SCAPULA

FRACTURE
EPIDEMIOLOGY
Fractures of the scapula account for only 0.4–1% of all
fractures in trauma patients

In polytrauma patients, fractures of the scapula are always

an indicator for severe thoracic trauma, sometimes
including rupture of the thoracic aorta

Associated ipsilateral fractures of the clavicle occur in about 25

% of all cases and may lead to a floating shoulder.
 MOI Associated Injury
 The mechanism of scapula  Isolated scapula fractures
fractures varies. Most often the
 Fractures of the ribs
fracture is caused by a direct
blow to the scapula, during a  Injuries to the thoracic cavity
traffic accident, or a fall from and lungs
height, or by the fall of a heavy
 Injuries to the shoulder girdle
object on the shoulder.
 The fracture pattern depends on  Head injuries
the shape of the object, the
energy of the blow, and the
force vector.
 Scapulothoracic Dissociation
 Scapulothoracic dissociation is
a traction (avulsion) injury of
the muscular apparatus of the
scapula, characterized by lateral
displacement of the scapula,
with a wide range of
concomitant injuries, including
those of the shoulder girdle,
while the skin is usually intact
CLASSIFICATION
Tscherne and Christ, Ada and
IDEBERG
Miller, and Euler and Rüedi.
 Fractures of the processes
 Fractures of the scapular body
 Fractures of the scapular neck
 Fractures of the glenoid
 Combined fractures of the
scapula
ASSESSMENT AND
DIAGNOSIS

The clinical symptoms of a scapular fracture are

quite nonspecific and frequently masked by the
symptoms of concomitant injuries

With a fracture of the scapular neck, the

suprascapular nerve is at risk of being injured as it
runs through the scapular notch at the superior
border.
The radiological examination consists of
three trauma views of the shoulder
(AP in scapular plane, lateral in scapular plane, and
axillary projection).

Involvement of the glenoid requires a CT scan to determine the number and size of the
fragments as well as the extent of the articular displacement.

The clavicle should always be assessed,

as associated fractures are not uncommon
 MEASUREMENTS OF ANGULATION,
TRANSLATION, MEDIALIZATION, AND GPA

Medialization -->medialization of 10 to
20 mm to be an indication for operative
treatment

Angulation--> angulation of more than

Neer projections and 3D CT
30 to 45 degrees as an indication for
reconstructions
operative treatment

Translation A strong indication for

operative treatment is considered to be
translation of fragments by 100%

GPA --> the angle subtended by two

lines, one connecting the most cranial
with the most caudal point of the glenoid
and one connecting the most cranial
point of the glenoid with the most caudal
part of the scapula.

Shoulder AP

Less than 20 degrees being likely to

compromise function
 Neer I projection, the true anteroposterior radiograph of the scapula, is
used to assess the glenohumeral joint space, dis- placement of the
glenoid in relation to the lateral border of the scapula, and to measure
the glenopolar angle (GPA).
 Neer II projection, also called Y-view, is a true lateral scapula
projection. This projection allows assessment of scapular body fractures
in terms of translation, angulation, and overlap of fragments,
particularly of the lateral border. In addition, it displays clearly the
relationship between the acromion and the lateral clavicle, and can be
used to identify any avulsion of the anterior rim of the glenoid.
TREATMENT
NONOPERATIVE
TREATMENT OF
SCAPULA FRACTURES
Nonoperative treatment is indicated in all undisplaced fractures.

Nonoperative treatment consists of pain relief and about 2 weeks

of sling immobilization

It is then possible to start passive range-of-motion exercises with the aim of

achieving a full passive range of motion within 1 month of the injury.

Full active range of motion should be restored during the second month. In the
third month, strengthening of the rotator cuff muscles and parascapular muscles
may be started

The potential disadvantages of nonoperative treatment include

deformity of the scapula and incongruity and instability of the
glenohumeral joint.
OPERATIVE TREATMENT OF
SCAPULA FRACTURES
 The main indication for operative treatment of the glenoid fractures is
displacement, that is, a gap, or step-off, ≥3 to 10 mm, with the
simultaneous involvement of 20% to 30% of the articular surface and/or
persisting subluxation of the humeral head
 The aim of operation is to restore congruity and stability of the
glenohumeral joint.
APPROACH
DELTOPECTORAL APPROACH

This approach is used

for fractures of the
anteroinferior glenoid
rim as the humeral head
can be partially
dislocated posteriorly
to visualize the glenoid
rim.
SUPERIOR APPROACH

This approach is used for

superior glenoid fragments.
The skin incision runs in the
middle between the clavicular
and scapular spine, as far
laterally as possible.
POSTERIOR APPROACHES

The classical approach, as described by Judet, gives access

to the posterior aspect of the scapular body, the scapular
neck, and the glenoid.
OPERATIVE TECHNIQUE
 Scapula fractures can be fixed
by small- and mini- implants,
including 3.5- or 2.7-mm
cortical screws, 3.5- or 2.7-mm
reconstruction plates, a 3.5-mm
semitubular plate, a 3.5-mm T-
plate, or a 2.7-mm L- or T-
shaped plate.
 Cannulated screws are useful in
internal fixation of fractures of
the coracoid process and
miniscrews (2.4 and 2 mm)
may be used in fixation of small
fragments of the glenoid fossa
or intermediate fragments of the
lateral border of the scapula
COMPLICATION
 Stiffness
 Infection
 Suprascapular nerve palsy
POSTOPERATIVE TREATMENT

The arm is immobilized in a sling. Drainage is removed by 48 hours after surgery.

Radiographs of the shoulder are obtained using Neer I and II views. After discharge,
the patient is reviewed 2 weeks after operation to assess wound healing and remove
sutures. Radiographs are taken at 6 weeks (Neer I and II views), 3 months (Neer I
view), 6 months (Neer I view, if necessary), and 1 year after operation (Neer I and II
views). Scapula fractures heal as a rule in 6 to 8 weeks.

Correct rehabilitation is very important for the final outcome. Passive range-of-
motion exercises of the shoulder should begin on the first postoperative day and
continue for about 6 weeks using a CPM machine if available. Active range-of-
motion exercises start at approximately 4 to 5 weeks postoperatively, Active
resistance exercises may be started approximately 8 weeks after operation. All
restrictions are lifted around 3 months postoperatively.
TERIMA KASIH