Scapular body fractures: Short-term results of surgical management with extended indications

doi:10.1016/j.injury.2020.09.006

Injury

Volume 52, Issue 3, March 2021, Pages 481-486

https://doi.org/10.1016/j.injury.2020.09.006 Get rights and content

Highlights

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Scapular body fractures represent <1% of all fractures, and are usually treated nonoperatively.
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This study evaluates the results of 45 patients with scapular body fractures, of whom 20 underwent surgery and 25 were treated nonoperatively.
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Surgical treatment resulted in better clinical and radiographic results in the short-term.
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Studies with longer follow-up and prospective design will be needed to support these results.

Abstract

Introduction

Scapular body fractures represent less than 1% of all skeletal fractures. Operative criteria and risk factors for scapular fracture instability are well defined. Non-operative management of scapular body fractures show satisfactory results but with shortening and medialization of the scapular body. The aim of this study is to evaluate if surgical treatment will result in an improved quality of life and shoulder function compared to non-operative treatment on patients suffering from a scapular body fracture.

Materials and Methods

From a total of 381 retrospectively identified scapular body fractures, we included 45 patients. The enrolled patients were divided into two groups: the surgical treatment (ST, n = 20) group and the non-operative treatment (NOT, n = 25) group. The Non-Union Scoring System (NUSS) was used to assess bone healing on radiographs. The functional evaluation of the two groups during the follow-up were performed using the Constant Shoulder Score (CSS) and the Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH). Complications, reoperation rates, and time until bony union were also documented. The minimum follow-up for this study was designated as 12 months.

Results

The ST group had better mean CSS and QuickDASH scores compared to the NOT group at 1, 3 and 6 months of follow-up. No statistically significant difference was detected at 12 months follow-up. ST group also demonstrated improved results in time until bone union, reduction of rehabilitation time, complications and return to work rates.

Conclusion

This study suggests that surgical treatment for extraarticular scapular fractures can achieve better short-term functional outcomes (3 to 6 months) compared to conservative treatment.

Introduction

Scapular body fractures represent less than 1% of all skeletal fractures [1]. Body fractures account for about 50% of all scapular fractures [2] and generally result from a high-energy, direct trauma to the shoulder sustained during motor vehicle accidents [3], [4], [5]. While these high-energy mechanisms have been well described, little literature exists on scapular body fractures sustained during sporting activities. It is therefore surprising that such little attention is paid to the pathoanatomy of these fractures, especially considering the growing number of cases treated operatively [2], [3], [4], [5]. Nowadays, operative criteria and risk factors for scapular fracture instability are well established [6]. Non-operative management of scapular body fractures had satisfactory results but with shortening and medialization of the scapular body [7], and thus leading potentially to pain, vascular problems, delayed union, malunion, persistent shoulder symptoms and loss of arm function (Fig. 1). There is still controversy about nonoperative versus operative treatment of scapular fractures, based on limited clinical evidence typically from small retrospective series [6].

The purpose of this study is to compare the short-term outcomes of operative and nonoperative treatments of scapular body fractures by means of functional scores and radiographic parameters. We hypothesize that surgical treatment (Fig. 2) will result in better outcomes; both functional and radiographic.

Section snippets

Materials and methods

From January 2015 to 2019, the patient databases of three Level I trauma centers were retrospectively evaluated for patients with a scapular fracture. Patients with an extraarticular scapular fracture involving the scapular body were enrolled after the application of following exclusion criteria: scapular fracture not limited to the body, lateral border offset (medialization / lateralization) ≤ 15 mm or ≥ 20 mm, glenoid angle ≥ 22°, angulation > 45°, fractures with > 15 mm medialization and >

Results

A total of 381 scapular fractures were found in the databases and from these fractures, 45 patients with a scapular body fracture were enrolled after the application of the above-mentioned exclusion criteria. After the enrollment procedure, 20 patients were in the ST group and 25 patients were in the NOT group. The demographic variables of the study groups are summarized on Table 1, and the radiographic parameters are summarized on Table 2.

The mean CSS before the trauma was 93.6 points (±6.4)

Discussion

Scapular fractures are uncommon injuries, accounting for approximately 3–5% of all fractures of the shoulder girdle and less than 1% of total fractures [14]. The reason for this is probably because they require high-energy trauma that also results in multi-system injuries [14]. Treatment of scapular fractures has traditionally been conservative; however, advancements in operative treatment have improved functional outcomes, and significant displacement is associated with poor long-term

Conclusion

This study suggests that surgical treatment for extraarticular scapular fractures can achieve better short-term functional outcomes (3–6 months) than conservative treatment, but the outcomes are similar at 12 months. The use of a modified Judet approach and easily contoured plates could be a good combination for the treatment of this injury.

Declaration of Competing Interest

The authors declare no conflict of interest.

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Letter to the editor regarding “Scapular body fractures: Short-term results of surgical management with extended indications”
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Citation Excerpt :
Fractures of the scapular body account for about 50 % of all scapular fractures [2]. These injuries typically occur secondary to high energy, direct trauma to the shoulder sustained during motor vehicle or sporting injuries [1,3,4]. Traditionally, fractures of the scapular body have been treated non-operatively.
Scapular body fractures are rare fractures that represent less than 1 % of all fractures and are typically associated with a high energy mechanism of injury. Traditionally these fractures have been treated non-operatively, resulting in union of the fracture and acceptable patient outcomes. We present a case of symptomatic scapular body fracture nonunion following non-operative management that was treated with open reduction and internal fixation with local autologous bone grafting. Our patient went on to successful union of his fracture as well as drastic improvement in shoulder function, range of motion, strength, and patient reported outcome measures assessed throughout his treatment course. The authors believe that scapular body fracture nonunion should be of clinical suspicion in forming the differential diagnosis for a patient who had previously sustained a scapular body fracture with persistent pain and failure to improve following non-operative management. We believe that open reduction and internal fixation with bone grafting can help promote fracture union in these patients and may result in improved shoulder function post-operatively.
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The Posterior and superior approach is suitable for the treatment of acromion, upper part of the glenoid or central transverse fractures [8–10]. In the actual operation, we found that the ligaments and tendons around the shoulder joint were invaded greatly during the operation, whether it was through the intermuscular groove approach or the Judet approach [11,12]. In the treatment of scapular glenoid fractures, the intermuscular groove approach requires incision of the subscapularis tendon, and the Judet approach requires the stripping of the subscapular muscle, which causes great trauma to the soft tissues around the shoulder joint [13].
The purpose of this study was to assess the efficacy of the scapular glenoid fractures by a new surgical approach (Axillary approach) through follow-up studies.
We retrospectively analyzed the prospectively collected data from 11cases of glenoid fractures were treated by open reduction and internal fixation through a Axillary approach approach between July 2019 and October 2020. All patients were required to conform to regular follow up postoperatively. X-ray film and CT scan was applied to all cases. The Constant score system, the UCLA score system and DASH score system were used to evaluate functional results.
All patients achieved bone union. At the final follow-up, the mean Constant score was 92.5 ± 3.0 (range 85–97) points and the mean UCLA score was 33.5 ± 1.6 (range 31–36) points. According to the UCLA score system, two patients achieved excellent results and one patients had good results. The mean DASH scores were 7.7 ± 3.2 (range 4–12). Compared with the preoperative functional score, it was significantly improved (P < 0.01).
The axillary approach as a new method for scapular glenoid fractures (especially the fracture of the lower half of the scapular glenoid) has achieved desired results, and it can provide new options for clinical treatment.
Level III; Development or Validation of Outcome Instrument© 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Supine harvest of vascularised scapular bone grafts–Anatomical study and clinical application
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Citation Excerpt :
Skin can be harvested through the scapular and parascapular flaps, muscle can be harvested through the latissimus dorsi and serratus and bone can be harvested from the scapula or rib. The scapula has excellent capacity for healing and compensates well after bone loss or fractures [10,11]. A major disadvantage perceived of flaps harvested from the subscapular system is the need for an intraoperative position change, as these flaps are traditionally harvested from the lateral decubitus position.
We report our findings from an anatomical study on harvest of a vascularized scapular bone graft from a supine position. A clinical case is presented to illustrate the operative approach.
Twenty cadaveric hemibody specimens were dissected in the supine position. Outcomes of interest included the characterization of anatomical variants and measurements of pedicle length. Specific measurements included distance from the origin of the subscapular artery (at the axillary artery) to the branch point of the angular artery from the thoracodorsal artery or serratus branch and the length of the angular branch proper.
There are five reported anatomic variations regarding the origin of the angular branch of the thoracodorsal artery. In our cadaveric cohort only four known types were seen, and an entirely new variant was encountered. Six cadaveric dissections exhibited a type 3 configuration, six were type 1, four were type 2, three were type 4, and one was a previously unreported variant we termed a type 6, with multiple angular artery branches originating from the posterior branch of the thoracodorsal. The mean distance between the origin of the subscapular artery and the takeoff of the angular branch was 6.3 ± 2.0 cm. The mean length of the angular branch was 3.7 ± 1.4 cm.
Supine positioning for harvest of a vascularized bone graft obviates the need for an intraoperative position change and allows reconstruction of bone defects in the hand and upper extremity within a single surgical field.
Finite element analysis of titanium anatomic plate and titanium reconstructive plate for treatment of extra-articular fractures of the scapula
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Management of Extra-articular Scapular Fractures: A Narrative Review and Proposal of a Treatment Algorithm
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View full text

Scapular body fractures: Short-term results of surgical management with extended indications

Highlights

Abstract

Introduction

Materials and Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Declaration of Competing Interest

Injury

Injury

J Electromyogr Kinesiol

Injury

Injury

Scapular body fracture in the athlete: a systematic review

HSS J

Classification of scapular body fractures

Rozhl Chir Winter

Management of scapular fractures

J Am Acad Orthop Surg

Treatment of scapula fractures: systematic review of 520 fractures in 22 case series

J Orthop Trauma