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 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 fractures,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 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 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 rotation) 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 fractures 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 Fractures,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 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 rim 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 10% 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 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 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 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,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 undertaken 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 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,