Operative Management of Shoulder Girdle Fractures: Clavicle, Scapula, and Proximal Humerus

Introduction to Shoulder Girdle Trauma

The shoulder girdle, comprising the clavicle, scapula, and proximal humerus, functions as a highly coordinated biomechanical linkage known as the Superior Suspensory Shoulder Complex (SSSC). Disruptions to this complex—whether through isolated high-energy fractures or combined polytrauma—demand meticulous evaluation and, frequently, operative intervention to restore the functional anatomy of the upper extremity.

Historically, many of these fractures were managed nonoperatively. However, contemporary evidence demonstrates that specific fracture patterns—such as displaced midshaft clavicle fractures, highly comminuted proximal humerus fractures, and the "floating shoulder"—benefit significantly from open reduction and internal fixation (ORIF) or arthroplasty. This masterclass delineates the indications, surgical approaches, and advanced fixation techniques required to manage these complex injuries effectively.

Operative Management of Clavicle Fractures

Clavicle fractures account for approximately 5% of all adult fractures. While non-displaced fractures heal reliably with conservative management, displaced fractures (particularly of the middle third) are associated with higher rates of nonunion, symptomatic malunion, and residual shoulder dyskinesia when treated closed.

Indications for Surgery

Evidence-based indications for the operative fixation of clavicle fractures include:
* Absolute shortening greater than 1.5 to 2.0 cm.
* 100% displacement (no cortical contact).
* Severe z-type comminution.
* Open fractures or impending skin necrosis (skin tenting).
* Concomitant neurovascular injury.
* Ipsilateral scapular neck fracture (the "floating shoulder").

Clinical Pearl: When evaluating a displaced lateral-third clavicle fracture, carefully assess the coracoclavicular (CC) ligaments. Fractures with detachment of the CC ligaments (Neer Type II) are highly unstable and carry a nonunion rate exceeding 30% if managed nonoperatively.

Surgical Positioning and Approach

1. Positioning: Place the patient in a beach-chair position with the head secured and the ipsilateral arm draped free to allow manipulation of the shoulder girdle.
2. Incision: Utilize an infraclavicular or direct superior approach. An infraclavicular incision is often preferred to minimize irritation from backpack straps and to preserve the supraclavicular nerve branches.
3. Dissection: Carry the dissection down through the platysma. Identify and protect the supraclavicular nerves. Strip the periosteum minimally to preserve the fracture hematoma and local vascularity.

Step-by-Step Fixation Techniques

• Midshaft Fractures (Plate Osteosynthesis):
  Reduce the fracture using pointed reduction forceps. For transverse or short oblique fractures, place an interfragmentary lag screw if the fracture pattern allows. Apply a pre-contoured superior or anteroinferior locking compression plate. Anteroinferior plating offers the biomechanical advantage of longer screw purchase in the narrow clavicle and reduces hardware prominence.
• Distal Clavicle Fractures:
  Unstable distal fractures require specialized fixation. Options include a clavicular hook plate, which leverages under the acromion to reduce the distal fragment, or coracoclavicular ligament reconstruction (e.g., suture button techniques) combined with a distal radius locking plate or specialized distal clavicle plate.

Operative Management of Scapula Fractures

Scapula fractures are rare, high-energy injuries often associated with pulmonary and neurovascular trauma. While the vast majority of scapular body fractures are managed nonoperatively, fractures involving the glenoid articular surface or causing severe medialization of the glenohumeral joint require surgical stabilization.

Indications and Biomechanics

Operative intervention is indicated for:
* Intra-articular glenoid step-off greater than 4 mm.
* Glenoid fractures involving more than 25% of the articular surface.
* Scapular neck fractures with >40 degrees of angulation or >1 cm of medial translation.
* Double disruptions of the SSSC (e.g., ipsilateral displaced clavicle and scapular neck fractures—the floating shoulder).

Surgical Warning: The "floating shoulder" represents a highly unstable biomechanical state. Fixation of the clavicle alone may indirectly reduce the scapular neck, but if the scapula remains displaced, direct fixation of the scapula is mandatory to prevent chronic rotator cuff dysfunction and impingement.

Surgical Approach: The Modified Judet

1. Positioning: Lateral decubitus position with the operative arm draped free over a sterile Mayo stand.
2. Incision: A classic or modified Judet (posterior) approach is utilized. Make an L-shaped incision along the scapular spine and the medial border of the scapula.
3. Interval: Elevate the infraspinatus off the scapular body, retracting it laterally to expose the scapular neck and posterior glenoid. Take extreme care to identify and protect the suprascapular nerve and vessels at the spinoglenoid notch.
4. Fixation: Reconstruct the articular surface first. Provisional fixation is achieved with Kirschner wires, followed by definitive fixation using 2.7-mm or 3.5-mm reconstruction plates along the lateral border (the thickest bone pillar of the scapula).

Operative Management of Proximal Humerus Fractures

Proximal humerus fractures present a complex reconstructive challenge, particularly in osteoporotic bone. The Neer classification—based on the displacement of the four anatomic segments (articular segment, greater tuberosity, lesser tuberosity, and diaphysis)—remains the standard for guiding treatment.

Predictors of Humeral Head Ischemia

Before selecting a fixation strategy, the surgeon must assess the risk of avascular necrosis (AVN). Hertel’s radiographic criteria for predicting ischemia include:
* Metaphyseal head extension (calcar length) of less than 8 mm.
* Disruption of the medial hinge (>2 mm displacement).
* Anatomic neck fracture patterns.

Surgical Approaches

• Deltopectoral Approach: The workhorse approach. The interval is between the deltoid (axillary nerve) and the pectoralis major (medial and lateral pectoral nerves). The cephalic vein is typically retracted laterally with the deltoid.
• Anterolateral Acromial Approach: Ideal for isolated greater tuberosity fractures or minimally invasive plate osteosynthesis (MIPO). The deltoid is split in line with its fibers. Pitfall: Do not split the deltoid distal to 5 cm from the acromion to avoid catastrophic injury to the axillary nerve.

Step-by-Step Surgical Techniques

1. Locking Plate Osteosynthesis (PHILOS)

Indicated for 2-part, 3-part, and select 4-part fractures in patients with adequate bone stock.
* Reduction: Achieve reduction via traction and manipulation. Pin the head to the shaft provisionally.
* Tuberosity Control: Pass heavy (#2 or #5) non-absorbable sutures through the bone-tendon junction of the rotator cuff (supraspinatus, infraspinatus, subscapularis).
* Plate Placement: Position the locking plate lateral to the bicipital groove and 5 to 8 mm distal to the tip of the greater tuberosity to prevent subacromial impingement.
* Fixation: Insert proximal locking screws. It is imperative to place inferomedial "calcar" screws to support the medial hinge and prevent varus collapse. Tie the previously placed tuberosity sutures through the plate's suture holes to neutralize the deforming forces of the rotator cuff.

2. Valgus Impaction Osteotomy (The Parachute Technique)

For valgus-impacted 4-part fractures, the articular surface is often preserved but driven down into the metaphysis.
* Elevate the articular segment gently ("parachute" it up) using an elevator.
* Graft the resulting metaphyseal void with cancellous allograft or autograft.
* Secure the construct with a locking plate or percutaneous threaded pins, ensuring the tuberosities are anatomically reduced beneath the elevated head.

3. Shoulder Arthroplasty

When the fracture is deemed un-reconstructible (e.g., head-splitting fractures, severe 4-part fractures with high ischemia risk in the elderly), arthroplasty is indicated.
* Hemiarthroplasty: Relies entirely on the anatomic healing of the tuberosities to the prosthesis for functional success. Precise height and retroversion (typically 20-30 degrees) are critical.
* Reverse Total Shoulder Arthroplasty (RTSA): Increasingly the treatment of choice for elderly patients with 4-part fractures. RTSA bypasses the need for tuberosity healing to achieve forward elevation, relying instead on the deltoid, thus offering more predictable functional outcomes in osteoporotic bone.

Adjunctive Fixation: Fragment-Specific Pin-Plate Techniques

In complex polytrauma involving the upper extremity—such as a floating shoulder combined with an ipsilateral comminuted distal radius fracture—fragment-specific fixation principles must be employed. When addressing small, highly comminuted articular fragments (e.g., radial styloid or specific tuberosity fragments), standard locking plates may be too bulky. In these instances, the application of a specialized pin-plate is required.

Surgical Technique: Pin-Plate Application
* Undercontour the plate to provide a springlike effect when applied, ensuring dynamic compression against the cortical surface.
* Position the plate, and secure the proximal limb of the plate with 2.3-mm screws. Application of screws through the distal limb of the plate usually is unnecessary, as the pins will capture the distal fragment.
* Apply the radial pin-plate over the initial styloid Kirschner wire.
* Reflect the first dorsal compartment tendons, and apply the plate beneath them to prevent attritional tendon rupture.
* Secure the plate with 2.3-mm screws through the proximal holes. Add a second or third 0.045-inch Kirschner wire if necessary, and cut, bend, and impact these wires in order from proximal to distal.
* Close the wounds in routine fashion, and apply a removable splint if patient compliance is expected.

Postoperative Rehabilitation Protocols

The success of shoulder girdle reconstruction is inextricably linked to postoperative rehabilitation.
* Phase I (0-4 weeks): The shoulder is immobilized in a sling. Pendulum exercises and passive range of motion (PROM) in forward elevation and external rotation are initiated immediately to prevent adhesive capsulitis. Exception: Limit external rotation if the lesser tuberosity/subscapularis was repaired.
* Phase II (4-8 weeks): Transition to active-assisted range of motion (AAROM). Radiographic evaluation should confirm early callus formation and maintenance of hardware position.
* Phase III (8-12 weeks): Initiate active range of motion (AROM) and progressive isotonic strengthening of the rotator cuff and periscapular stabilizers.
* Phase IV (>12 weeks): Return to heavy labor and sports, contingent upon radiographic union and symmetric strength.

Complications and Salvage Procedures

Despite meticulous surgical technique, complications can arise:
* Varus Collapse: The most common mode of failure in proximal humerus plating. Prevented by anatomic reduction of the medial calcar and the use of inferomedial locking screws.
* Avascular Necrosis (AVN): Can occur even after successful ORIF. If symptomatic, salvage typically requires conversion to a total shoulder arthroplasty or RTSA.
* Hardware Penetration: Primary screw penetration into the glenohumeral joint must be avoided by utilizing intraoperative fluoroscopy in multiple planes (AP, scapular Y, and axillary lateral). Secondary penetration occurs due to osteoporotic settling and requires prompt hardware removal.
* Nonunion: Clavicular nonunions are treated with revision ORIF using a robust locking plate and autologous iliac crest bone grafting.

Mastery of these operative techniques, combined with a profound respect for the soft tissue envelope and local biomechanics, allows the orthopedic surgeon to navigate the complexities of shoulder girdle trauma and restore optimal function to the patient.