1、Scapula Fractures Thomas P. Goss, MD Robert V. Cantu, MD University of Massachusetts Medical Center Scapulothoracic Dissociation Andrew H. Schmidt, MD Created March 2004,Outline,1. Incidence and Mechanisms2. Diagnosis and Nonoperative Treatment3. Fractures of the Glenoid Process4. Isolated Fractures
2、 of the Coracoid Process,Outline Continued,5. Isolated Fractures of the Acromial Process6. Double Disruptions of the Superior Shoulder Suspensory Complex7. Scapulothoracic Dissociation8. Complications,Incidence of Scapula Fractures,1% of all fractures3% of injuries to shoulder girdle5% of shoulder f
3、ractures,Location of Scapula Fractures,Diagnosis,History typically high energy injury (80-95% incidence other injury)Mechanism often direct but can be indirectDiagnosis ultimately radiographic,Radiographs,“Scapula trauma series”: AP and Lat of scapula, true glenohumeral axillary viewCT scanning for
4、complex injuries with 3D reconstructionsStress AP projection if injury to the clavicular-scapular linkage suspected,Nonoperative Treatment,90% scapular fractures minimally displacedTreatment in sling and swathe with gradual increase of functional use for first 6 weeksx-rays at 2 week intervals until
5、 6 weeks,Nonoperative Tx Continued,At 6 weeks osseous union usually present and sling/swathe discontinuedFull recovery may take 6 months to 1 year,Operative Indications,1. Significantly displaced (5-10mm) fractures of glenoid cavity (rim and fossa)2. Significantly displaced (10mm or 40 degrees rotat
6、ion) fractures of the glenoid neck3. Double Disruptions of the superior suspensory shoulder complex with displacement of one or more elements,Glenoid Process,Glenoid process includes glenoid cavity (rim and fossa) and glenoid neck,Fractures of the Glenoid Cavity (Rim and Fossa),10% of scapula fractu
7、res of which no more than 10% are significantly displaced,Classification Glenoid Cavity Fractures,Ia= anterior rim fractureIb=posterior rim fracture,Classification Glenoid Cavity Fractures,II= fracture line through glenoid fossa exiting at lateral border of scapula,Classification Glenoid Cavity Frac
8、tures,III= fracture line through glenoid fossa exiting at superior border of the scapula,Classification Glenoid Cavity Fractures,IV= fracture line through glenoid fossa exiting at the medial border of the scapula,Classification Glenoid Cavity Fractures,Va= combination types II and IV Vb= combination
9、 types III and IV Vc= combination types II,III, and IV,Classification Glenoid Cavity Fractures,VI= comminuted fracture,Glenoid Rim Fractures,Instability anticipated if fracture displaced 10mm and involves one fourth anterior aspect or one third posterior aspect glenoid cavityFractures of anterior ri
10、m approached anteriorly and posterior rim posteriorly,Fractures of the Glenoid Fossa,Surgery if articular step-off 5-10mm or displacement causes subluxation humeral head out of glenoid cavityAll glenoid fossa fractures approached posteriorly,Glenoid Neck Fractures,25% of scapula fractures of which 1
11、0% or less are significantly displacedMechanism can be direct blow, fall on outstretched arm, or fall on superior aspect shoulder,Classification Glenoid Neck Fractures,Type I: non and minimally displaced (10mm) Type II: translational displacement 1cm or more or angulatory displacement 40 degrees or
12、more,Glenoid Neck Fractures Continued,Surgery for type II fracturesPosterior approach between infraspinatus and teres minor Fixation with 3.5mm recon plate, and possibly k-wires or interfragmentary screws,Isolated Fractures of the Coracoid Process,Fracture can be at base of coracoid, between CA and
13、CC ligaments, or at tip (avulsion)Diagnosis often on plain films but CT scan may be needed to better define fractureFractures at tip of coracoid typically treated non-operatively (athletes and manual laborers may be exceptions),Coracoid Fractures Cont,Surgical options include ORIF (cannulated 3.5 or
14、 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. F
15、ibrous union may occur but rarely source discomfort,Isolated Fractures of the Acromial Process,Scapula series detects most acromial fracturesOs acromionale may complicate evaluationMost are nondisplaced or minimally displaced and treated symptomatically,Fixation of Acromial Fractures,If ORIF underta
16、ken tension band construct for fractures at distal portion and 3.5mm recon plate for more proximal fractures,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
17、process, CC ligaments, distal clavicle, AC joint, acromial process Superior strut is middle third clavicle Inferior strut is lateral scapular body and spine,Superior Shoulder Suspensory Complex,Double Disruption of SSSC,Traumatic disruption 2 or more components SSSC usually secondary to high energy
18、injury and frequently require surgical managementFrequently described as “Floating Shoulder”Potential long term consequences non-operative treatment include: nonunion, malunion, impingement, altered shoulder mechanics, DJD, neurovascular compromise,Floating Shoulder,Operative management recommended
19、because of potential instability, displacement of glenoidRecent series of floating shoulders treated nonoperatively shows good results with conservative care.,Nonoperative Management of Ipsilateral Fractures of the Scapula and Clavicle,Retrospective review of 20 cases 11 of 20 clavicle fxs displaced
20、 10 mm 5 of 20 scapular fxs displaced 5 mm Treated with sling or immobilizer Evaluated by 3 different shoulder scores, strength compared to uninjured shoulder.,Edwards SG, et al. JBJS 82B: 774-80, 2000,Results,1 clavicle nonunion (segmental bone loss at injury) Strength = to opposite arm in all Cons
21、tant score 96, Rowe score 95 17-18 patients excellent results depending on evaluation system,Edwards SG, et al. JBJS 82B: 774-80, 2000,Summary - Floating Shoulder,Nonoperative treatment sufficient for many of these injuries. Each component of the injury should be separately evaluated for indications
22、 for surgery, but the combination itself does not mandate operative intervention,Scapulothoracic Dissociation,Traumatic disruption of scapula from posterior chest wallNeurovascular injury common,Scapulothoracic Dissociation = Closed Forequarter Amputation,Scapulothoracic Dissociation,Left scapulotho
23、racic dissociation with brachial artery disruption,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 ob
24、vious fracture or dislocation about the shoulder Sometimes without obvious bone injury,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
25、extremity in 52% Early amputation in 21% Death in 10%, 8% due to this injury,Damschen et al, J Trauma 42:537, 1997.,Musculoskeletal Injuries,Damschen et al, J Trauma 42:537, 1997.,Clavicle Injury: 47%,Sternoclavicular separation: 28%,Acromioclavicular separation: 25%,Brachial Plexus Injury,Complete
26、brachial plexopathy: 81% Partial plexopathy: 13% None: 6%,Damschen et al, J Trauma 42:537, 1997.,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 avulsio
27、ns and complete deficits have a poor prognosis Partial plexus injuries have good prognosis and functional use extremity often regained,Vascular Injury,Subclavian or axillary artery: 88% None: 12%,Damschen et al, J Trauma 42:537, 1997.,Diagnosis,Massive swelling of shoulder region Pulseless arm Compl
28、ete or partial neurologic deficit Lateral displacement of scapula on a non-rotated chest radiograph is diagnostic,37 year old male, found lying on ground, intoxicated. Paramedics noted broken branches above. Patient later found to have fallen from 2nd story balcony,Intoxicated Pale In acute distress
29、 Bilateral breath sounds present Left shoulder swelling Absent pulses left arm Unable to move left arm,Distal Clavicle Fracture,Chest Radiography,Ratio of distance between medial border of scapula and spinous process on non-rotated CXR (A/B)= 1.07,Chest Radiography has many pitfalls:Absence of bony
30、injuryPatient positionBilateral injuries,Kelbel et al, CORR 209:210, 1986.,CT Scan,Subclavicular swelling,Arteriogram,Classification,Type I: Musculoskeletal injury alone Type IIA: Musculoskeletal injury with vascular disruption Type IIB: Musculoskeletal injury with neurologic impairment Type III: Mu
31、sculoskeletal injury with both neurologic and vascular injury,Damschen et al, J Trauma 42:537, 1997.,Initial Treatment,Patients often polytraumatized ATLS protocols must be followed. Angiography of limb. Vascular repair, with exploration of brachial plexus.,Case Example,To OR immediately Revasculari
32、zation of Left Arm with Goretex graft. Musculocutaneous nerve avulsion ?,What can the orthopedist do?,Stabilize associated bone or joint injury Clavicle fractures are most common.,Benefits of Skeletal Stabilization,Avoid delayed or nonunion Stabilize shoulder girdle Protect vascular and/or neurologi
33、c repairs,ORIF Clavicle,Complications of Revascularization,Graft thrombosis Compartment syndrome Hyperkalemia Rhabdomyolysis, myoglobinuria,Case Example,CPK levels: 9579 IU/L just after admission Hb: 13.7 admission to 8.1 4 hrs laterTreated with iv fluids and alkalinization of urine, no renal failur
34、e seen.,Deep Vein Thrombosis,Severe swelling of arm 2 weeks later DVT L cephalic and brachial veins,Later Treatment,3 weeks: EMG 6 weeks: cervical myelography Shoulder arthrodesis and/or above-elbow amputation may be necessary if the limb is flail.,Prognosis,Nerve avulsion or complete neurologic def
35、icit: poor Partial neurologic deficit: good,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.,Limb Salvage,If initial explo
36、ration 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.,Summary - Scapulothoracic Dissociation,Scapulothoracic dissociation may be a life or limb-threat
37、ening 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.,Intrathoracic Dislocation of the Scap
38、ula,Extremely rareInferior angle scapula locked in intercostal spaceChest CT may be needed to confirm diagnosis,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,Complications of Scapula Fractures,Nonunion (rare) Malunion more common DJD glenohumeral joint Shoulder instability Glenohumeral pain and dysfunction Infection, neurovascular injury, loss of fixation,Return to Upper ExtremityIndex,
