Lisa K. Schroder

Mapping of Scapular Fractures with Three-Dimensional Computed Tomography

BACKGROUND Fractures of the scapula involve a unique and challenging set of considerations, which must be understood to provide optimal treatment. The primary goal of this study was to create a frequency map of a series of surgically treated scapular fractures that specifically involved the scapular body and/or neck. METHODS A prospective database was used in the collection of consecutive radiographic imaging studies of patients undergoing operative treatment of scapular fractures. Scanned three-dimensional computed tomography images were superimposed and oriented to fit a model scapular template. Size dimensions were normalized by aligning specific scapular landmarks. Fracture lines were identified and traced over the combined three-dimensional computed tomography model to create a scapular fracture map. RESULTS Of ninety fractures that met the criteria for inclusion, 68% involved the inferior aspect of the glenoid neck and 71% involved the superior vertebral border. Seventeen percent of the patterns included articular extension, and 22% of the fractures entered the spinoglenoid notch. Of fractures involving the inferior aspect of the glenoid neck at the lateral scapular border, 84% traversed medially to exit just inferior to the medial extent of the scapular spine, and 59% of these inferior neck fractures also had propagation to the inferior third of the vertebral border. Among the fractures involving the spinoglenoid notch, the most common pattern was demonstrated by coexisting fracture lines; 60% of the fractures of the spinoglenoid notch exited just inferior to the glenoid, 65% extended to the superior-medial vertebral border, and 45% extended to the inferior-medial vertebral border. In contrast, articular fractures did not follow predictable patterns; they demonstrated the greatest variability in trajectory, which was almost random, and there was a wide distribution of exit points along the vertebral border. CONCLUSIONS Surgically treated scapular fractures display very common patterns. The most common pattern is the lateral border fracture immediately inferior to the glenoid, which extends to the superior vertebral border in more than two-thirds of cases. A smaller proportion of scapular fractures enter the spinoglenoid notch or the articular surface. There is great variation in the patterns of fractures involving the articular surface.

Management of scapular fractures.

&NA; With the exception of displaced articular glenoid fractures, management of scapular fractures has largely consisted of benign neglect, with an emphasis on motion as allowed by the patients pain. Better understanding of this injury has resulted in greater acceptance of surgical management of highly displaced variants. However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. Scapular fractures are the result of high‐energy mechanisms of injury, and they often occur in conjunction with other traumatic injuries. In addition to performing meticulous physical and neurologic examination, the surgeon should obtain plain radiographs, including AP shoulder, axillary, and scapular Y views. Three‐dimensional CT is used to determine accurate measurements in surgical candidates. Surgical approach, technique, and timing are individualized based on fracture type and other patient‐related factors.

Surgical and functional outcomes after operative management of complex and displaced intra-articular glenoid fractures

BACKGROUND Operative treatment is indicated for displaced fractures of the glenoid fossa. However, little is known regarding functional outcomes in these patients. This study assesses surgical and functional results after treatment of displaced, high-energy, complex, intra-articular glenoid fractures. METHODS Thirty-three patients with displaced intra-articular fractures of the glenoid were treated surgically between 2002 and 2009. The indications for operative treatment included articular fracture gap or step-off of ≥ 4 mm. Twenty-five patients also had extra-articular scapular involvement. A posterior approach was utilized in twenty-one patients, an anterior approach in seven, and a combined approach in five. Functional outcomes, including Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores, shoulder motion and strength, and return to work and/or activities, were obtained for thirty patients (91%). RESULTS At a mean follow-up of twenty-seven months (range, twelve to seventy-three months), all patients had radiographic union of the fracture. The mean DASH score was 10.8 (range, 0 to 42). All mean SF-36 subscores were comparable with those of the normal population. Twenty-six patients (87%) were pain-free at the time of follow-up, and four had mild pain with prolonged activity. Twenty-seven (90%) of thirty patients returned to their preinjury level of work and/or activities. CONCLUSIONS Our data suggest that surgical treatment for complex, displaced intra-articular glenoid fractures with or without involvement of the scapular neck and body can be associated with good functional outcomes and a low complication rate.

Delayed operative management of fractures of the scapula

Between 1998 and 2007, 22 patients with fractures of the scapula had operative treatment more than three weeks after injury. The indications for operation included displaced intra-articular fractures, medialisation of the glenohumeral joint, angular deformity, or displaced double lesions of the superior shoulder suspensory complex. Radiological and functional outcomes were obtained for 16 of 22 patients. Disabilities of the Arm, Shoulder, Hand (DASH) and Short form-36 scores were collected for 14 patients who were operated on after March 2002. The mean delay from injury to surgery was 30 days (21 to 57). The mean follow-up was for 27 months (12 to 72). At the last review the mean DASH score was 14 (0 to 41). Of the 16 patients with follow-up, 13 returned to their previous employment and recreational activities without restrictions. No wound complications, infection or nonunion occurred. Malunion of the scapula can be prevented by surgical treatment of fractures in patients with delayed presentation. Surgery is safe, effective, and gives acceptable functional results.

Surgery for scapula process fractures: Good outcome in 26 patients

Background Generally, scapula process fractures (coracoid and acromion) have been treated nonoperatively with favorable outcome, with the exception of widely displaced fractures. Very little has been published, however, regarding the operative management of such fractures and the literature that is available involves very few patients. Our hypothesis was that operative treatment of displaced acromion and coracoid fractures is a safe and effective treatment that yields favorable surgical results. Methods We reviewed 26 consecutive patients (27 fractures) treated between 1998 and 2007. Operative indications for these process fractures included either a painful nonunion, a concomitant ipsilateral operative scapula fracture, ≥ 1 cm of displacement on X-ray, or a multiple disruption of the superior shoulder suspensory complex. All patients were followed until they were asymptomatic, displayed radiographic fracture union, and had recovered full motion with no pain. Patients and results 21 males and 5 females, mean age 36 (18–67) years, were included in the study. 18 patients had more than one indication for surgery. Of the 27 fractures, there were 13 acromion fractures and 14 coracoid fractures. 1 patient was treated for both a coracoid and an acromion fracture. Fracture patterns for the acromion included 6 acromion base fractures and 7 fractures distal to the base. Coracoid fracture patterns included 11 coracoid base fractures and 3 fractures distal to the base. Mean follow-up was 11 (2–42) months. All fractures united and all patients had recovered full motion with no pain at the time of final follow-up. 3 patients underwent removal of hardware due to irritation from hardware components that were too prominent. There were no other complications. Interpretation While most acromion and coracoid fractures can be treated nonoperatively with satisfactory results, operative management may be indicated for displaced fractures and double lesions of the superior shoulder suspensory complex.

Extra-articular malunions of the scapula: a comparison of functional outcome before and after reconstruction.

Objective: To assess surgical and functional results after corrective reconstruction of malunited, scapula neck or body fractures in patients who presented with chronic pain, limited range of motion, weakness, and gross deformity of the shoulder. Design: Case series. Setting: Level I teaching trauma center. Patients: Between 2000 and 2008, five patients (mean age, 44 years) underwent operative reconstruction of a malunited, scapula neck and/or body fracture. Mean time from injury to surgery was 15 months (range, 8–41 months). All patients presented with debilitating pain and weakness and were unable to return to work. When measured on three-dimensional computed tomographic scan, mean preoperative fracture deformity included 3.0 cm (range, 1.7–4.2 cm) of medial/lateral displacement, 25° (range, 10°–40°) of angular deformity, and a 25° (range, 19°–29°) glenopolar angle. Intervention: Surgical osteotomy and reorientation of scapula neck and/or body, with fixation using 2.7- or 3.5-mm implants and autogenous graft, through a posterior Judet approach. Main Outcomes Measures: Pre- and postoperative functional measures of range of motion and strength testing and patient-based outcome scores (Disabilities of the Arm, Shoulder and Hand and Short Form-36). Results: Mean follow-up was 39 months (range, 18–101 months). All patients united radiographically, were pain-free with regard to the shoulder, and expressed satisfaction with their result. Four of five patients returned to their original occupation and activities. Mean Disabilities of the Arm, Shoulder and Hand score improved from 39 (range, 27–58) preoperatively to 10 (range, 0–35) postoperatively. There were no complications. Conclusions: Malunion after nonoperative treatment of a displaced scapula fracture may be associated with poor functional and cosmetic outcomes. Operative reconstruction can yield good surgical and functional results.

Functional Outcomes After Operative Management of Extra-Articular Glenoid Neck and Scapular Body Fractures

BACKGROUND This studys purpose was to assess patient-based functional outcomes following open reduction and internal fixation (ORIF) of displaced scapular body and glenoid neck fractures. This series represents a 9-year experience at a level-I trauma center and referral destination for this injury. METHODS A database was established to record surgical and functional outcomes of scapular fractures treated with ORIF. For this report, the cases of all patients who had a glenoid neck or scapular body fracture (AO/OTA 14-A3 or 14-C1) without intra-articular involvement were reviewed. Operative indications included medial/lateral displacement of ≥20 mm, angulation of ≥45°, medial/lateral displacement of ≥15 mm with angulation of ≥30°, double disruptions of the superior shoulder suspensory complex with both displaced ≥10 mm, a glenopolar angle of ≤22°, and an open fracture. The results of clinical testing, including measurements of range of motion and strength and scores on the Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) questionnaires, were recorded at each follow-up appointment. RESULTS Between 2002 and 2011, 61 patients with an extra-articular scapular fracture were treated surgically within 20 days after the injury; 19 patients (31%) had ≥2 operative indications. Of the 61 patients, 49 (80%) were followed for ≥1 year (mean, 33 months; range, 12 to 138 months) following surgery. There was a 100% union rate at the time of final follow-up, with a mean DASH score of 12.1 points (range, 0 to 54 points). For all parameters, the mean SF-36 scores of the study patients were comparable with normative population scores. The range of motion of the operatively treated and contralateral shoulders averaged, respectively, 154° and 159° of forward flexion, 106° and 108° of abduction, and 66° and 70° of external rotation. The strength of the operatively treated and contralateral shoulders averaged, respectively, 20 and 23 lb (89.0 and 102.3 N) of force in forward flexion, 14 and 16 lb (62.3 and 71.2 N) in abduction, and 19 and 23 lb (84.5 and 102.3 N) in external rotation. Complications and/or secondary surgery were recorded for 8 patients (16%). CONCLUSIONS Displaced scapular body and glenoid neck fractures that meet current published standards for ORIF can be treated operatively with predictably good functional outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Patient Follow-up Program for Short-Term Surgical Mission Trips to a Developing Country

BACKGROUND We describe a follow-up program for patients undergoing surgical procedures with documented results from short-term surgical mission trips to the developing world. The surgical procedures were all performed at a government hospital in Pucallpa, Peru, a remote city in the Amazon. METHODS Between July 2007 and January 2012, ten surgical mission trips were completed with a mean time of six days on location and a mean number of 2.3 surgeons (range, two to five surgeons) per trip. A Peruvian general surgeon conducted postoperative visits at time intervals of two to four weeks, five to sixteen weeks, four to seven months, and eight to twelve months. Each visit included the completion of a patient outcome form, radiographs, and functional range-of-motion photographs. Patient demographic characteristics; type of surgical procedure; completed follow-up; complications including infection, malunion, or nonunion; and clinical results were analyzed. RESULTS Of the 127 patients eligible for analysis, twenty-three patients were lost to follow-up, leaving a follow-up rate of 81.9% (104 of 127 patients). Patients were predominantly male (63.5%) and had a mean age of 37.0 years (range, ten months to 93.4 years). The mean length of follow-up was 11.8 months, with a mean number of 3.7 postoperative encounters. Orthopaedic trauma fixation was the predominant surgical procedure (57%), with forty-two procedures (40%) being open reduction and internal fixation. In the 104 patients, successful wound-healing occurred in 101 (97%) and 100 (96%) had a functional outcome deemed to be good or fair by the in-country physician. The infection rate was 2.9% (three patients), with 97% (fifty-seven of fifty-nine) of fractures united. There was one nerve injury in a pediatric patient treated for supracondylar humeral malunion, and two cases of prominent implant necessitating removal. The mean direct cost of the follow-up program was

Triple and quadruple disruptions of the superior shoulder suspensory complex

20,041 in U.S. dollars per year. CONCLUSIONS It is possible to develop a sustainable surgical patient follow-up program with robust results and to achieve acceptable outcomes for orthopaedic conditions, even in an austere medical environment.

A Biomechanical Study Comparing Minimally Invasive Anterior Pelvic Ring Fixation Techniques to External Fixation

Objectives: The purpose of this study is to report on a series of patients who sustained triple and quadruple disruptions to the superior shoulder suspensory complex (SSSC), their associated injuries, and functional outcomes of open reduction and internal fixation. Design: Prospective observational study. Setting: Level 1 trauma center. Patients/Participants: Patients who sustained more than 2 lesions to the SSSC that underwent surgery. Outcome Measurements: Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion, and shoulder strength measurements. Results: Fifteen patients with greater than 2 disruptions (12 triple and 3 quadruple) were identified. There were 14 scapula neck fractures, 8 clavicle fractures, 6 acromioclavicular separations, 10 coracoid, and 10 acromion fractures. Rib fractures were present in 87% (13 of 15) patients. Thirteen patients (87%) sustained nerve injuries with 13 lesions distal to the brachial plexus, 5 at the level of the brachial plexus, 3 nerve root, and 2 spinal cord injuries. At final follow-up (14 of 15 patients, mean follow-up = 30.7 months), DASH scores averaged 14.9 and mean range of motion when expressed as the percentage of injured shoulder over the contralateral shoulder was 95% forward flexion, 92% abduction, and 78% external rotation. Mean strength measured by a hand-held dynamometer and expressed as the percentage of injured over contralateral was 67% forward flexion, 61% abduction, and 65% external rotation. Conclusions: Patients with triple and quadruple disruptions of the SSSC had a high rate of associated injuries including a majority with spinal and peripheral nerve lesions. Treatment with open reduction internal fixation of the scapula was associated with satisfactory functional outcomes despite decreases in shoulder strength measurements. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.