATHOGENESIS

 

^{Scapular fractures usually are the result of high-energy trauma and have a high rate of associated musculoskeletal and underlying thoracic injuries.5}

 

^{Fractures of the acromion process may be the result of direct trauma due to its subdermal location, whereas coracoid process fractures may be due to a sudden muscular contraction.4}

^{NATURAL HISTORY}

 

^{The results of nonoperative treatment of nonarticular scapular fractures generally are good. Nonunion is rare because the area has a rich blood supply. Angular deformities often are well compensated for by the wide range of motion of the glenohumeral joint and scapulothoracic articulation.}

 

^{PATIENT HISTORY AND PHYSICAL FINDINGS}

 

^{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.}

 

^{A thorough neurovascular examination must be performed and deficits evaluated with angiography and electromyography, as necessary.}

 

^{A thorough soft tissue examination also is warranted, as wounds may represent an open fracture and warrant}

^{exploration. Blisters or swelling may delay surgery.}

 

^{IMAGING AND OTHER DIAGNOSTIC STUDIES}

 

^{Nonarticular scapular fractures usually are identified on routine shoulder trauma series radiographs: a true anteroposterior (AP) view of the shoulder with the arm in neutral rotation, a true axillary view of the glenohumeral joint, and a true lateral scapular view. An AP weight-bearing view may be indicated.}

 

^{Computed tomography (CT) scans and three-dimensional reconstructions can be helpful for identification and classification of fractures owing to the complex bony anatomy in this region. In addition, the bony relationships should be evaluated for evidence of any ligamentous disruption.}

 

 

²³¹

 

^{DIFFERENTIAL DIAGNOSIS}

^{Nonarticular scapular fractures Intra-articular scapular fractures}

^{Double disruptions of the superior shoulder suspensory complex including a floating shoulder (ie, glenoid neck fracture with ipsilateral middle third clavicle fracture)}

^{Scapulothoracic dissociation}

 

 

^{NONOPERATIVE MANAGEMENT}

 

^{Most (over 90%) scapular fractures can be treated nonoperatively.}

 

^{Glenoid fossa and rim fractures may require operative management and are discussed in Chapter 25.}

 

^{Glenoid neck fractures with more than 40 degrees of angulation in the coronal or sagittal plane or translational displacement of 1 cm or more require surgical management. Anatomic neck fractures (lateral to the coracoid}

^{process) are inherently unstable and should also be considered for operative intervention.2}

 

^{Isolated acromial and coracoid process fractures usually are minimally displaced and can be managed nonoperatively. Significant displacement or fractures in conjunction with other bony and soft tissue injuries to}

^{the shoulder girdle may require surgical stabilization.4}

 

 

 

^{FIG 2 • A. The lateral decubitus position is used for posterior and posterosuperior approaches to the glenoid process. B. The beach-chair position.}

 

^{SURGICAL MANAGEMENT}

^{Preoperative Planning}

 

^{Imaging studies should be reviewed and available for reference in the operating room. A draped fluoroscopy unit and competent technician should be available during the surgery.}

 

^Positioning

 

^{Open reduction with internal fixation (ORIF) of scapular fractures requires wide access to the entire shoulder girdle. The patient may be placed in either the lateral decubitus position (FIG 2A) or in the beach-chair position (FIG 2B), but 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.”}

 

^{Alternatively, a staged procedure can be performed using separate positions, sterile preparations, and separate exposures.10}

 

^Approach

 

^{Glenoid neck fractures are approached posteriorly.}

 

 

^{A superior approach can be added for control and positioning of a difficult-to-control glenoid fragment. An anterior approach is used for coracoid process fractures.}

 

^{A superior approach is used for access to acromial process fractures.}

 

 

²³²

 

^TECHNIQUES

• ^{Posterior Approach to Glenoid Neck}

^{Bony landmarks are outlined with marking pen (TECH FIG 1A).}

 

 

^{An incision is made along the scapular spine and acromion and down the lateral aspect of the shoulder, as needed.}

 

^{The origins of the posterior and middle heads of the deltoid muscle are sharply detached from the scapular spine-acromial process and retracted distally (TECH FIG 1B).}

 

^{The interval between infraspinatus and teres minor is developed.}

 

^{If access to the glenoid fossa is necessary, the infraspinatus tendon and underlying posterior glenohumeral joint capsule are incised 2 cm lateral to their insertion on the greater tuberosity and reflected laterally (TECH FIG 1C,D).}

 

 

 

^{TECH FIG 1 • A. The standard posterior incision extends along the inferior margin of the scapular spine and the acromion. At the lateral tip of the acromion, the incision continues in the midlateral line for 2.5 cm.}

^{B. The posterior and middle heads of the deltoid muscle have been detached from the scapular spine-posterior acromial process and retracted distally to expose the infraspinatus musculotendinous unit. C. The infraspinatus-teres minor interval has been developed, with the infraspinatus retracted superiorly and the teres minor retracted inferiorly to expose the posterior glenohumeral joint capsule (the inferior portion of the infraspinatus insertion has been released). D. The infraspinatus tendon and underlying posterior glenohumeral joint capsule are incised 2 cm from insertion on the greater tuberosity to allow access to the glenohumeral joint. (From Goss T Glenoid fractures: open reduction and internal fixation. In Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia: Lippincott-Raven, 1998:1-17.)}

 

 

^{Mobilization of the teres minor muscle allows access to the lateral scapular border.}

 

^{Reduction of the fracture is performed with lateral traction on the draped arm and manipulation of the fracture site.}

 

^{Temporary fixation may be obtained with Kirschner wires (K-wires).}

 

^{Rigid fixation may be obtained with a contoured reconstruction plate and 3.5-mm cortical screws (TECH FIG 1D).}

 

^{Care must be taken to avoid violating the glenoid fossa with the screws in the glenoid fragment.}

 

^{Meticulous repair of the deltoid origin to the scapular spine-acromion should be performed with permanent sutures through drill holes.}

• ^{Superior Approach to Glenoid Neck}

   

  ^{The superior approach to the glenoid neck is made in an extensile fashion by extending the posterior incision superiorly.}

   

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

   

   

   

  ^{TECH FIG 2 • In the interval between the clavicle and the scapular spine-acromial process, the trapezius and supraspinatus tendon have been split in line of their fibers for exposure. (From Goss T Glenoid fractures: open reduction and internal fixation. In Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia: Lippincott-Raven, 1998:1-17.)}

   

   

  ²³³

• ^{Open Reduction with Internal Fixation of Acromial Process Fracture}

   

  ^{Incision directly over the acromial process}

   

  ^{Subperiosteal dissection to expose the superior surface of the acromion}

   

   

   

  ^{TECH FIG 3 • Fixation techniques for acromion process fractures. A. Plate-and-screw construct for a fracture of the base of the acromion. B. Tension band wire construct.}

   

   

  ^{Anatomic fracture reduction under direct visualization}

   

   

  ^{Proximal fractures: fixation with a contoured 3.5-mm reconstruction plate (TECH FIG 3A) Distal fractures: fixation with a tension band construct (TECH FIG 3B)}

• ^{Open Reduction with Internal Fixation of Coracoid Process Fracture}

 

^{Vertical incision 1 cm lateral to coracoid process (TECH FIG 4A)}

 

^{Development of deltopectoral interval or split of the deltoid muscle in line with its fibers directly over the coracoid process}

 

^{Exposure of the fracture site (may need to open the rotator interval)}

 

 

 

^{TECH FIG 4 • A. Standard anterior incision extends from the superior to inferior margin of the humeral}

^{head, centered over the glenohumeral joint. B-D. Three repair techniques for coracoid fractures. B.}

^{Cannulated screw fixation of tip avulsion with sufficient bone to repair. (continued)}

 

 

^{If coracoid tip has sufficient stock, cannulated screw fixation can be performed (TECH FIG 4B).}

 

^{If not, fragment excision and suture fixation of conjoint tendon to remaining coracoid is performed (TECH FIG 4C).}

 

^{Coracoid base fractures are fixed with a single cannulated cortical screw (TECH FIG 4D).}

 

 

²³⁴

 

 

 

^{TECH FIG 4 • (continued) C. Suture fixation of conjoint tendon when insufficient bone is available to repair.}

 

 

^{D. Cannulated screw fixation for proximal fracture. (A: From Goss T Open reduction and internal fixation of glenoid fractures. In: Craig EV, ed. Master Techniques in Orthopaedic Surgery: The Shoulder, ed 2. Philadelphia: Lippincott Williams & Wilkins, 2004.)}

 

PEARLS AND PITFALLS
	Indications ▪ CT can help define the fracture, assess possible intra-articular involvement, and identify concomitant injuries. Most nonarticular injuries and all scapular body-spine fractures are treated nonoperatively.     Approach ▪ Deltoid detachment and reflection provides maximal visualization and is recommended for surgeons unfamiliar with the posterior approach. During the posterior approach, the internervous plane is between the infraspinatus (a bipennate muscle) superiorly and the teres minor inferiorly.     Reduction ▪ K-wires can be placed to serve as “joysticks” to assist with fracture reduction.

 

	Fixation ▪ K-wires should be avoided for permanent fixation. However, they can be placed percutaneously and used for temporary or supplemental fixation, being removed at 4-6 weeks. Reconstruction plates may be precontoured using a scapula model.     Closure ▪ Meticulous repair of the deltoid to the scapular spine-acromial process is necessary, using nonabsorbable sutures placed through drill holes.

 

 

 

^{POSTOPERATIVE CARE}

 

^{How aggressive the rehabilitation program following ORIF of nonarticular scapular fractures must be is determined by the rigidity of the fixation construct and the adequacy of the soft tissue repair.3}

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

^{Progressive passive and active-assisted range-of-motion exercises are emphasized during weeks 2 through 6 postoperatively.}

^{All protection is discontinued by 6 weeks postoperatively.}

^{Strengthening is begun after 6 weeks postoperatively and after range of motion is satisfactory. Return to sports or labor is restricted until 4 to 6 months postoperatively.}

 

^OUTCOMES

^{Relatively few outcome studies detailing the results of scapular fractures treated operatively are available.}

^{Although most nonarticular scapular fractures are treated nonoperatively, those that warrant surgical intervention appear to benefit from this treatment.7, 8}

 

 

²³⁵

 

^{COMPLICATIONS}

^{When neurologic complications occur, they most commonly are caused by overly aggressive retraction or misdirected dissection.}

^{The musculocutaneous and axillary nerves are vulnerable in the anterior approach, the suprascapular nerve in the superior approach, and the axillary and suprascapular nerves in the posterior approach.10}

 

 

^REFERENCES

1. ^{Goss T Double disruptions of the superior shoulder complex. J Orthop Trauma 1993;7:99-106.}

    

2. ^{Goss T Fractures of the glenoid neck. J Shoulder Elbow Surg 1994;3:42-52.}

    

    

3. ^{Goss T Glenoid fractures: open reduction and internal fixation. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures, ed 2. Philadelphia: Lippincott Williams & Wilkins, 2006.}

    

    

4. ^{Goss T The scapula: coracoid, acromial, and avulsion fractures. Am J Orthop 1996;25:106-115.}

    

    

5. ^{Goss T Scapular fractures and dislocation: diagnosis and treatment. J Am Acad Orthop Surg 1995;3:22-33.}

    

    

6. ^{Goss TP, Owens BD. Fractures of the scapula: diagnosis and treatment. In: Iannotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and Management, ed 2. Philadelphia: Lippincott Williams & Wilkins, 2007:793-840.}

    

    

7. ^{Hardegger FH, Simpson LA, Weber BG. The operative treatment of scapular fractures. J Bone Joint Surg Br 1984;66(5):725-731.}

    

    

8. ^{Kavanagh BF, Bradway JK, Cofield RH. Open reduction of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75(4):479-484.}

    

    

9. ^{Owens BD, Goss T The floating shoulder. J Bone Joint Surg Br 2006;88(11):1419-1424.}

    

    

10. ^{Owens BD, Goss T Surgical approaches for glenoid fractures. Tech Shoulder Elbow Surg 2004;5:103-115.}