Open Reduction and Internal Fixation of Intra-articular Scapular Fractures
DEFINITION
Brett D. Owens Joanna G. Branstetter Thomas P. Goss
Intra-articular scapular fractures include fractures of the glenoid cavity, which includes the glenoid rim and the
glenoid fossa. They account for 10% of scapular fractures.6 Most scapular fractures are extra-articular, and 50% involve the body and spine.
Over 90% of fractures of the glenoid cavity are insignificantly displaced and are managed nonoperatively.3 Significant displacement requires evaluation for surgical intervention to achieve the best possible outcome.
ANATOMY
The scapula is a flat triangular bone with three processes: the glenoid process, the acromial process, and the coracoid process.
The glenoid process consists of the glenoid cavity (the glenoid rim and glenoid fossa) and the glenoid neck.
The glenoid cavity provides a firm concave surface with which the convex humeral head articulates. The average depth of the articular cartilage is 5 mm.
Glenoid cavity fractures are classified according to whether they involve the glenoid rim or the glenoid fossa and the direction of the fracture line (FIG 1).
PATHOGENESIS
Scapular fractures usually are the result of high-energy trauma and have a high rate (90%) of associated bony and soft tissue injuries, both local and distant.5
Fractures of the glenoid rim occur when the humeral head strikes the periphery of the glenoid cavity. They are true fractures, not avulsion injuries caused by indirect forces applied to the periarticular soft tissues by the humeral head.
Fractures of the glenoid fossa occur when the humeral head is driven into the center of the concavity. The fracture then promulgates in a number of different directions, depending on the characteristics of the humeral head force.
NATURAL HISTORY
The results of nonoperative treatment of intra-articular scapular fractures usually are good if the fracture displacement is minimal and the humeral head lies concentrically within the glenoid cavity.
Significant displacement can result in posttraumatic degenerative joint disease, glenohumeral instability, and even nonunion.2
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. Deficits are evaluated with angiography and electromyography, as necessary.
A thorough soft tissue examination also is warranted. Wounds may represent an open fracture and warrant exploration. Blisters or swelling may delay surgery.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Intra-articular scapular fractures initially are evaluated with a routine scapula trauma radiographic series (a true anteroposterior view of the shoulder with the arm in neutral rotation, a true axillary view of the glenohumeral joint, and a true lateral scapular view; FIG 2A).
Computed tomography (CT) scans and three-dimensional studies with reconstructions can be helpful in evaluating articular congruity and fracture displacement (FIG 2B-D). In addition, the bony relationships should be evaluated for evidence of ligamentous disruption(s) or instability.
DIFFERENTIAL DIAGNOSIS
Intra-articular scapular fractures Nonarticular scapular fractures Scapulothoracic dissociation
Double disruptions of the superior shoulder suspensory complex, including a floating shoulder (a glenoid neck fracture with an ipsilateral middle third clavicle fracture)
NONOPERATIVE MANAGEMENT
Most (over 90%) intra-articular scapular fractures are insignificantly displaced and are managed nonoperatively.
Significantly displaced glenoid fossa and glenoid rim fractures require operative management.
SURGICAL MANAGEMENT
Surgical indications are as follows:
Rim fractures: 25% or more of the glenoid cavity anteriorly or 33% or more of the glenoid cavity posteriorly and displacement of the fragment 10 mm or more
Fossa fractures: an articular step-off of 5 mm or more, significant separation of the fracture fragments, or failure of the humeral head to lie in the center of the glenoid cavity
Preoperative Planning
Imaging studies should be reviewed before the surgery and should be available for reference in the operating room. A draped fluoroscopy unit and a competent technician should be available. An examination for instability can be performed while under anesthesia.
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FIG 1 • Goss-Ideberg classification of glenoid cavity fractures. Ia, anterior rim; Ib, posterior rim; II, inferior glenoid; III, superior glenoid; IV, transverse through the body; V, combination of II to IV; VI, comminuted.
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FIG 2 • A. The anteroposterior (AP) radiograph shows a type Vc glenoid cavity fracture. B. Axillary CT image shows a large anterosuperior glenoid cavity fragment including the coracoid process. (continued)
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FIG 2 • (continued) C. Axillary CT image shows the lateral aspect of the scapular body lying between the two glenoid cavity fragments and abutting the humeral head. D. Axillary CT image shows a large posteroinferior cavity fragment. (From 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.)
Positioning
Open reduction with internal fixation (ORIF) of intraarticular scapular fractures requires wide access to the entire shoulder girdle. Depending on the particular fracture, the patient is placed in either the lateral decubitus position (FIG 3A) or the beach-chair position (FIG 3B).
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.”
In some cases, a staged procedure may be necessary using separate positions, sterile preparations, and exposures.10
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FIG 3 • Patient position: lateral decubitus (A) and beach chair (B).
Approach
The posterior approach is used for fractures of the posterior glenoid rim and most fractures of the glenoid fossa.
The superior approach is used, in conjunction with a posterior approach, for fractures of the glenoid fossa with a difficult-to-control superior fragment.
The anterior approach is used for fractures of the anterior glenoid rim and some fractures involving the superior aspect of the glenoid fossa.
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TECHNIQUES
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Posterior Approach to the Glenoid Cavity
Bony landmarks are outlined with a marking pen.
An incision is made along the scapular spine and acromion and down the midlateral aspect of the shoulder, as needed (TECH FIG 1A).
Origins of the posterior and middle heads of the deltoid muscle are sharply detached from the scapular spine-acromial process, and the deltoid muscle is split in the line of its fibers for 2.5 cm in the midlateral line. It is then retracted distally (TECH FIG 1B).
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TECH FIG 1 • A. Posterior approach using a skin incision along the scapular spine and acromion. B. The posterior and posteromedial heads of the deltoid are detached from the scapular spine and acromial process. C. Interval developed between the infraspinatus and teres minor. D. The infraspinatus tendon and underlying posterior glenohumeral capsule are incised 2 cm from insertion on the greater tuberosity to allow access to the glenohumeral joint. (From Goss TP. Glenoid fractures: open reduction and internal fixation. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia: Lippincott-Raven, 1998:1-17.)
The interval between infraspinatus and teres minor is developed (TECH FIG 1C). To gain access to the glenoid fossa, the infraspinatus tendon and underlying posterior glenohumeral joint capsule are incised 2 cm lateral to their insertion on the greater tuberosity and reflected posteriorly (TECH FIG 1D).
Subperiosteal mobilization of the teres minor muscle allows access to the lateral scapular border.
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Superior Approach to the Glenoid Cavity
The superior approach to the glenoid cavity is made by extending the posterior incision superiorly. The trapezius and underlying supraspinatus muscles are split in the line of their fibers (TECH FIG 2).
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TECH FIG 2 • Superior approach. The trapezius and underlying supraspinatus muscles are split in line with their fibers. (From Goss TP. Glenoid fractures: open reduction and internal fixation. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia: Lippincott-Raven, 1998:1-17.)
Anterior Approach to the Glenoid Cavity
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The incision is made in Langer lines and centered over the glenohumeral joint from the superior to inferior level of the humeral head (TECH FIG 3A).
The deltoid muscle is split in the line of its fibers over the palpable coracoid process and retracted medially and laterally.
The conjoined tendon is retracted medially after division of the overlying fascia along its medial border (TECH FIG 3B).
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TECH FIG 3 • A. Anterior approach using a skin incision made in Langer lines and centered over the glenohumeral joint. B. The conjoined tendon is retracted medially. C. Incise the subscapularis tendon 2
cm from its insertion on the lesser tuberosity, dissect it off the glenohumeral capsule, incise the capsule similarly, and turn both of them back medially to gain access to the glenohumeral joint. (From Goss TP. 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.)
Care must be taken to protect all neurovascular structures from injury.
Incise the subscapularis tendon vertically 2.5 cm medial to its insertion on the lesser tuberosity and along its superior and inferior borders.
Dissect it off the underlying anterior glenohumeral capsule.
Tag the corners of the subscapularis unit and turn it back medially (TECH FIG 3C).
Incise the anterior glenohumeral capsule in the same fashion, tag its corners, and turn it back medially to gain access to the glenohumeral joint.
Fixation Techniques
The fracture is reduced as anatomically as possible.
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 or with cannulated interfragmentary compression screws, depending on the characteristics of the fracture.
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TECH FIG 4 • A. Postoperative AP image of the patient shown in TECH FIG 1. B. Axillary radiograph showing the glenoid cavity fragments secured together with cannulated screws and the glenoid unit secured to the scapular body with a malleable reconstruction plate (the acromial fracture was reduced and stabilized with a tension band construct). (continued)
Care must be taken to avoid violating the glenoid fossa with any screws placed in the glenoid fragment (TECH FIG 4A,B).
If severe comminution is present, an iliac crest tricortical bone graft is an option (TECH FIG 4C).
All soft tissues divided to gain access to the fracture site must be meticulously repaired. With posterior approaches, the deltoid must be securely reattached to the acromion and scapular spine with permanent sutures through drill holes.
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TECH FIG 4 • (continued) C. If severe comminution is present, an iliac crest tricortical bone graft is an option. (A,B: From 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.)
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PEARLS AND PITFALLS
Indications ▪ Rim fractures: 25% or more of the glenoid cavity anteriorly or 33% or more of the glenoid cavity posteriorly and displacement of the fragment 10 mm or more
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Fossa fractures: an articular step-off of 5 mm or more, significant separation of the fracture fragments, or failure of the humeral head to lie in the center of the glenoid cavity
Approach ▪ Incising the rotator interval and leaving the subscapularis unit intact may allow adequate exposure for injuries involving a displaced superior glenoid fragment.
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Some injuries require combined anteroposterior or posterosuperior approaches.
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Deltoid detachment and retraction provide maximal posterior exposure and access.
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During the posterior approach, develop the internervous plane in 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. They also can be driven across the fracture site to provide temporary or permanent fixation.
Fixation ▪ Bone stock capable of allowing internal fixation is at a premium in the scapula. The four satisfactory areas include the glenoid neck, the acromion-scapular spine, the lateral scapular border, and the coracoid process. Reconstruction plates may be precontoured using a scapula model and flash sterilized. If severe comminution is present, an iliac crest tricortical bone graft is an option. Cannulated interfragmentary screws can be inserted using previously placed K-wires as guidewires.
Closure ▪ If the deltoid muscle is detached, meticulous repair to the scapular spine-acromial process is necessary using nonabsorbable sutures placed through drill holes.
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POSTOPERATIVE CARE
The aggressiveness of the rehabilitation program following ORIF of intra-articular scapular fractures is determined by the rigidity of the fixation construct and the adequacy of the soft tissue repair.4
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 emphasizing forward flexion and internal-external rotation are prescribed during weeks 2 through 6 postoperatively.
All protection is discontinued at 6 weeks postoperatively.
Strengthening is begun after 6 weeks postoperatively and when range of motion is satisfactory. Return to sports or physical labor is restricted until 3 to 6 months postoperatively.
Close outpatient follow-up with radiographs, especially early in recovery, and a well-defined, closely monitored physical therapy program are extremely important.
OUTCOMES
Good results have been reported for the operative management of glenoid rim fractures.9,12
Bauer et al1 reviewed six patients treated surgically for glenoid cavity fractures. Four patients with an anatomic reduction had good results; two patients with nonanatomic reductions developed arthritic changes.
Kavanagh and colleagues7 presented their experience at the Mayo Clinic in which 10 displaced intra-articular fractures of the glenoid cavity were treated with ORIF. They found ORIF to be “a useful and safe technique” that “can restore excellent function of the shoulder.” In their series, the major articular fragments were displaced 4 to 8 mm.
Schandelmaier and coauthors11 reported a series of 22 fractures of the glenoid fossa treated with ORIF with good results.
Leung and colleagues8 reviewed 14 displaced intra-articular fractures of the glenoid treated with ORIF (30.5-year average follow-up) and reported nine excellent and five good results.
On the basis of these reports, it seems reasonable to conclude that there is a definite role for surgical management in the treatment of glenoid cavity fractures.
COMPLICATIONS
Neurologic complications 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 is at risk in the superior approach, and the axillary and suprascapular nerves are vulnerable in the posterior approach.10
A variety of other complications can occur as a result of poor surgical technique, inadequately directed or managed rehabilitation, and poor patient compliance.
REFERENCES
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Bauer G, Fleischmann W, Dussler E. Displaced scapular fractures: indication and long-term results of open reduction and internal fixation. Arch Orthop Trauma Surg 1995;14:215-219.
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DePalma AF. Surgery of the Shoulder, ed 3. Philadelphia: JB Lippincott, 1983.
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Goss TP. Fractures of the glenoid cavity. J Bone Joint Surg Am 1992;74:299-305.
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Goss TP. Glenoid fractures—open reduction and internal fixation. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia: Lippincott-Raven, 1998:1-17.
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Goss TP. Scapular fractures and dislocation: diagnosis and treatment. J Am Acad Orthop Surg 1995;3(1):22-33.
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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.
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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.
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Leung KS, Lam TP, Poon KM. Operative treatment of displaced intraarticular glenoid fractures. Injury 1993;24:324-328.
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Niggebrugge AH, van Heusden HA, Bode PJ, et al. Dislocated intraarticular fracture of the anterior rim of glenoid treated by open reduction and internal fixation. Injury 1993;24:130-131.
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Owens BD, Goss TP. Surgical approaches for glenoid fractures. Tech Shoulder Elbow Surg 2004;5:103-115.
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Schandelmaier P, Blauth M, Schneider C, et al. Fractures of the glenoid treated by operation. A 5- to 23-year follow-up of 22 cases. J Bone Joint Surg Br 2002;84(2):173-177.
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Sinha J, Miller AJ. Fixation of fractures of the glenoid rim. Injury 1992;23:418-419.