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Advancements

in the

Treatment of

Scapula

Fractures

Peter A. Cole, MDDepartment of Orthopaedic Surgery, University of Minnesota, Regions Hospital, St. Paul, MN

www.ScapulaInstitute.org

@PeterAColeMD

Disclosures

•Bone Foams Inc, LLC: Stock/Stock Options

•Stryker: Research support

•Synthes: Research support

Scapula History

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One Surgeon’s Journey

•Scapula fractures treated differently

•Nonoperative management the norm for all fxs

•New frontier?

Length, Alignment, Rotation

Anatomic Articular Reduction

Restore Stability

Respect Soft Tissue

Principles of Fracture

Management

AO principles of fracture management

Deformity=Dysfunction

Unless it’s a

scapula?

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Deformity

Angulation Intraarticular

SSSC

Medialization

Glenopolar angle

Studying Deformity

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Outline• Classification, Diagnosis, Radiographic

Measurements & Indications

• Diagnostic Interpretations, Perioperative Considerations & Associated Injuries

• Surgical Approaches, Reduction Techniques, implants

• Cases

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Scapula Fractures:

DiagnosisRadiographic Measurement

ClassificationIndications

Babar Shafiq, MD, MSPTAssistant Professor

Trauma Division

Department of Orthopaedic Surgery

Johns Hopkins School of Medicine

Disclosures

I have no disclosures

related to this talk

Diagnosis: History & Physical

• Blunt injury high-energy trauma

• 90% associated injuries

• Scapula fractures often overlooked– Life-threatening injuries treated first

– Detection and management often delayed

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Diagnosis: Clinical Deformities

Diagnosis: Clinical

Deformities

Diagnosis: Skin

Delay surgery until re-epithelialization 10-14 days

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Diagnosis: Associated Injuries

• Chest Wall

• Head Injury

• Cervical & Thoracic Spine Fractures

• Neurovascular

Document Neurovascular Exam

Chest, C-Spine XR or CT

Imaging

• Radiographs– Trauma Series

– True AP (Grashey)

– Axillary

– Scapular “Y”

• CT– Fine Cuts (≤2mm)

– 3D Reconstructions

Measurement Terms

Medialization(Lateral Border Off-set)

Glenopolar Angle(GPA)

Angulation

J Am Acad Orthop Surg 2012;20: 130-141

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Step-off

22mm

18mm

28mm

25mm

4mm

GPA (Glenopolar Angle)

36°

Angulation

42°

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Medialization/Lateral Border Offset

28mm

How do we interpret the injury?

Classification: Brief History

1579 – 1900s French

1723 Petit

1913 Lambotte

1984 Hardegger

1991 Ada & Miller

1998 Ideberg (Mod. Mayo)

Pare, Petit, Desault, DuVerney, Lenormant,

Dujarier, Malgaigne, Basset, Dupont, Judet,

and EvrardBodyNeck

ProcessInternal Fixation

Indications Criteria:Angulation >40 degMedialization >1cm

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90 3D-CT Scans

Scapula Maps – Inferior Glenoid Neck (n=61)

Classification: History

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Kavanagh BF, et

al.

(1993)

>2mm

Mayo KA, et al.

(1998)>5mm

Herrera DA, et al

(2009)> 4mm

Jones CB, et al

(2009)>3mm

Jones CB, et al

(2011)>3mm

Anavian J, et al

(2012)> 4mm

Articular Step-OffCurrent Expert Surgical Indications

> 4mm

Ada JR and Miller

ME

(1991)

> 10 mm

Herrera DA, et al

(2009)> 15 mm

Jones CB, et al

(2009)> 20 mm

Jones CB, et al

(2011)> 20 mm

Gauger EM, et al

(2012)> 20 mm

Cole PA, et al.

(2012)> 20 mm

MedializationCurrent Expert Surgical Indications

> 20mm

Ada JR and

Miller ME

(1991)

> 40

Jones CB, et

al

(2009)

> 45

Jones CB, et

al

(2011)

> 45

Bartoníček J

and Fric V

(2011) > 30

Cole PA, et

al.

(2012)

> 45

Gauger EM,

et al

(2012)

> 45

> 45°

AngulationCurrent Expert Surgical Indications

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GPA

Cole PA, et al.

(2012)< 22

Gauger EM, et

al.(2012)< 22

Glenopolar Angle (GPA)Current Expert Surgical Indications

< 22°

Poor Outcomes GPA < 20°

Bestard et al Contemp Ortho 12:47, 1986

Bozkurt et al. Injury, 36, 2005

Romero, Arch Ortho Trauma, 121, 2001

Pace et al. J Shoulder & Elbow, Nov/Dec, 2005

Multiple DisruptionsCurrent Expert Surgical Indications

34mm

35mm

16mmClavicle > 10mm

Scapula > 10mm

M/L > 15mm

Angular > 30°41

°

AO/OTA – 1996 (r2007)

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Glenoid Involved

73% agreementKappa 0.79

Body Fractures

82% agreementKappa 0.75

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Summary:Classification

Indications

• Multiple classification schemes– Historical– Body, glenoid & processes

• AO/OTA– In development, comprehensive– Does not help guide treatment (Yet)

• Surgical Indications– Medialization (Lateral Border Off-set) > 20mm

– Glenopolar Angle (GPA) < 22°

– Angulation > 45°

– Step-off > 4mm

GPA

Medialization

Angulation

Step

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Steven Gammon, MDOrthopaedic Trauma Surgeon

Rocky Mountain Orthopaedic Associates, Inc.

St. Mary’s Hospital Regional Medical Center

Grand Junction, Colorado

August 18, 2015

Disclosures

• I do not have any monetary or nonmonetary disclosures related to this talk.

Overview

• Significance of scapula fractures in the “Big Picture”

• Associated injuries:

– Global injuries

– Ipsilateral upper extremity injuries

• Examples

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Overall Significance

• Scapula fractures account for <1% of all fractures but are common – especially at tertiary trauma centers.

– 3-5% of shoulder girdle injuries

• The diagnosis is missed or delayed in 12.5% of multiply-injured patients

• Rarely “isolated injuries”

– >90% have associated injuries

– Always look for other injuries.

Associated Injuries

95% (n=168)

Only 4 pts with

isolated scapula fx

Ipsilateral

Shoulder

Injuries

57%Gauger, et al. “Surgical and Functional Outcomes after Operative Management of Extra-articular Glenoid Neck and Scapula Body Fractures” Presented at 2010 OTA Annual Mtg.

Associated Injuries (90-95%)

• Thoracic injuries – 80% (rib fx, pulm cont, PTX)

• Ipsilateral extremity injury – 50%

– “Superior Shoulder Suspensory Complex” (SSSC)

– Anywhere else in that ipsilateral extremity

• Head injuries – 48%

• Spine injuries – 26%

– Cervical spine or brachial plexus lesions – 15%

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Superior Shoulder Suspensory Complex (SSSC)

• A bone-soft-tissue ring that provides a stable connection of the glenoid and scapula to the axial skeleton.

– Position and orientation of glenoid in space determines shoulder function and range of motion.

Superior Shoulder Suspensory Complex (SSSC)

• Four bony landmarks:

– Clavicle

– Acromion

– Coracoid Process

– Glenoid

• Supporting ligamentous complexes

– AC joint

– CC ligament

Disruptions in SSSC

• Large disruptions in either clavicle or any components of SSSC can have major effects on normal shoulder mechanics

– Decreased ROM, pain, loss of function

• Multiple disruptions in SSSC = Floating Shoulder

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Disruptions in SSSC

• Classified as:

– Single

– Double

– Triple

– Quadruple

• Multiple disruptions lead to discontinuity or malposition of the glenohumeral joint relative to the scapula body.

Double SSSC Lesion

“The Floating

Shoulder”

Goss, JOT, 1993

Case Example 1Double Disruption – Scapula/Clavicle

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Case Example 1Double Disruption – Scapula/Clavicle

>100%Displacement

14° GPA

2.5 cm

Case Example 1Double Disruption – Scapula/Clavicle

Case Example 1Double Disruption – Scapula/Clavicle

40° GPA0mm Medialization

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Case Example 2Double Disruption – Scapula/Clavicle

*16 year old in MVA

Case Example 2Double Disruption – Scapula/Clavicle

Case Example 2Double Disruption – Scapula/Clavicle

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Case Example 3Triple Disruption – Scapula/Acromion/Coracoid

*45 year old in snowmobile

accident

Case Example 3Triple Disruption – Scapula/Acromion/Coracoid

Case Example 3Triple Disruption – Scapula/Acromion/Coracoid

*Stage One Surgery: Posterior

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Case Example 3Triple Disruption – Scapula/Acromion/Coracoid

*Stage Two Surgery: Anterior/Superior

Additional ExamplesScapula Fractures with Multiple Rib Fractures

Steven Gammon, MDOrthopaedic Trauma Surgeon

Rocky Mountain Orthopaedic Associates, Inc.

St. Mary’s Hospital Regional Medical Center

Grand Junction, Colorado

August 18, 2015

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Surgical Approaches, Reduction Techniques & Implants

Dr. Peter ColeChief of Orthopaedics: Regions Hospital

Professor, University of Minnesota

Surgical Approaches•Posterior: positioning =

lateral decubitus•Judet

•Extensile submuscular•Intermuscular window

•Straight Posterior•MIO

•Anterior: positioning = beach chair

•Deltopectoral: anterior/superior glenoid fractures

Vulnerable structures with posterior approach

Suprascapular Nerve

Ascending

Branch of

the Circumflex

Scapular Artery

Cole PA, Schroder LK, Jacobson AR. Scapula and Rib

Fractures. In: Browner B, Jupiter J, Krettek C, Anderson P,

eds. Skeletal Trauma. Fifth Edit. Philadelphia, PA:

Saunders/Elsevier; 2014.

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JudetExtensile: elevation of infraspinatus, teres minor, and

posterior deltoid

Muscular windows: infraspinatus and teres minor intervalAccess to lateral border and posterior glenoid

Judet Posterior

Approach

Deltoid

Infraspinatus

T

Minor

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Posterior Straight: over glenoid-humeral joint

MIO: access to lateral and vertebral borders: for “simple” patterns and <14 days from injury

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Reduction techniques

• Lateral border and glenoid neck = best bone stock

• Access to medial and lateral borders required

• Many deforming forces

Cole PA, Schroder LK, Jacobson AR. Scapula and Rib Fractures. In:

Browner B, Jupiter J, Krettek C, Anderson P, eds. Skeletal Trauma. Fifth

Edit. Philadelphia, PA: Saunders/Elsevier; 2014.

Tools to Aid Reduction

1. Schanz pins with T-handled chucks

2. Jungbluth clamp over screws

3. Lamina spreader between cephalad and caudad fragments

4. Shoulder Hook inside a pilot hole on the inferior lateral border an a Schanz pin in the glenoid neck

5. Once reduction attained – small pointed bone reduction forceps can maintain.

Cole PA, Schroder LK, Jacobson AR. Scapula and Rib Fractures. In: Browner B, Jupiter J, Krettek

C, Anderson P, eds. Skeletal Trauma. Fifth Edit. Philadelphia, PA: Saunders/Elsevier; 2014.

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Implants

• 2.7 mm low profile plates

–Straight 2.7 DC plate - lateral border

–Scapula spine and vertebral borders:

2.7 mm recon plates more easily

contoured.

–Superomedial angle contour requires

bending the implant in 3 planes!

Cole PA, Schroder LK, Jacobson AR. Scapula and Rib Fractures. In:

Browner B, Jupiter J, Krettek C, Anderson P, eds. Skeletal Trauma.

Fifth Edit. Philadelphia, PA: Saunders/Elsevier; 2014.

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Cole PA, Schroder LK, Jacobson AR. Scapula and Rib Fractures. In: Browner B, Jupiter J, Krettek C,

Anderson P, eds. Skeletal Trauma. Fifth Edit. Philadelphia, PA: Saunders/Elsevier; 2014.

Questions ?

Scapula

Approaches

Reduction

Techniques

Implants

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Ivan S. Tarkin, MDDivision Chief Traumatology

Department of Orthopaedic SurgeryUniversity of Pittsburgh Medical Center

21 y/o LHD M involved in altercation, hit with a pipe and ran over by a car.

Presents with bilateral scapular fractures, pneumothorax, rib fractures, grade 1 liver laceration,

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2.6cm

34 degrees

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Judet Incision

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54 y/o M laborer (road construction) s/p MCC presents with crush injury to right chest/ shoulder girdle

No relevant PMH

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Intra-op finding: suprascapular nerve entrapped in fracture site

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Back to work

Regained full ROM/Strength

Resolved weakness with external rotation (suprascapular nerve)

“Feels normal”

Intraop Photo courtesy of PA Cole

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56 y/o M vending machine technician s/p occupational crush injury to left face, shoulder and chest.

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100% satisfied with his result

Has regained his motion and strength

Full passive and active ROM

Strength is 5/5 for abduction, forward flexion, external and internal rotation

47 y/o polytrauma pt (head, chest, abd, pelvis, extremity)

Ipsilateral scapula fx, elbow dislocation

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45 y/o M s/p MCC with multiple rib fracture, pneumothorax, scapula fracture, and liver laceration

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36 y/o M transferred from OSH 3 days after MCC for definitive care

Injuries: right rib fractures (1-11), tension hemotopneumothorax s/p chest tube, right clavicle fracture, right scapular fracture

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28 y/o M involved in roll over MVC

Injuries to pancreas, splenic laceration s/p splenectomy, liver laceration, head blead, rib fracture, thoracic spine fracture, kidney infarct/hematoma, clavicle fracture, scapula fracture.

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53 y/o M un-helmeted MCC

Injuries: left hemopneumothorax, left 1st through 9th rib fractures, mediastinal hematoma, pilon ankle fracture, T3-8 spinousprocess fractures, T3 and T4 compression fractures, left scapula fracture

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Doing well. Only pain remaining from pilonankle fracture

Full, pain free ROM of the left shoulder

5/5 Strength in the entire left upper extremity

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