Chapter 39: Scapular Fractures

Jan Bartoníček

Chapter Outline

Introduction to Scapula Fractures

Scapula fractures occur relatively infrequently. According to various studies, they account for 0.4% to 0.9% of all fractures and for about 3% to 5% of all fractures of the shoulder girdle.38,157,159 The reason for such low incidences is that the scapula is well protected against injury by a robust muscular envelope, the surrounding bones (clavicle, humerus), and its mobility and location on the elastic chest wall. Scapula fractures result mostly from high-energy trauma and, therefore, are often found in polytrauma patients. They are, as a rule, unilateral. Bilateral or open fractures are rare.85 Scapula fractures occur predominantly in men (72%) with the mean age of 44 years.191 
Until recently, little attention had been paid to these fractures. Of late, however, interest in scapula fractures has grown and the debate increasingly focuses on their operative treatment.31,35,51,90,94,102,119,120,128,137,138,192,200 

Anatomy Relating to Scapula Fractures

The scapula, together with the clavicle, comprises the shoulder girdle. The scapula is attached to the axial skeleton solely by the clavicle, or, more specifically, by the acromioclavicular (AC) and sternoclavicular (SC) joints. The scapula is enveloped in multiple layers of muscles and is separated from the chest wall by thin gliding fibrofatty tissue, allowing its smooth excursion over the chest wall. Thanks to its relatively free connection with the axial skeleton, the scapula is mobile but at the same time provides an efficient support to the humeral head. As a result, compression forces are optimally transmitted from the upper limb to the shoulder girdle, without compromising stability and mobility of the glenohumeral joint. 

Scapula Architecture

The basic part of the scapula is the body, which is triangular, when viewed anteroposteriorly, with its base situated superiorly and its apex inferiorly. The triangle is bounded by its three borders (superior, medial, and lateral) and three angles (superior, inferior, and lateral). Although the bone at the former two angles is relatively thin, the lateral angle gets gradually thicker to form the scapular neck, bearing the articular surface—the glenoid fossa. The hook-shaped coracoid process curves forward from the superior surface of the scapular neck. On the posterior surface of the scapular body there arises a prominent plate of bone—the scapular spine—gradually becoming more elevated and ending in a flattened bony process—the acromion—curving forward. 
The distribution of the bony mass of the scapula is highly uneven, with areas of thick bone and areas that are almost translucent.26,181,188 When held up to the light, the scapula shows the highest concentration of bony mass in the glenoid, the scapular neck, including the base of the coracoid process and the lateral border of the scapular body (Fig. 39-1). 
Figure 39-1
 
Anatomy and internal architecture of the right scapula: A: Posterior aspect of scapula after resection of scapular spine. B: The same specimen transilluminated. C: Posteroinferior aspect of transilluminated scapula. SMA, spinomedial angle; CSS, the thinner center of scapular spine; CoGN, coracoglenoidal notch; SP, spinal pillar; LP, lateral pillar.
Anatomy and internal architecture of the right scapula: A: Posterior aspect of scapula after resection of scapular spine. B: The same specimen transilluminated. C: Posteroinferior aspect of transilluminated scapula. SMA, spinomedial angle; CSS, the thinner center of scapular spine; CoGN, coracoglenoidal notch; SP, spinal pillar; LP, lateral pillar.
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Figure 39-1
Anatomy and internal architecture of the right scapula: A: Posterior aspect of scapula after resection of scapular spine. B: The same specimen transilluminated. C: Posteroinferior aspect of transilluminated scapula. SMA, spinomedial angle; CSS, the thinner center of scapular spine; CoGN, coracoglenoidal notch; SP, spinal pillar; LP, lateral pillar.
Anatomy and internal architecture of the right scapula: A: Posterior aspect of scapula after resection of scapular spine. B: The same specimen transilluminated. C: Posteroinferior aspect of transilluminated scapula. SMA, spinomedial angle; CSS, the thinner center of scapular spine; CoGN, coracoglenoidal notch; SP, spinal pillar; LP, lateral pillar.
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Extending between the glenoid and the scapular body are two bony pillars that transmit compression forces from the glenoid fossa.108 The lateral pillar, part of which is the lateral border, connects the inferior border of the glenoid with the inferior angle. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine. Its course can be seen better by viewing the scapula from the front against the light. From the posterior view it is evident that the two pillars connected by a markedly thinner medial border of the scapular body are the basic load-bearing structure of the scapular body. This triangle constitutes the biomechanical body of the scapula, as the superior angle and the adjacent part of the supraspinous fossa form merely an appendage, which serves as a surface of insertion or origin of muscles, but does not transmit compression forces from the glenoid. Therefore, it is necessary to distinguish between the anatomical and biomechanical bodies of the scapula.181 
The weakest area of the circumference of the biomechanical body of the scapula is the connection of the scapular spine and the medial border of the scapula, the spinomedial angle. In the majority of scapula body fractures one of the main fracture lines passes through this region. Another area of weak bone is in the central part of the scapular spine where fracture lines can also be seen fairly frequently. 

Superior Shoulder Suspensory Complex

The superior shoulder suspensory complex (SSSC) was defined by Goss.70 The SSSC is a bony and soft tissue ring composed of the glenoid process, coracoid process, coracoclavicular (CC) ligament, lateral clavicle, AC joint, and acromion (Fig. 39-2). This ring is connected by two bony struts. The superior strut consists of the middle third of the clavicle, whereas the inferior strut is the junction of the most lateral portion of the scapular body and the most medial portion of the scapular neck. Goss subdivided the whole complex into three units: The clavicular–AC joint–acromial strut; the junction of the glenoid, coracoid, and acromion with the scapular body; and the clavicular–coracoclavicular ligamentous–coracoid linkage. The complex as a whole maintains a normal stable relationship between the scapula and upper extremity and the axial skeleton, allows limited motion to occur through the AC joint and the CC ligament and provides a firm point of attachment for several soft tissue structures. 
Figure 39-2
Superior shoulder suspensory complex (SSSC), anterior aspect of the right scapula.
 
A, acromion; AC, acromioclavicular joint; Ca, articular capsule of glenohumeral joint; Cla, clavicle; Co, coracoid process; CoA, coracoacromial ligament; CoH, coracohumeral ligament; CC, coracoclavicular ligament; LB, lateral border of scapular body; ScN, scapular neck; Sub, insertion of subscapularis tendon into lesser tuberosity.
A, acromion; AC, acromioclavicular joint; Ca, articular capsule of glenohumeral joint; Cla, clavicle; Co, coracoid process; CoA, coracoacromial ligament; CoH, coracohumeral ligament; CC, coracoclavicular ligament; LB, lateral border of scapular body; ScN, scapular neck; Sub, insertion of subscapularis tendon into lesser tuberosity.
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Figure 39-2
Superior shoulder suspensory complex (SSSC), anterior aspect of the right scapula.
A, acromion; AC, acromioclavicular joint; Ca, articular capsule of glenohumeral joint; Cla, clavicle; Co, coracoid process; CoA, coracoacromial ligament; CoH, coracohumeral ligament; CC, coracoclavicular ligament; LB, lateral border of scapular body; ScN, scapular neck; Sub, insertion of subscapularis tendon into lesser tuberosity.
A, acromion; AC, acromioclavicular joint; Ca, articular capsule of glenohumeral joint; Cla, clavicle; Co, coracoid process; CoA, coracoacromial ligament; CoH, coracohumeral ligament; CC, coracoclavicular ligament; LB, lateral border of scapular body; ScN, scapular neck; Sub, insertion of subscapularis tendon into lesser tuberosity.
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Muscles of the Scapula

In total, 18 muscles are attached to the scapula. Only three of them, namely the subscapularis, supraspinatus, and infraspinatus, originate from the broad surface of the scapula in their respective fossae. Other muscles insert into, or originate from, the borders of the scapula or its processes. 
The muscles of the scapula may be divided into two systems. The first, the scapuloaxial system connects the scapula with the axial skeleton, particularly the vertebral column and the chest wall. This system controls movement of the scapula over the chest wall. The second, the scapulobrachial system is formed by the muscles originating from the scapula and attaching to the bones of arm, that is, the humerus, proximal radius, and proximal ulna. Its task is to control movements between the scapula and arm. 
The scapula, thereby, integrates activity of the two groups of muscles and provides optimal support for the humeral head during motion. 

Blood Vessels and Nerves of the Scapula

A number of blood vessels and nerves pass in the region of the scapula. However, only the suprascapular nerve and vessels and the scapular circumflex artery are intimately related to it. 
The suprascapular nerve arises from the supraclavicular part of the brachial plexus. Together with the suprascapular vessels, it travels posteriorly through the scapular notch and then along the bottom of the supraspinatous fossa, covered by the supraspinatus muscle belly. At the bottom of the fossa, the trunk sends motor branches medially to the supraspinatus, and to the upper portion of the infraspinatus. The main suprascapular nerve descends around the base of the lateral border of the scapular spine, through the spinoglenoid notch, to the infraspinous fossa, passing under the spinoglenoid ligament. Then it runs medially and splits into several motor branches to supply the distal portion of the infraspinatus (Fig. 39-3). 
Figure 39-3
Course of suprascapular neurovascular bundle on posterior aspect of the right scapula.
 
AXN, axillary nerve; CSA, circumflex suprascapular artery; LHT, long head of triceps; SSN, suprascapular nerve accompanied by suprascapular artery.
AXN, axillary nerve; CSA, circumflex suprascapular artery; LHT, long head of triceps; SSN, suprascapular nerve accompanied by suprascapular artery.
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Figure 39-3
Course of suprascapular neurovascular bundle on posterior aspect of the right scapula.
AXN, axillary nerve; CSA, circumflex suprascapular artery; LHT, long head of triceps; SSN, suprascapular nerve accompanied by suprascapular artery.
AXN, axillary nerve; CSA, circumflex suprascapular artery; LHT, long head of triceps; SSN, suprascapular nerve accompanied by suprascapular artery.
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The scapular circumflex artery curves around the lateral border of the scapular body to the posterior surface of the scapula about 3 cm distal to the inferior border of the glenoid. It passes through the teres minor and usually splits into two branches, one entering the anterior surface of the infraspinatus and the other anastomosing in the spinoglenoid groove with the suprascapular artery. 

Injury Assessment of Scapula Fractures

A knowledge of injury mechanisms, and careful clinical and radiologic examinations are essential to determine the proper diagnosis. 

Mechanisms of Injury for Scapula Fractures

The mechanism of scapula fractures varies. Most often the fracture is caused by a direct blow to the scapula, during a traffic accident, or a fall from height, or by the fall of a heavy object on the shoulder.12,30 The fracture pattern depends on the shape of the object, the energy of the blow, and the force vector. 
Scapula fractures may be caused by the humeral head, either by its direct impact on the surrounding processes of the scapula, or as a result of its dislocation over the rim of the glenoid fossa. In cases of a direct impact, the fracture pattern is determined by the position of the arm at the time of injury.14 With the arm in abduction, the humeral head is driven against the inferior glenoid, which separates off, together with some, or all, of the lateral border of the scapula. With the arm in adduction, a blow on the elbow along the axis of the humerus proximally dislocates the humeral head, which hits the acromion or the coracoid.73,106 Anterior dislocation of the humeral head may result in separation of the anteroinferior rim of the glenoid fossa, whereas posterior dislocation may cause a fracture of the posterior rim of the glenoid fossa.66 
Scapula fractures may also be caused by a violent muscle contracture, mostly as a result of electrical injury, or epileptic seizure.91 Typical of this mechanism are compression fractures of the scapular body, fractures of the glenoid, or avulsion of the part of the bone carrying a muscle attachment. Avulsion fracture of the coracoid caused by pull of the CC ligament is described in AC dislocation.112,116 Scapula fractures resulting from gunshot injuries or pathologic fractures (bone cyst, osteodystrophy, tumor metastasis) are quite rare. Fatigue fractures of the coracoid have been described in athletes and fatigue fractures of the scapular spine and the acromion are described in cases of insufficiency of the rotator cuff.29,78,171 

Associated Injuries with Scapula Fractures

Most scapular injuries are caused by medium- to high-energy violence. As a result, these fractures are often associated with other injuries and may be found not infrequently in polytrauma patients. These associated injuries are of different severity and affect both the shoulder girdle and other parts of the body. Some of them occur commonly with scapula fractures, for example, rib fractures, whereas others are rare, such as a fracture of the scapular body penetrating through the chest wall.170 
Isolated scapula fractures are less frequent. In the relevant literature, their incidence ranges between 14% and 33% of all scapula fractures,9,12,24,86,110,119,135,174,180 although Thompson178 recorded only 1.8% of such single injuries in a group of 56 patients. 
Fractures of the ribs are the most frequent injuries associated with scapula fractures which is not surprising in view of its location on the rib cage.9,12,57,82,98,174,180,187 Their frequency ranges from 27%98 up to 65%.180 Such a wide range may have several explanations. The study by Imatani98 was published in 1975, when rib fractures were diagnosed only by radiographs. By contrast, in all patients in the Tucˇek’s180 group a CT scan was obtained, capturing the surrounding ribs. Another reason may be an increase in the number of high-energy traumas with a much higher incidence of associated injuries, including rib fractures. 
Injuries to the thoracic cavity and lungs, such as pneumothorax, hemothorax, emphysema, and lung contusion have been reported, in 16% to 67% of cases.82,136,166,170,174,187 
Injuries to the shoulder girdle, that is to the clavicle, proximal humerus, and AC joint occur in between 8% and 47% of cases of scapula fracture.12,119,180 The reason for the wide range may be that some authors focused merely on clavicular fractures, whereas others also included AC joint dislocation. 
Head injuries, that is, cerebral contusion, intracerebral hemorrhage, and fractures of the skull occur in 10% to 42% of all cases of scapula fracture.12,110,135,174,180 
Other injuries occur at variable rates in groups of patients described by individual authors. Certain groups show a higher share of pelvic injuries, sometimes up to 20%.174 In contrast, Tucˇek recorded only one fracture of the acetabulum in 25 cases. Thompson178 described injuries to major blood vessels in the shoulder region (brachial, subclavian, and axillary arteries) in 10% of cases. In addition to blood vessels, injuries may involve also the brachial plexus. Scapula fractures may be associated, additionally, with other injuries to the skeleton including fractures of thoracic, or lumbar, vertebrae, distal humerus, forearm, femoral shaft, proximal tibia, tibial shaft, ankle, metatarsals, or even subtalar dislocations.180 
Mortality in scapula fractures is reported to vary between 2% and 14%.9,35,174,178,191 

Signs and Symptoms of Scapula Fractures

Clinical examination of patients with scapular injuries depends on the patient’s general condition. In polytrauma patients, where the priority is to save life, the treatment of a scapula fracture, even if identified during primary examination, may be postponed to a later time. An exception is an open scapula fracture. In a number of polytrauma patients, scapula fractures are often found coincidentally on a radiograph or a CT scan of the chest.176 
Patients in a less severe general condition who are able to communicate may undergo standard clinical examination. As scapula fractures are often associated with other injuries, it is essential first to make a thorough comprehensive examination of the patient and only then to focus on the shoulder. Where one fracture of a shoulder girdle is found, for example, that of the clavicle, it is necessary to exclude other potential injuries in the same area. 
Patient’s medical history: A knowledge of the exact mechanism of the injury and the patient’s subjective complaints are essential to a successful diagnosis. 
Visual assessment: Careful examination is performed of the shoulder and the entire chest, including the axilla. The shoulder may be deformed by a clavicle fracture, an AC dislocation, a shoulder dislocation, a displaced scapula fracture, or by significant swelling. The skin should be examined as a skin abrasion may indicate a site of impact. 
Palpation: A large part of the skeleton of the shoulder girdle may be examined by palpation, that is, the clavicle, SC joint, AC joint, the acromion and scapular spine, the tip of the coracoid, and the humeral head; in less muscular individuals also the inferior angle and medial border of the scapula. Palpation may reveal crepitus, or pathologic mobility. It is also important to palpate the axilla and the adjacent chest. As the fracture may be combined with a lesion of the brachial plexus or vascular injury, it is important to examine distal neurovascular function. 
Range of motion: Examination of the range of motion, mainly the active motion, in scapula fractures is limited by pain. If possible, passive motion in the glenohumeral joint is carefully examined. 
Periphery: A thorough assessment of other parts of the ipsilateral extremity should be undertaken to exclude associated injuries. 

Imaging and Other Diagnostic Methods for Scapula Fractures

Radiologic examination is essential for the diagnosis of scapula fractures, the determination of the fracture patterns, and the method of treatment. Other imaging methods may include MRI and ultrasound scanning, although they are indicated only exceptionally and their contribution is limited.134 As scapula fractures often occur in polytrauma patients, the radiodiagnostic algorithm described below has to be adjusted to the patient’s general condition. 

Radiology

Anteroposterior radiograph of the entire shoulder girdle covering the whole scapula, the whole clavicle, AC and SC joints, and proximal humerus is part of the basic examination in a suspected scapula fracture. It provides general information about the whole shoulder girdle. Scapula fractures are often associated with a clavicular fracture, less frequently with a proximal humeral fracture or AC dislocation. This projection is usually not sufficient to determine the fracture pattern and displacement of fragments. Therefore, in cases of a suspected scapula fracture it should be combined with both Neer projections. 
Neer I projection, the true anteroposterior radiograph of the scapula, is used to assess the glenohumeral joint space, displacement of the glenoid in relation to the lateral border of the scapula, and to measure the glenopolar angle (GPA).20 
Neer II projection, also called Y-view, is a true lateral scapula projection. This projection allows assessment of scapular body fractures in terms of translation, angulation, and overlap of fragments, particularly of the lateral border. In addition, it displays clearly the relationship between the acromion and the lateral clavicle, and can be used to identify any avulsion of the anterior rim of the glenoid. 
A chest radiograph in polytrauma patients is often the first examination in which a diagnosis of a scapula fracture is suspected. It is important mostly for assessment of the position of both scapulae in relation to the spine (scapulothoracic dissociation). 
Other special projections, axillary in particular, are recommended by some authors as complementary views, to diagnose fractures of the glenoid, acromion, and coracoid.31,72,102 However, for most patients with a scapular or rib fracture an axillary projection is painful. In addition, it should not be a substitute for CT examination. 

CT Scans

CT examination has fundamentally changed the radiodiagnostics of scapula fractures.16,29,43,133,175 It is always indicated when radiographic examination does not reveal the exact fracture pattern, involvement of the articular surface, or displacement. 
CT transverse sections are very useful in the assessment of the glenoid fossa. They may also reveal undisplaced fractures of the scapular processes, especially those of the coracoid and acromion. However, they do not provide a three-dimensional image of the fracture anatomy. 
Two-dimensional CT reconstructions (2D CT), mainly in the frontal plane, are used to assess the glenoid articular surface, especially in fractures of the base of the coracoid process involving the glenoid fossa. 
Three-dimensional CT reconstructions (3D CT) are the only way to obtain a reliable determination of the fracture pattern, particularly in fractures of the scapular body and neck, although they do not show fine fracture lines, especially in minimally displaced fragments. Reconstructions should be made in several basic views, preferably with subtraction of ribs, clavicle, and proximal humerus. The posterior view (Fig. 39-4B) allows assessment of the course of fracture lines with regard to the scapular spine. The anterior view (Fig. 39-4A) is important in fractures of the scapular neck and helps to identify the different fracture lines in injuries of the anatomical and surgical necks of the scapula. Glenoid fractures require a lateral view, always with subtraction of the humeral head. In fractures of the lateral border of the scapular body, this view helps to assess its shortening, angulation, and translation, or the shape and displacement of small intermediate fragments (Fig. 39-4C). 
Figure 39-4
Three standardized views of the scapula in 3D CT reconstructions.
 
A: Anterior aspect. B: Posterior aspect. C: Lateral aspect.
A: Anterior aspect. B: Posterior aspect. C: Lateral aspect.
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Figure 39-4
Three standardized views of the scapula in 3D CT reconstructions.
A: Anterior aspect. B: Posterior aspect. C: Lateral aspect.
A: Anterior aspect. B: Posterior aspect. C: Lateral aspect.
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Measurements of Angulation, Translation, Medialization, and GPA

These measurements quantify different types and directions of displacement of fragments, particularly of the lateral border of the scapula, and support management decisions (Fig. 39-5). Measurements may be made using both the Neer projections and 3D CT reconstructions.4,35 Anavian et al.6 have proved that displacement of some extra-articular fractures may progress during the postinjury period, which may require a further radiologic assessment after a short time. 
Figure 39-5
Measurement of displacement of fractures of the scapular body or scapular neck.
 
A: Mediolateral displacement. B: Angular displacement. C: Translational displacement.
A: Mediolateral displacement. B: Angular displacement. C: Translational displacement.
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Figure 39-5
Measurement of displacement of fractures of the scapular body or scapular neck.
A: Mediolateral displacement. B: Angular displacement. C: Translational displacement.
A: Mediolateral displacement. B: Angular displacement. C: Translational displacement.
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Medialization of the main fragments of the lateral border of the scapula is measured in the Neer I projection on the anterior view (Fig. 39-5A) and in 3D CT reconstructions. Cole31,34,35 considers medialization of 10 to 20 mm to be an indication for operative treatment. However, the term medialization is not quite correct.156,201 In most cases there occurs lateral displacement of the infraglenoid part of the scapular body by the pull of muscles as the intact clavicle maintains a constant distance between the glenoid and the sternum. Zuckerman et al.201 described, in scapula fractures, a slight lateral displacement of the glenoid with regard to the other side. The displacement of fragments is more accurately expressed by the term mediolateral displacement. 
Angulation of the main fragments of the lateral border of the scapula may be evaluated in the Neer II projection (Fig. 39-5B), or in the lateral view based on 3D CT reconstructions. Cole31,34,35 considers angulation of more than 30 to 45 degrees as an indication for operative treatment. 
Translation of the main fragments of the lateral border of the scapula is also measured by the Neer II view (Fig. 39-5C). A strong indication for operative treatment is considered to be translation of fragments by 100%.14,31,34,35 
GPA, defined by Bestard et al.,20 is the angle subtended by two lines, one connecting the most cranial with the most caudal point of the glenoid and one connecting the most cranial point of the glenoid with the most caudal part of the scapula (Fig. 39-6). The normal GPA is 30 to 46 degrees. In recent studies, some authors used the GPA as a radiologic predictor of the functional outcome after nonoperative treatment of scapula fractures.24,44,111,117,155,163 Romero et al.163 reported that a GPA of less than 20 degrees was associated with a poor functional outcome whereas another study111 encountered worse functional outcomes in patients with a GPA of less than 30 degrees. Labler et al.117 considered a GPA of less than 30 degrees to be an indirect indication of injury to the surrounding ligaments. A detailed analysis of various studies, however, shows that GPA measurement has not been standardized. In addition, it cannot be used in all fractures of the scapular body and neck. Despite these reservations, the GPA is, unlike medialization, angulation, and translation, the only radiologic measurement where correlation between its value and the functional outcome has been reported,24,44,111,117,155,163 with a value of less than 20 degrees being likely to compromise function. 
Figure 39-6
Glenopolar angle.
 
The GPA is defined as the angle between the line connecting the superior and inferior poles of the glenoid and the line connecting the superior pole of the glenoid and the center of the inferior angle of scapula. A GPA of less than 20 degrees is one of the criteria for operative treatment.
The GPA is defined as the angle between the line connecting the superior and inferior poles of the glenoid and the line connecting the superior pole of the glenoid and the center of the inferior angle of scapula. A GPA of less than 20 degrees is one of the criteria for operative treatment.
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Figure 39-6
Glenopolar angle.
The GPA is defined as the angle between the line connecting the superior and inferior poles of the glenoid and the line connecting the superior pole of the glenoid and the center of the inferior angle of scapula. A GPA of less than 20 degrees is one of the criteria for operative treatment.
The GPA is defined as the angle between the line connecting the superior and inferior poles of the glenoid and the line connecting the superior pole of the glenoid and the center of the inferior angle of scapula. A GPA of less than 20 degrees is one of the criteria for operative treatment.
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Classification of Scapula Fractures

Since the time of Petit, classification has developed over time13 but there is still no generally accepted classification of scapula fractures. Currently there are several different classifications.1,14,42,53,54,69,83,96,97,132,179,192 

Overview of Present Classifications

In 1975, Tscherne and Christ179 divided scapula fractures into five basic patterns: 
  1.  
    Fractures of processes
  2.  
    Fractures of the scapular body
  3.  
    Fractures of the scapular neck
  4.  
    Fractures of the glenoid fossa
  5.  
    Combined and comminuted fractures
In 1991, Ada and Miller1 published a similar anatomical alphanumerical classification based on an analysis of conventional radiographs of 113 scapula fractures: 
  1.  
    Fractures of processes: IA—acromion fractures, IB—scapular spine fractures, IC—coracoid process fractures
  2.  
    Fractures of the neck: IIA—fracture of the surgical neck, II B—transspinous fractures of the neck, IIC—fractures of the neck inferior to the scapular spine
  3.  
    Fractures of the glenoid
  4.  
    Fractures of the body
In 1992, Euler et al.53 developed an anatomical classification based on 153 scapula fractures, of which only 18, mostly fractures of the glenoid, were treated operatively. This classification was revised by Euler and Rüedi54 in 1996, using an alphanumeric code analogous to the Müller/AO classification. 
  1.  
    Body fractures
  2.  
    Fractures of processes (B1—spine, B2—coracoid, and B3—acromion)
  3.  
    Neck fractures (C1—anatomical neck, C2—surgical neck, C3—surgical neck with clavicular and/or acromial fracture, or rupture of CC and/or coracoacromial [CA] ligaments)
  4.  
    Intra-articular fractures (D1—glenoid rim fractures, D2—glenoid fossa fractures with inferior fossa fragment, with horizontal scapula split, with glenocoracoid block, comminuted fractures of the glenoid fossa, and D3—combined fractures of glenoid fossa and scapular neck, or body)
  5.  
    Scapula fractures combined with humeral head fractures
In 1996, the OTA (Orthopaedic Trauma Association) presented an alphanumerical classification that grouped fractures of individual anatomical parts of the scapula according to the principles of the Müller/AO classification.151 
In 1984, and again in 1995, Ideberg96,97 published a classification of glenoid fractures, based on analysis of conventional AP and lateral radiographs of 338 scapula fractures. He recognized five types: (1) Anterior glenoid rim fracture, (2) inferior glenoid fracture involving part of the neck, (3) superior glenoid fracture extending through the base of the coracoid process, (4) horizontal fracture involving both the scapular neck and body, the fracture line always running inferior to the spine of the scapula, and (5) horizontal fracture as in type IV, but with additional complete or incomplete neck fracture. 
In 1992, Goss69 modified the Ideberg classification, without specifying the radiographic examination technique or the number of his cases. Using Roman numerals instead of the Arabic ones, he converted the Ideberg’s type I to Ia—fracture of anterior rim and type Ib—fracture of posterior rim. Type V was divided into three subtypes—type Va (combination of types II and IV), type Vb (combination of types III and IV), and type Vc (combination of types II, III, and IV). Type VI was also added. 
In 1998, Mayo et al.132 revised the Ideberg classification and changed the numerical order of individual types. The revision was based on a group of 27 patients who had surgery for a glenoid fracture. In several patients, 3D CT reconstruction was used and found to be more valuable than either routine radiographs of the scapula or 2D CT reconstructions. 

Controversies of Present Classifications

The weakness of classifications of scapula fractures is the difficulty in accurate interpretation of the imaging. Different types of scapula fractures were identified primarily on the basis of plain radiographs. In view of the complicated anatomy of the scapula and its position on the chest, standard views are not easy to obtain and their unambiguous interpretation and determination of the type of fracture was difficult or impossible. CT was used only minimally, correlation of radiologic and intraoperative findings was not mentioned, because only a minimum of analyzed cases were treated operatively. Thus, almost no author was able to verify whether the identification of the types of fractures on the basis of plain radiographs was accurate. 
Another disadvantage of the current classifications is the oversimplified schematic drawings of fracture lines mostly on the anterior surface of the scapula69,151,152 as it is not always possible to determine the course of a fracture line in relation to the scapular spine. Simplistic schematic drawings of the scapular shape, mainly of the relationship of the upper part of the glenoid to the coracoid base, are also misleading151,152 The coracoid arises directly from the superior pole of the glenoid and the upper surface of the neck is reduced to a small notch only a few millimeters deep. However, the illustrations in most classifications show the origin of the coracoid shifted markedly medially which makes the upper surface of the anatomical neck of the scapula seem significantly longer. As a result, the drawings of fracture lines running in this region are not realistic. 
The current classifications also describe certain fracture patterns whose existence is questionable, or that are misinterpreted. 
Scapular neck fractures: A number of authors use only the term “fracture of the scapular neck,” without specifying its type.33,75,102,162 Schematic drawings in the OTA classification, published in 2007, include only a fracture of the anatomical neck. Fracture of the surgical neck is missing.152 
Analyses of 3D CT reconstructions and intraoperative findings have proved that most fractures, interpreted on the basis of plain radiographs as fractures of the scapular neck, were actually fractures of the scapular body (Fig. 39-7). 
Figure 39-7
A common mistake in interpretation of shoulder radiograph.
 
A: An AP radiograph of the injured right shoulder is often interpreted as a fracture of scapular neck. B: The posterior aspect of scapula on 3D CT reconstruction of the same patient demonstrates the actual type of fracture, that is, a two-part fracture of the scapular body.
A: An AP radiograph of the injured right shoulder is often interpreted as a fracture of scapular neck. B: The posterior aspect of scapula on 3D CT reconstruction of the same patient demonstrates the actual type of fracture, that is, a two-part fracture of the scapular body.
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Figure 39-7
A common mistake in interpretation of shoulder radiograph.
A: An AP radiograph of the injured right shoulder is often interpreted as a fracture of scapular neck. B: The posterior aspect of scapula on 3D CT reconstruction of the same patient demonstrates the actual type of fracture, that is, a two-part fracture of the scapular body.
A: An AP radiograph of the injured right shoulder is often interpreted as a fracture of scapular neck. B: The posterior aspect of scapula on 3D CT reconstruction of the same patient demonstrates the actual type of fracture, that is, a two-part fracture of the scapular body.
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Another problem is terminology. Ada and Miller1 classified transverse infraspinous fractures as type IIC fractures of the neck inferior to the scapular spine. This fracture line does not separate the glenoid from the scapular body, but splits the scapular body into two parts. In spite of this, some authors have taken over this incorrect term and further contributed to the confusion in scapula fracture classification.71,133 
These issues cast doubt on the existing statistical data on incidence rates of individual types of scapula fractures and on the outcomes of clinical studies dealing with fractures of the scapular body and neck, and floating shoulder. 
Glenoid fractures: Euler and Rüedi,53,54 Goss,69 and the OTA classification151,152 described comminuted fractures of the entire glenoid fossa. However, their existence is questionable, as no 3D CT reconstruction of such a fracture has been published so far. 
The so-called transverse fractures of the glenoid, that is, type 5(V) of the Ideberg,97 Goss,69 or Mayo et al.132 classifications, are in fact fractures of the inferior glenoid involving the lateral border of the scapular body. The fracture line in these fractures runs through the infraspinous part of the scapular body and not through the supraspinous part as it may seem from the accompanying drawings. These classifications also present a fracture of the superior pole of the glenoid fossa as a transverse fracture of the glenoid. However, these are intra-articular fractures of the coracoid base that may involve the superior border, or superior angle, of the scapula. 

Importance of Internal Architecture of Scapula for Fracture Classification

Currently, 3D CT reconstructions are increasingly used to characterize scapula fractures.16,35,133 In addition, the volume of information related to operative treatment of these fractures is growing. This allows a more exact determination of the course of fracture lines in individual cases and their distribution in relation to the anatomical parts of the scapula.8,181 
The scapular spine is essential to the distribution of fracture lines. The posterior view shows the separation of the anatomical body of the scapula into two parts. The supraspinous thin portion of the anatomical body constitutes, together with the acromion and the coracoid, the “upper scapula” serving for attachment of muscles and ligaments. The lower, infraspinous portion of the anatomical body, that is, the biomechanical body of the scapula receives compression forces transmitted from the glenoid by two pillars, the spinal and the lateral one, as described earlier. The scapular spine is actually a barrier preventing the propagation of fracture lines from the infraspinous to the supraspinous body and vice versa. This is supported by clinical experience as fractures of the anatomical body are less common than fractures of the biomechanical body. 
As revealed by Armitage et al.8 in their study as well as by 3D CT reconstruction of cases,14,16 barring a few exceptions, fracture lines propagate from the infraspinous to the supraspinous fossae through the weaker areas, that is, through the spinomedial angle, or through the central thin part of the scapular spine.8,181 

Comprehensive Anatomical Classification

This classification is based on classifications developed by Tscherne and Christ,179 Ada and Miller,1 and Euler and Rüedi.54 However, the basic groups of this classification include only the fracture lines whose existence has been verified by 3D CT reconstructions or intraoperatively. 
  •  
    Fractures of the processes
  •  
    Fractures of the scapular body
  •  
    Fractures of the scapular neck
  •  
    Fractures of the glenoid
  •  
    Combined fractures of the scapula
Process Fractures.
These fractures may be caused by a direct blow to the upper part of the scapula, a direct impact of the dislocated humeral head, or pull of muscles and ligaments. They include also fractures of the superior border and the superior angle of the scapula. As these fractures often occur simultaneously, they may be called fractures of “the upper scapula” (Fig. 39-8). 
Figure 39-8
Fractures of the scapular processes (fractures of “upper” scapula) in 3D CT reconstruction.
 
A: Anterior aspect. B: Posterior aspect. Both views demonstrate an intra-articular fracture of the coracoid base, a fracture of the superior angle, a fracture of the scapular spine, and a fracture of acromion. (Courtesy Prof. Zwipp.)
A: Anterior aspect. B: Posterior aspect. Both views demonstrate an intra-articular fracture of the coracoid base, a fracture of the superior angle, a fracture of the scapular spine, and a fracture of acromion. (Courtesy Prof. Zwipp.)
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Figure 39-8
Fractures of the scapular processes (fractures of “upper” scapula) in 3D CT reconstruction.
A: Anterior aspect. B: Posterior aspect. Both views demonstrate an intra-articular fracture of the coracoid base, a fracture of the superior angle, a fracture of the scapular spine, and a fracture of acromion. (Courtesy Prof. Zwipp.)
A: Anterior aspect. B: Posterior aspect. Both views demonstrate an intra-articular fracture of the coracoid base, a fracture of the superior angle, a fracture of the scapular spine, and a fracture of acromion. (Courtesy Prof. Zwipp.)
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  •  
    A1—fractures of the superior border and the superior angle
  •  
    A2—fractures of the acromion and the lateral part of the scapular spine
  •  
    A3—fractures of the coracoid process
There is no exact dividing line between fractures of the scapular spine and of the acromion and therefore they are included in one group. Fractures of the acromion and of the lateral part of the scapular spine and fractures of the coracoid process may be further subdivided.55,91,99,115,144147 
Body Fractures.
These fractures may be divided, in terms of severity, into two groups: 
  •  
    B1—fractures of the anatomical body
  •  
    B2—fractures of the biomechanical body
In fractures of the anatomical body, fracture lines pass from the supraspinous fossa through the scapular spine to the infraspinous fossa, whereas in fractures of the biomechanical body they run only within the infraspinous fossa (Fig. 39-9). 
Figure 39-9
Fractures of the scapular body.
 
A: A two-part fracture of the biomechanical body, (B) a three-part fracture of the biomechanical body, (C) a comminuted fracture of the biomechanical body involving the base of the scapular spine, (D) a comminuted fracture of the anatomical body.
A: A two-part fracture of the biomechanical body, (B) a three-part fracture of the biomechanical body, (C) a comminuted fracture of the biomechanical body involving the base of the scapular spine, (D) a comminuted fracture of the anatomical body.
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Figure 39-9
Fractures of the scapular body.
A: A two-part fracture of the biomechanical body, (B) a three-part fracture of the biomechanical body, (C) a comminuted fracture of the biomechanical body involving the base of the scapular spine, (D) a comminuted fracture of the anatomical body.
A: A two-part fracture of the biomechanical body, (B) a three-part fracture of the biomechanical body, (C) a comminuted fracture of the biomechanical body involving the base of the scapular spine, (D) a comminuted fracture of the anatomical body.
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Neck Fractures.
These fractures may be defined as those separating the glenoid from the scapular body.42,58 The following three basic fractures of the scapular neck may be distinguished according to the course of the fracture line and the shape of the glenoid fragment (Figs. 39-10 and 39-11). 
Figure 39-10
Fractures of the scapular neck in an AP shoulder radiograph.
 
A: Fracture of the anatomical neck. B: Fracture of the surgical neck. C: A transspinous neck fracture.
A: Fracture of the anatomical neck. B: Fracture of the surgical neck. C: A transspinous neck fracture.
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Figure 39-10
Fractures of the scapular neck in an AP shoulder radiograph.
A: Fracture of the anatomical neck. B: Fracture of the surgical neck. C: A transspinous neck fracture.
A: Fracture of the anatomical neck. B: Fracture of the surgical neck. C: A transspinous neck fracture.
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Figure 39-11
Fractures of the scapular neck in 3D CT reconstruction—anterior aspect.
 
A: A fracture of the anatomical neck. The fracture line passes through the coracoglenoid notch, lateral to the coracoid process. B: Fracture of the surgical neck The fracture line passes through the suprascapular notch medial to coracoid process. The glenoid fragment bears the coracoid process. C: A transspinous neck fracture. The fracture line passes medial to the suprascapular notch. The glenoid fragment bears the coracoid process, acromion, and the lateral part of the scapular spine.
A: A fracture of the anatomical neck. The fracture line passes through the coracoglenoid notch, lateral to the coracoid process. B: Fracture of the surgical neck The fracture line passes through the suprascapular notch medial to coracoid process. The glenoid fragment bears the coracoid process. C: A transspinous neck fracture. The fracture line passes medial to the suprascapular notch. The glenoid fragment bears the coracoid process, acromion, and the lateral part of the scapular spine.
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Figure 39-11
Fractures of the scapular neck in 3D CT reconstruction—anterior aspect.
A: A fracture of the anatomical neck. The fracture line passes through the coracoglenoid notch, lateral to the coracoid process. B: Fracture of the surgical neck The fracture line passes through the suprascapular notch medial to coracoid process. The glenoid fragment bears the coracoid process. C: A transspinous neck fracture. The fracture line passes medial to the suprascapular notch. The glenoid fragment bears the coracoid process, acromion, and the lateral part of the scapular spine.
A: A fracture of the anatomical neck. The fracture line passes through the coracoglenoid notch, lateral to the coracoid process. B: Fracture of the surgical neck The fracture line passes through the suprascapular notch medial to coracoid process. The glenoid fragment bears the coracoid process. C: A transspinous neck fracture. The fracture line passes medial to the suprascapular notch. The glenoid fragment bears the coracoid process, acromion, and the lateral part of the scapular spine.
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  •  
    C1—fracture of the anatomical neck separates only the glenoid from the scapular body. The fracture line starts proximally between the upper rim of the glenoid and the coracoid base, that is, in the coracoglenoid notch (Fig. 39-11A).
  •  
    C2—fracture of the surgical neck (Fig. 39-11B) starts in the scapular notch and passes through the spinoglenoid notch, that is, lateral to the scapular spine base. The lateral fragment is formed by the glenoid and the coracoid. Surgical neck fractures are divided into stable and unstable ones. Instability is caused by rupture of the CC and CA ligaments, or by avulsion of that part of the coracoid process to which these ligaments are attached.
  •  
    C3—transspinous fracture of the scapular neck is rare and little known. The fracture line starts medial to the scapular notch and passes through the centre of the scapular spine (Fig. 39-11C). The lateral fragment is formed by the glenoid, the coracoid, and the lateral part of the scapular spine, including the acromion.
Glenoid Fossa Fractures.
These intra-articular fractures may be divided according to the part of the glenoid that is affected (Fig. 39-12). 
Figure 39-12
Types of glenoid fractures in 3D CT reconstruction, right scapula.
 
A: Superior glenoid fracture. B: Fracture of anterior glenoid rim. C: Inferior glenoid fracture.
A: Superior glenoid fracture. B: Fracture of anterior glenoid rim. C: Inferior glenoid fracture.
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Figure 39-12
Types of glenoid fractures in 3D CT reconstruction, right scapula.
A: Superior glenoid fracture. B: Fracture of anterior glenoid rim. C: Inferior glenoid fracture.
A: Superior glenoid fracture. B: Fracture of anterior glenoid rim. C: Inferior glenoid fracture.
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If they are displaced, congruence and stability of the glenohumeral joint are compromised, depending on the location, size, and degree of displacement of the separated fragment. 
  •  
    D1—fractures of the superior glenoid are caused by avulsion of the coracoid base, including part of the articular surface. Part of the fragment may be a portion of the superior border of the scapula, variable in size. The fracture line always passes superior to the scapular spine (Fig. 39-12A).
  •  
    D2—avulsion of the anteroinferior rim of the glenoid occurs in association with anterior dislocation of the humeral head (Fig. 39-12B). The size of fragment(s) varies.
  •  
    D3—fractures of the inferior glenoid affect the one to two distal thirds of the glenoid fossa, together with a part of the lateral border of the scapula, of variable length. The fracture line extends as far as the lateral pillar of the scapula, at a variable distance from the inferior rim of the glenoid (Fig. 39-12C). In most of these fractures, however, there are also additional fracture lines involving the scapular body.
  •  
    D4—fractures of the posterior rim of the glenoid are very rare, occurring in association with the posterior dislocation of the humeral head.
Combined Fractures.
This miscellaneous group may be divided into two subgroups. 
The first subgroup includes a combination of the four basic scapula fracture patterns. The most common fractures of this subgroup are combined fractures of the scapular body and the distal glenoid. 
The second subgroup comprises combinations of one or two basic scapula fractures with injuries to other bones, or joints, of the shoulder girdle. A specific type of combined fracture is the so-called floating shoulder, that is, an unstable fracture of the surgical neck of the scapula combined with a fracture of the shaft of the clavicle. 

Scapulothoracic Dissociation

Scapulothoracic dissociation is a traction (avulsion) injury of the muscular apparatus of the scapula, characterized by lateral displacement of the scapula, with a wide range of concomitant injuries, including those of the shoulder girdle, while the skin is usually intact.3,65,118,198 

Treatment of Scapula Fractures

The aim of treatment of scapula fractures is to restore a full, pain-free range of motion of the shoulder and to prevent the development of late complications, including malunion, nonunion, osteoarthritis of the glenohumeral joint, lesions of the rotator cuff, and chronic pain. Specifically, it implies restoration of the congruence and stability of the glenohumeral joint in glenoid fractures; restoration of the anatomical form and alignment of the scapular body and the glenoid in fractures of the scapular neck and body; and prevention of painful nonunion, or impingement of humeral head, resulting from malunion of fractures of the acromion or coracoid processes. 

Treatment Options for Scapula Fractures

There is a general consensus that all nondisplaced fractures of the scapula should be treated nonoperatively. Until recently, nonoperative treatment had also been used in most displaced extra-articular fractures of the scapular neck and body, based on repeated reports of good outcomes of this treatment.98,124,166,193,197 However, the authors evaluated their results without taking into account individual types of injury often with very short review periods of a few months. The only indications for operation were usually displaced glenoid fractures. 
Of late, the situation has started to change, mainly in view of a number of studies evaluating the long-term results of nonoperatively treated displaced scapular neck and body fractures.1,9,77,140,155,163 These studies have revealed that a number of patients with malunion of the scapular body or neck suffer from pain, disability, limited range of motion, and sometimes even damage to the rotator cuff, proven by MRI. Views on treatment have also changed following the introduction of CT scanning, and especially 3D reconstructions. Although the debate has not delivered clear conclusions, a number of authors prefer operative treatment for displaced scapula fractures, mainly those of the body and neck. Other authors, on the other hand believe that nonoperative treatment is best based on some reported good outcomes. An analysis of retrospective studies was made by two groups of authors.119,200 
Zlowodzki et al.200 analyzed 520 scapula fractures from 22 case series and reported that 
  •  
    80% of the glenoid fractures were treated operatively and excellent-to-good results were achieved in 82% of them.
  •  
    80% of isolated fractures of the scapular body were treated nonoperatively and excellent or good results were achieved in 86% of them.
  •  
    83% of all nonarticular fractures of the scapular neck were treated nonoperatively and excellent-to-good results were achieved in 77% of them.
Lantry et al.119 reviewed the results of 243 scapula fractures treated operatively in 17 studies and reported that 
  •  
    48% of patients sustained a fracture of the glenoid fossa, 7% a fracture of the glenoid rim, 26% a fracture of the scapular neck, 8% a process fracture, 26% of patients sustained an ipsilateral fracture of the clavicle, or an AC dislocation.
  •  
    the indication for surgery in glenoid fractures was displacement of 4 to 10 mm, most often 5 mm.
  •  
    4.2% of patients developed postoperative infective complications, 2.4% sustained suprascapular nerve injury, and 7.1% of cases required removal of the hardware for local problems or breakage of the implant.
  •  
    163 patients were evaluated in terms of their functional outcomes, using different scoring systems, with excellent-to-good results achieved in 83% of cases, and fair or poor results in 17% of patients, with an average follow-up of 50 months.
The authors of both reviews stated that there were significant differences between individual studies and that the validity of the presented data was often questionable. Prospective multicentre studies were recommended. 

Outcome Measurements

Different shoulder scoring systems are in use to evaluate functional outcomes: American Shoulder and Elbow Surgeons score,160 Constant score,37 DASH score,95 Herscovici score,89 Neer score,139 Rowe score,164 Oxford questionnaire,40 Short Form 36 score,189 Simple Shoulder Test,125 University of California Los Angeles score,50 or subjective scores based on the surgeon’s assessment.80 The details of these are reviewed in Chapter 37

Nonoperative Treatment of Scapula Fractures

Nonoperative treatment is indicated in all undisplaced fractures. It should also be used in intra- or extra-articular displaced fractures when the patient’s general, or local, condition does not allow operation. 
Nonoperative treatment consists of pain relief and about 2 weeks of sling immobilization. It is then possible to start passive range-of-motion exercises with the aim of achieving a full passive range of motion within 1 month of the injury.35 A full active range of motion should be restored during the second month. In the third month, strengthening of the rotator cuff muscles and parascapular muscles may be started. 
The potential disadvantages of nonoperative treatment include deformity of the scapula and incongruity and instability of the glenohumeral joint. 

Recent Results of Nonoperative Treatment

Over the past 12 years, a number of studies have evaluated the outcome of nonoperative treatment of scapula fractures by means of the different scoring systems listed above. This allowed a more objective assessment of functional outcomes. However, with few exceptions, the problem of these studies remains the verification of the types of fractures being evaluated. 
Romero et al.163 in 2001 evaluated the results of nonoperative treatment of scapular neck fractures in 19 patients with a mean age of 42 years (21 to 61) and a mean follow-up of 8 years (2 to 21), using the Constant–Murley score. The authors found functional problems in patients with a GPA less than 20 degrees. Pace et al.155 described nine patients with glenoid neck fractures, with pain in the shoulder in seven cases associated with a subacromial bursitis, diagnosed by MRI. The mean age of patients was 34 years (21 to 64) and the mean follow-up 58 months (24 to 96). The authors attributed the pain to malunion of the scapula. Bozkurt et al.24 reported the outcomes of conservative treatment of scapular neck fractures (surgical neck 12, anatomical neck 6) in 18 patients with a mean age of 43 years (23 to 62) and a mean follow-up of 25 months. The authors found a positive correlation between the Constant–Murley score and GPA. 
The outcome of conservative treatment of scapular neck fractures in 13 patients with a mean age of 45 years and a mean follow-up of 5.5 years (1.6 to 12) was reported by Van Noort et al.184 GPA was always more than 20 degrees, and the Constant–Murley score indicated good and excellent results in all the patients. Gosens et al.68 in 2009 analyzed a total of 22 patients with a scapular body fracture treated conservatively, with a mean age of 49 years (7 to 67) and a mean follow-up of 63 months (41 to 85). In 14 patients it was the sole injury, but 8 patients had polytrauma. Based on DASH, SST, and SF 36 scores, the authors found worse results in the polytrauma patients. 
Good results of nonoperative treatment after a mean review time of 65 months were reported in 50 patients with a mean age of 44 years (20 to 82) at the time of injury.169 The mean follow-up was 65 months (13 to 120). Fractures of the scapular neck and body accounted for 82%, glenoid fractures for 10%, and fractures of processes for 8%. Regardless of the fracture type and using the Constant score, 23% of results were considered excellent, 51% good, 20% fair, and 6% poor. Restriction of range of motion had no impact on the functional outcome. 
Dimitroulias et al.44 in 2011 evaluated 32 patients with a mean age of 47 years (21 to 84), each with a displaced fracture of the scapular body. The mean follow-up was 15 months (6 to 33). The fracture type was verified by 3D CT reconstruction. The mean GPA value on the affected side was 9 degrees less than that on the intact side. The mean change in the DASH score of 10.2 was considered of minimal clinical importance but a high ISS and the presence of rib fractures compromised the outcome. 

Operative Treatment of Scapula Fractures

Operative treatment of scapula fractures is currently the subject of an intense debate with the number of its advocates increasing. A standard operative method is open reduction and internal fixation,11,14,18,74,80,101,126 although there are also some reports in the literature on treatment of certain types of scapula fractures (acromion, glenoid) by arthroscopically assisted internal fixation19,27,64,93,165,173,177 or partial resection.81 

Indications/Contraindications

The main indication for operative treatment of the glenoid fractures is displacement, that is, a gap, or step-off, ≥3 to 10 mm, with the simultaneous involvement of 20% to 30% of the articular surface (Fig. 39-13) and/or persisting subluxation of the humeral head.35 The aim of operation is to restore congruity and stability of the glenohumeral joint. 
Figure 39-13
Criteria for operative treatment of intra-articular fractures of the scapula.
Rockwood-ch039-image013.png
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In displaced fractures of the processes, particularly the coracoid, acromion, and scapular spine, the aim is to achieve healing in an anatomical position, as healing in displacement may cause impingement syndrome and compromise the rotator cuff. Nonunion of processes of the scapula is often painful because of muscle pull. Displacement of fragments of more than 1 cm has been cited as an indication for operative treatment in fractures of the acromion or coracoid.7 
In displaced extra-articular fractures of the scapular body and neck, the aim is restoration of the original alignment of the glenoid with the scapular body (GPA), primarily by reconstruction of the length and integrity of the lateral border. This will restore the normal orientation of the glenoid in relation to the scapular body and the humeroscapular rhythm (shoulder imbalance), as well as the normal course of muscles, particularly those of the rotator cuff. For normal mobility of the scapula it is also important to restore the congruence between its anterior surface and the chest wall and, if necessary, to remove fragments of the scapula impacted in the chest wall. Current indications for operative treatment are fractures of the scapular body and neck with the following types of displacement.14,3133,35 
  •  
    100% translation of fragments of the lateral border
  •  
    30- to 40-degree angulation of main fragments of the lateral border
  •  
    Mediolateral displacement of the glenoid in relation to the lateral border of the scapular body of more than 1 to 2 cm
  •  
    GPA less than 20 degrees
These criteria are not absolute. It is necessary to take into account all other injuries, mainly those of the chest, the patient’s age, physical condition, skin integrity of the shoulder and consider all potential risks. 

Surgical Approaches

Most scapula fractures are exposed from the Judet posterior, or the anterior deltopectoral, approach. Some authors recommend the Dupont–Evrard posterolateral, or the superior approach of Goss. 
Judet Posterior Approach.
This surgical approach, described by Robert Judet105 in 1964, is currently used in various modifications.17,46,104,141,150 The Judet approach provides an excellent exposure of the entire infraspinous fossa, lateral and medial borders of the scapula, the scapular spine, the scapular neck, and the posterior and inferior rims of the glenoid. 
Indication.
The Judet approach is indicated as a universal exposure in fractures of the scapular body, scapular neck, posteroinferior glenoid, and in combinations of these fractures. 
Patient Positioning and Draping.
The patient is placed in a semiprone position on the intact side with supports in the region of the lumbar spine and chest. Reference structures are marked on the skin, that is, contours of the scapular body, the scapular spine, and acromion. The extremity must be draped free to allow its manipulation during surgery. 
Incision and Dissection.
Judet typically retracted the skin flap together with the portion of the deltoid arising from the scapular spine. In the author’s modification, the Judet approach has three phases. The first phase consists of a boomerang skin incision along the scapular spine and the medial border of the scapula. A skin flap is then raised and the posterior border of the deltoid identified. In the next phase, the posterior deltoid is detached from the scapular spine and turned back laterally and distally. Finally, the infraspinatus is mobilized and retracted proximally (Fig. 39-14). 
Figure 39-14
Judet approach—anatomical dissection.
 
A: Posterior aspect of the right scapula. Note that the fascia of the infraspinatus continues into the deltoid fascia. B: The spinous portion of deltoid is released from the scapular spine and reflected laterally; the dotted line indicates the incision into the infraspinatus fascia. C: Identification of the interval between infraspinatus and teres minor. D: The released infraspinatus is retracted superiorly. Care must be taken not to overdistract the suprascapular neurovascular bundle. D, deltoid; IS, infraspinatus and its fascia; SS, scapular spine; T, trapezius, Tmin, teres minor; Tmaj, teres major; LHT, long head of triceps; AXN, axillary nerve; SSN, suprascapular nerve; CSA, circumflex scapular artery, Ca, articular capsule of glenohumeral joint.
A: Posterior aspect of the right scapula. Note that the fascia of the infraspinatus continues into the deltoid fascia. B: The spinous portion of deltoid is released from the scapular spine and reflected laterally; the dotted line indicates the incision into the infraspinatus fascia. C: Identification of the interval between infraspinatus and teres minor. D: The released infraspinatus is retracted superiorly. Care must be taken not to overdistract the suprascapular neurovascular bundle. D, deltoid; IS, infraspinatus and its fascia; SS, scapular spine; T, trapezius, Tmin, teres minor; Tmaj, teres major; LHT, long head of triceps; AXN, axillary nerve; SSN, suprascapular nerve; CSA, circumflex scapular artery, Ca, articular capsule of glenohumeral joint.
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Figure 39-14
Judet approach—anatomical dissection.
A: Posterior aspect of the right scapula. Note that the fascia of the infraspinatus continues into the deltoid fascia. B: The spinous portion of deltoid is released from the scapular spine and reflected laterally; the dotted line indicates the incision into the infraspinatus fascia. C: Identification of the interval between infraspinatus and teres minor. D: The released infraspinatus is retracted superiorly. Care must be taken not to overdistract the suprascapular neurovascular bundle. D, deltoid; IS, infraspinatus and its fascia; SS, scapular spine; T, trapezius, Tmin, teres minor; Tmaj, teres major; LHT, long head of triceps; AXN, axillary nerve; SSN, suprascapular nerve; CSA, circumflex scapular artery, Ca, articular capsule of glenohumeral joint.
A: Posterior aspect of the right scapula. Note that the fascia of the infraspinatus continues into the deltoid fascia. B: The spinous portion of deltoid is released from the scapular spine and reflected laterally; the dotted line indicates the incision into the infraspinatus fascia. C: Identification of the interval between infraspinatus and teres minor. D: The released infraspinatus is retracted superiorly. Care must be taken not to overdistract the suprascapular neurovascular bundle. D, deltoid; IS, infraspinatus and its fascia; SS, scapular spine; T, trapezius, Tmin, teres minor; Tmaj, teres major; LHT, long head of triceps; AXN, axillary nerve; SSN, suprascapular nerve; CSA, circumflex scapular artery, Ca, articular capsule of glenohumeral joint.
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The skin incision is made from the posterior border of the acromion along the scapular spine to the spinomedial angle, where it curves following the medial border of the scapula and continues to the inferior angle of the scapula. Subcutaneous fibrofatty tissue is incised down to, but not through, the common fascia of the deltoid and infraspinatus. A skin flap is raised, retracted laterodistally and held in this position by two sutures. 
A prerequisite for a careful mobilization of the deltoid is identification of its posterior edge, which is not always easy. The spinal portion of the deltoid and the medial portion of the infraspinatus are covered by a common fascia passing from the medial part of the infraspinatus to the posterior edge of the deltoid (Fig. 39-14A). After identification of the posterior border of the deltoid, the common fascia is split by a T-shaped incision, with one part of the incision following the posterior edge of the deltoid and the other running perpendicular to it (Fig. 39-14B). This incision exposes both the posterior border of the deltoid and the medial half of the infraspinatus. Subsequently, the spinal portion of the deltoid is carefully released from the scapular spine as far as the posterior rim of the acromion and retracted laterally and distally. This will display the entire posterior surface of the infraspinatus. 
Before releasing the infraspinatus, it is necessary to identify the interval between its lateral border and the teres minor (Fig. 39-14C), exposing the scapular circumflex vessels perforating teres minor (Fig. 39-14D). These lie some 3 to 4 cm distal to the lower rim of the glenoid and pass round the lateral border of the scapula to its posterior surface. These blood vessels must be ligated and cut. Only then can the infraspinatus be detached from the scapular spine, the medial border, the lateral border, the inferior angle, and from the infraspinous fossa. When retracting the infraspinatus proximally, care should be taken to avoid injury to the neurovascular bundle of the muscle which can be seen in the spinoglenoid notch (Fig. 39-14D). 
Limited Approaches.
In some cases it is possible to make only medial and lateral windows without mobilizing the whole infraspinatus. On the lateral side it is sufficient to detach the infraspinatus from the lateral border of the scapula only; on the medial side it is typically released in the spino-medial angle. 
Reinsertion of Muscles and Wound Closure.
After completion of the internal fixation, the infraspinatus is carefully reinserted to the inferior angle of the scapula, preferably using the infraspinatus fascia. The spinal portion of the deltoid is then carefully reattached and the subcutaneous tissues and skin closed. 
Extended Judet Approach.
In 2008, the author17 described a combination of the Judet and the sabre-cut approaches. This combined approach allows treatment of any associated fracture of the lateral clavicle, or AC dislocation, via a single incision. 
Posterosuperior Approach.
This approach uses the horizontal part of the Judet incision.59,113 It is indicated in isolated fractures of the posterior rim of the glenoid, the scapular spine, and the acromion. The incision extends along the posterior border of the acromion and the lateral part of the scapular spine. After detachment of the spinal, and partially of the acromial, portions of the deltoid from the scapula, the muscle can be retracted distally, allowing exposure of the tendon of the infraspinatus. The infraspinatus tendon and posterior capsule of the shoulder are incised or osteotomized from the greater tuberosity and the resultant flap retracted medially. This exposes the posterior surface of the glenoid and the scapular neck. When necessary, this approach may be extended to the Judet approach. 
Mini-Invasive Posterior Approach.
Gauger and Cole62 described a mini-invasive approach that is based on the principles of the Judet approach but is performed from two separate shorter incisions. 
Dupont–Evrard Posterolateral Approach.
The Dupont–Evrard approach, described in 1932, provides direct exposure of the lateral border of the scapula in the interval between the infraspinatus and the teres minor.45 Its main disadvantage is that it exposes only the lateral border of the scapula and cannot be extended, if necessary. Modifications of this approach have been described in the literature, differing only in respect of the type of the skin incision.25,103,109,142,185,196 
Deltopectoral Approach.
This classical approach is indicated in fractures of the anteroinferior rim of the glenoid and of the coracoid process. It is described in Chapter 37
Superior Approach.
This approach was described by Goss74 as a complementary approach in fractures of the superior part of the glenoid. The skin incision runs over the superior aspect of the shoulder. The trapezius is split within the angle between the clavicle, acromion, and the scapular spine, to expose the underlying supraspinatus. Splitting of the supraspinatus in the line of its fibers exposes the superior surface of the glenoid. 

Operative Technique, Postoperative Treatment

The operative technique of scapula fractures has been described by many authors.14,15,32,34,52,74,80,101,126,141 However, their procedures differ in a number of details. 
Implants.
Scapula fractures can be fixed by small- and mini-implants, including 3.5- or 2.7-mm cortical screws, 3.5- or 2.7-mm reconstruction plates, a 3.5-mm semitubular plate, a 3.5-mm T-plate, or a 2.7-mm L- or T-shaped plate. Some authors recommend anatomically shaped plates, designed specifically for the scapula52 whereas others prefer locking plates.3,35 Cannulated screws are useful in internal fixation of fractures of the coracoid process and miniscrews (2.4 and 2 mm) may be used in fixation of small fragments of the glenoid fossa or intermediate fragments of the lateral border of the scapula. 
Reduction and Fixation.
The scapula is a bone with an uneven distribution of bony mass. Therefore, only certain areas offer sufficient anchorage for implants, primarily the lateral border of the scapular body, the scapular spine, and the scapular neck with the glenoid although it may also be necessary to fix fractures in less suitable locations, for example, in the spinomedial, or inferior angles. The scapula heals very well, with rapid callus formation. As most scapula fractures are operated on after a delay of several days, it is sometimes necessary to clear the fracture site of callus prior to reduction. 
In fractures of the scapular body and neck it is essential to restore the integrity of the biomechanical body and in particular the lateral border of the scapula. Therefore, the first step is to stabilize fractures of the lateral border. 
Displaced fractures of the body cause shortening of the lateral border of the scapula. Reduction may be achieved by means of two Schanz pins driven into each of the main fragments, used as joysticks, or by a small external fixator.31,35 Another option is reduction using two bone hooks. For easier manipulation, it is helpful to have the hook tips inserted into holes drilled in the lateral border of the scapula by a 2.5-mm drill bit, or to manipulate 3.5-mm cortical screws inserted into these holes. The chosen locations of the holes should allow their subsequent use for attachment of the plate. 
In unstable oblique fractures of the lateral border of the body, reduction may be maintained by the technique of the “lost” K-wire inserted as an intramedullary peg into a track drilled into each of the main fragments (Fig. 39-15).14,15 If larger intermediate fragments are separated from the lateral border of the scapula, they have to be fixed with screws to restore the integrity of the lateral border. 
Figure 39-15
Technique of lost K-wire.
 
A: A three-part fracture of the biomechanical body of the scapula. B: AP radiograph after surgery. C: Oblique radiograph after surgery. Both radiographs show that the K-wire has been inserted as an intramedullary peg.
A: A three-part fracture of the biomechanical body of the scapula. B: AP radiograph after surgery. C: Oblique radiograph after surgery. Both radiographs show that the K-wire has been inserted as an intramedullary peg.
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Figure 39-15
Technique of lost K-wire.
A: A three-part fracture of the biomechanical body of the scapula. B: AP radiograph after surgery. C: Oblique radiograph after surgery. Both radiographs show that the K-wire has been inserted as an intramedullary peg.
A: A three-part fracture of the biomechanical body of the scapula. B: AP radiograph after surgery. C: Oblique radiograph after surgery. Both radiographs show that the K-wire has been inserted as an intramedullary peg.
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Final fixation may be completed with a 2.7- or 3.5-mm reconstruction plate or in some cases with a 3.5-mm semitubular plate. In simple fractures of the lateral border it is sufficient to use 2+2 plate fixation, that is, two screws in each of the two fragments. In fractures of the lateral border with intermediate fragments, a 3+3 fixation is preferred. It may also be necessary to fix a fracture in the spinomedial angle, preferably with a 2.7-mm reconstruction plate. The inferior angle of the scapula may be fixed using a 2.7-mm reconstruction plate or a 3.5-mm T-plate. 
Fractures of the scapular spine that are part of fractures of the anatomical body, or transspinous fractures of the neck, are best fixed by either a 2.7-mm reconstruction plate or a preshaped semitubular plate. 
Scapular neck fractures are in most cases fixed using a combination of implants, for example, a 2.7- or 3.5-mm reconstruction plate, a 3.5-mm semitubular plate, or a 3.5-mm T-plate. When inserting screws into a glenoid fragment, care should be taken to avoid intra-articular penetration. Fixation of the lateral border is complemented with a plate placed on the posterior surface of the neck, or by 3.5-mm cortex screws inserted into the glenoid fragment from the scapular spine.126 Care should be used to avoid injury to the neurovascular structures in the spinoglenoid notch. 
Glenoid fractures are treated according to the type of injury. An avulsed fragment of the anterior rim of the glenoid is fixed depending on its size with lag screws and washers or with a small plate. Similar procedures may be applied to fractures of the posterior rim. Reduction and fixation of the superior pole, that is, intra-articular fractures of the coracoid, may be difficult because of the pull of the muscles attached to the coracoid. These fractures may be fixed using cannulated lag screws with washers inserted through the coracoid into the glenoid or the scapular neck. 
Fractures of the inferior glenoid are usually associated with fractures of the scapular body. If the joint capsule and labrum are not ruptured, incision of the capsule should run parallel to the posterior rim of the glenoid and labrum. This allows both palpation and a visual check of the glenoid fossa reduction. Reduction and fixation depend on the shape of the inferior joint fragment. This variable fragment may carry either a small, or a large, part of the lateral border. In both cases, it is necessary to clean the fracture surfaces carefully. Reduction and fixation of a short fragment is usually easier. A long fragment may be reduced by means of two screws inserted into the scapular neck close to the fracture line. Screws are compressed together by small Spanish forceps. Reduction of a long fragment must be accurate along the whole length of the fracture line. This is the only guarantee of an anatomical reduction of the joint surface. If there is another separate, usually smaller, fragment, it has to be anatomically reduced and fixed by small lag screws. The main two fragments may be fixed using various techniques, most often by a combination of different plates, that is, a 3.5-mm T-plate, 3.5-mm reconstruction or semitubular plates, or 2.7-mm L-shaped or straight plates, and lag screws. 
Postoperative Treatment.
Postoperatively, the arm is immobilized in a sling. Drainage is removed by 48 hours after surgery. Radiographs of the shoulder are obtained using Neer I and II views. After discharge, the patient is reviewed 2 weeks after operation to assess wound healing and remove sutures. Radiographs are taken at 6 weeks (Neer I and II views), 3 months (Neer I view), 6 months (Neer I view, if necessary), and 1 year after operation (Neer I and II views). Scapula fractures heal as a rule in 6 to 8 weeks. 
Correct rehabilitation is very important for the final outcome. Passive range-of-motion exercises of the shoulder should begin on the first postoperative day and continue for about 6 weeks using a CPM machine if available. Active range-of-motion exercises start at approximately 4 to 5 weeks postoperatively, depending on the extent of the surgical approach and presence of other injuries. The range of motion is assessed at 6 weeks and, if unsatisfactory, the shoulder is examined under general anesthesia and careful manipulation performed if necessary. Active resistance exercises may be started approximately 8 weeks after operation. All restrictions are lifted around 3 months postoperatively. Between the third and twelfth months, the range of motion usually improves only slightly. The final subjective, objective, and radiologic outcomes of the operation cannot be assessed before 1 year after the operation at the earliest. 

Results

There are many studies in the literature that evaluate the outcome of operative treatment of scapula fractures. Their validity and comparisons between studies are questionable for a number of reasons. Firstly, most case series are heterogeneous in terms of fracture pattern. Authors often evaluate both extra- and intra-articular fractures together. Homogeneity of the case series cannot even be guaranteed by separate evaluation of intra- or extra-articular fractures. For instance, fractures of the anterior rim of the glenoid are different from and require a different surgical approach from those of the inferior glenoid, which are usually associated with fractures of the scapular body. 
Secondly, data on individual types of fractures should be interpreted with caution. Most such reported fractures were diagnosed only by means of standard radiographs. A further problem is the low number of patients in individual case series and the relative lack of experience of the treating surgeons, and the long period over which patients are recruited. The presence of associated injuries to the shoulder girdle, the brachial plexus, or the ribs may influence the outcome. In addition, the methods of evaluation of functional outcomes are also heterogeneous with different authors using different scoring systems. There are no prospective studies, or comparative studies examining surgically and nonsurgically treated fractures. 
Hardegger et al.80 in 1984 evaluated 34 of 37 patients treated surgically for a scapula fracture. Their mean age was 42 years (17 to 85) with a mean follow-up of 6.5 years (1.5 to 18). Fractures included four process fractures, 11 fractures of the glenoid rim, 12 fractures of the glenoid fossa, three fractures of the surgical neck, two fractures of the anatomical neck, and five combined scapula fractures. The authors evaluated range of motion, pain, and muscle strength. In 21 patients (64%) full function of the shoulder was restored, and in 79% of patients the result was evaluated as excellent or good. 
Bauer et al.18 in 1995 evaluated the results of surgery in 20 patients with a scapula fracture. The mean age was 36 years, (16 to 69) and the mean follow-up was 6 years (1 to 11). This series included two fractures of the scapular body, six process fractures, six fractures of the neck (surgical and anatomical), and six glenoid fractures. Evaluation on the basis of the Constant score showed 75% very good and good results, 20% fair results, and 5% poor results. 
Herrera et al.87 in 2009 treated 22 patients with a scapula fracture treated surgically 3 and more weeks after injury. Fourteen of 16 patients available for review were evaluated by means of the DASH and Short Form 36 scores. The mean follow-up was 27 months (12 to 72). Nine cases were intra-articular and five cases extra-articular fractures. The mean DASH score was 14. Of all 16 patients, 13 resumed their normal activities without restriction. 
A number of authors have reported the results of fixation of glenoid fractures. Kavanagh et al.109 in 1993 described nine patients with glenoid fossa fractures. The mean age was 35 years (22 to 49) and the mean follow-up was 4 years (2 to 10). The authors evaluated range of motion and reported that the mean abduction was 167 degrees (110 to 180). A study of 22 cases of glenoid fractures of Ideberg types II to V, with a follow-up of 5 to 23 years revealed a median Constant score which was 94% of the opposite shoulder. In four patients it was less than 50%. In two cases, internal fixation failed and one patient developed a deep infection.167 
In another study of 14 glenoid fractures of Ideberg types II to V, with the mean age of patients of 35 years (23 to 53) all cases had excellent or good results.122 The mean follow-up was 30 months (18 to 68). Mayo et al.132 in 1998 evaluated the results of 27 surgically treated glenoid fractures with a mean follow-up of 2 years. The mean age of patients was 29 years (15 to 64), the mean follow-up was 43 months (25 to 75). Anatomical reduction was achieved in 89% of cases. Results were based on the Shoulder rating score and were excellent in 22%, good in 60%, and fair in 11% of cases. Seven percent of results were poor. 
More recently Heim et al.86 evaluated 11 patients with a mean age of 34 years (22 to 49), of whom 10 sustained a scapular neck or body fracture and 1 patient a fracture of the scapular neck and glenoid. All the patients were operated on via the Judet approach. The mean follow-up was 24 months (6 to 53). Evaluation was based on the UCLA score; eight patients had excellent-to-good results, two patients fair results, and one patient a poor result. 
Khallaf et al.110 in 2005 operated on 14 patients with a mean age of 34 years (19 to 44) and a displaced fracture of the scapular neck although according to the description and radiographs published they were fractures of the scapular neck and body. The Judet approach was used. The mean follow-up was 20 months (6 to 30). Using the UCLA shoulder score there were excellent in 86% and good results in 14% of cases. A further study104 in 2009 evaluated 37 patients with a mean age of 30 years (16 to 68) with fractures of the scapular body and neck fixed using the Judet approach. The review period was a minimum of 1 year. In 17 cases the fracture also involved the clavicle, which was always treated operatively. No infection or internal fixation failure was recorded. The reported range of motion averaged 158 degrees (range 90 to 180 degrees). Esenkaya and Ünay52 in 2011 treated 11 fractures of the scapular body or neck in nine patients with a mean age of 37 years (19 to 52) and a mean follow-up of 40 months (12 to 77). The result, evaluated according to the Herscovici score, was excellent in all the patients. 
Bartonícˇek and Frič 14 evaluated 22 patients with a mean age of 35 years (19 to 56) and a mean follow-up of 26 months (19 to 56). All the patients were operated on by the same surgeon using the Judet approach. In 17 patients an infraspinous fracture of the scapular body (biomechanical body) was recorded and in five cases this fracture was combined with a fracture of the inferior glenoid. The mean Constant score was 94. In 21 patients the results were evaluated as excellent or very good (Constant score 95 to 100). One poor result was recorded in a patient with an injury to the brachial plexus. 
A radiographic review of 84 fractures of the scapular body, or neck, with or without articular involvement was reported by Cole et al.34 Surgery was performed by a single surgeon via the Judet approach. The mean age of the patients was 45 years (18 to 76) and the mean follow-up was 23.5 months (6 to 70). All fractures healed, but with three malunions. Neither infection nor wound dehiscence was reported. 
Anavian et al.7 examined 26 patients with 27 fractures of the processes of scapula treated operatively. The mean age was 36 years (18 to 67) and the mean review period was 11 months (2 to 42). Acromion fracture patterns included six acromion base fractures and seven fractures lateral to the base. Coracoid fracture patterns included 11 fractures of the coracoid base and 3 fractures distal to the base. The results were evaluated by means of the DASH and SF 36 scores. All fractures healed and all patients had recovered full range of motion without pain. 

Treatment of Individual Fracture Types for Scapula Fractures

In selecting the appropriate treatment it is important to know the exact type and displacement of the fracture and the age, functional expectations, and general condition of the patient. 

Process Fractures

Process fractures include those involving the coracoid, acromion and the scapular spine, and the superior angle and the superior border of the scapula.73 All of these parts of the scapula serve only for attachment of muscles and ligaments, and are not involved in the transmission of compressive forces from the glenoid to the scapular body. Fractures of processes are avulsion fractures caused by the pull of muscles and ligaments, by a direct blow and stress fractures.21,66,78,91,143 
Fractures of processes often occur in various combinations, such as fractures of the acromion and the coracoid,73,123,199 fractures of the acromion and the scapular spine or rarely in all the four processes simultaneously (fractures of the upper scapula). Fractures of the acromion, scapular spine, and coracoid are usually associated with a fracture of the humeral head, clavicle, AC dislocation,28,99,116 rupture of the tendon of the long head of biceps, or injuries to the suprascapular nerve or brachial plexus.145 
Clinically the most important are fractures of the coracoid, acromion, and the lateral part of the scapular spine. Malunion may compromise the subacromial and subcoracoid spaces and cause impingement and the pull of muscles on a nonunited fragment may cause pain.23,61 
Fractures of the Acromion and the Lateral Scapular Spine.
These fractures may be divided according to the course of the fracture line145 or the type of displacement.115 The fracture line usually passes out with the AC joint. It may be difficult to distinguish between a fracture and an os acromiale. Acromion fractures may be associated with an extensive rotator cuff tear when the radiographs may show proximal migration of the humeral head. In such cases imaging of the rotator cuff is necessary. 
Undisplaced fractures may be treated conservatively. Immobilization in a sling for 3 weeks is often sufficient. Passive mobilization may begin immediately after the injury, and active exercises after the fracture union. If displaced fractures compromise the subacromial space, they should be reduced and stabilized.7,67,73 Fixation may be performed using cerclage wiring, lag screws, or a plate.190 Hsu93 describes an arthroscopically assisted fixation. If the avulsed acromial fragment is small, it should be excised. 
Coracoid Fractures.
Coracoid fractures may be isolated, but mostly they are associated with other injuries to the scapula or the shoulder such as fractures of the glenoid, the surgical neck of the scapula or the acromion,199 AC dislocation,112 lateral clavicle fractures, dislocation of the humeral head, or a rotator cuff tear.106 
Coracoid fractures are divided according to the location of the fracture line. Eyres et al.55 described five types, Goss73 three, and Ogawa144,147 only two. The Ogawa type I is a fracture of the coracoid base, with the fracture line passing posterior to the insertion of the CC ligament into the coracoid. Ogawa does not distinguish between extra- and intra-articular fractures of the coracoid base. In Ogawa type II, which is an avulsion fracture of the coracoid tip, the fracture line passes anterior to the insertion of CC ligament. Type I is more frequent. 
The author has modified the Goss classification and divided coracoid fractures into three basic types. Type I is an avulsion fracture of the coracoid tip. The fracture line passes anterior to the attachment of the CC ligament. The tip is displaced distally by the pull of the conjoined tendon of the coracobrachialis and the short head of biceps. Type I fractures may result in a painful nonunion or exceptionally they may prevent reduction of a dislocated humeral head. In types II and III, the fracture line runs posterior to the attachment of the CC ligament. Type II is an extra-articular fracture of the coracoid base. Type III includes intra-articular fractures of the coracoid or fractures of the superior pole of the glenoid extending as far as the superior border of the scapula. There is a direct relation between the size of the separated articular surface of the glenoid fossa and extension of the fracture line as far as the superior border or superior angle of the scapula. Types II and III occur more frequently than type I. Fracture types II and III are equivalent to a CC ligament rupture and may compromise the integrity of the SSSC. In addition, type III displaced fractures compromise the congruence of the glenoid fossa. 
There is no consensus in the literature about the treatment of coracoid fractures.7,130,147 Some authors prefer conservative treatment for undisplaced or minimally displaced fractures. The aim of treatment of displaced fractures is to prevent progression to a painful nonunion (type I), displacement and instability in associated injuries to the AC joint, floating shoulder in associated fractures of the surgical neck of scapula, or glenoid incongruence (types II and III). For these reasons it is preferable, especially in younger active individuals, to treat displaced fractures operatively by open reduction and fixation with screws, or, if necessary, with a small plate in fractures of the coracoid base112 In type I fractures it is better to excise the small fragment and reattach the conjoined tendon.73 
Fracture of the Superior Border, or Superior Angle, of the Scapula.
Fractures of the superior border or superior angle of the scapula occur rarely in isolation mostly being part of fractures of the upper scapula.146,195 Fractures of the superior border of the scapula are often associated with intra-articular fractures of the coracoid base. Isolated fractures may be displaced by the pull of the levator scapulae on the superior angle. Despite displacement, these fractures are treated conservatively. 

Body Fractures

Fractures of the scapular body are often confused with fractures of the scapular neck and vice versa. In terms of severity, they may be divided into fractures of the anatomical body and fractures of the biomechanical body.14,181 Fractures of the biomechanical body are more common. In terms of the number of border fragments, they may be divided into two-, three-, and multifragment fractures.14 Fractures of the anatomical body are less common and almost all of them are comminuted. This demonstrates that these are high-energy injuries, as they also involve the strong scapular spine. Both groups may be combined with fractures of the surgical neck of the scapula, fractures of the clavicle, or AC dislocations. 
Fractures of the scapular body compromise the alignment between the glenoid and the lateral border of the scapular body without affecting the relation between the glenoid, coracoid, and acromion. Diagnosis of scapular body fractures and an exact determination of the fracture pattern are impossible without 3D CT reconstructions. 
Until recently these fractures were treated conservatively. Currently there is a growing number of articles documenting very good outcomes from operative treatment of displaced scapular body fractures.14,34,35,52 

Author’s Preferred Method of Treatment for Scapula Body Fractures

 
 

Significantly displaced fractures of the scapular body are indications for operative treatment via the Judet approach (Fig. 39-16). The first and most important goal is restoration of the integrity of the lateral border of the body and, consequently, the relationship between the border and glenoid. Where necessary, internal fixation is performed in the spinomedial and inferior angles of the scapula. In the presence of an associated fracture of the clavicle, internal fixation of the scapula should be performed first and then followed by internal fixation of the clavicle.14,15

 
Figure 39-16
Reduction and fixation of a comminuted fracture of the anatomical body of the scapula.
 
A: AP radiograph after injury, (B) 3D reconstruction of injured scapula, anterior aspect, (C) anatomical reduction and fixation of lateral border with 3.5-mm reconstruction plate and scapular spine with 2.7-mm reconstruction plate.
A: AP radiograph after injury, (B) 3D reconstruction of injured scapula, anterior aspect, (C) anatomical reduction and fixation of lateral border with 3.5-mm reconstruction plate and scapular spine with 2.7-mm reconstruction plate.
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Figure 39-16
Reduction and fixation of a comminuted fracture of the anatomical body of the scapula.
A: AP radiograph after injury, (B) 3D reconstruction of injured scapula, anterior aspect, (C) anatomical reduction and fixation of lateral border with 3.5-mm reconstruction plate and scapular spine with 2.7-mm reconstruction plate.
A: AP radiograph after injury, (B) 3D reconstruction of injured scapula, anterior aspect, (C) anatomical reduction and fixation of lateral border with 3.5-mm reconstruction plate and scapular spine with 2.7-mm reconstruction plate.
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Neck Fractures

There are many publications on fractures of the glenoid neck in relation to unsatisfactory outcomes of conservative treatment and also in connection with the floating shoulder41,71,88,121,155,163,184 and also some case reports.10,110,186 Malunion of the scapular neck changes the GPA and relations in the subacromial and subcoracoid space. 

Anatomical Neck Fractures.

This type of fracture has been mentioned by many authors,18,42,71,80,101 although it is quite rare. Anatomical neck fractures are unstable. The glenoid fragment is displaced distally with the humeral head by the pull of the long head of triceps, and the subacromial space becomes wider. 
There are only four radiologically documented cases of anatomical neck fractures. Two cases were published by Hardegger et al.,80 one case by Arts and Louette,10 and one case by Jeong,102 who included also 3D CT reconstruction. The author himself recorded two cases, in one of which 3D CT reconstruction was performed. In all six cases fracture displacement was the indication for operative treatment, using the Judet approach. Fixation was performed with two plates, lag screws, or a combination of both. 

Surgical Neck Fractures.

Surgical neck fractures are the most frequently discussed of all scapular neck fractures.71,92,126,184 Surgical neck fractures are stable if they are not associated with rupture of the CC and CA ligaments. Magerl126 described two degrees of instability. Type I includes injuries consisting of rupture of only the CA ligament, combined with anterior displacement of the glenoid. In type II, both ligaments are ruptured and the glenoid is displaced anteriorly, distally, and medially by the pull of the muscles attached to the coracoid. The CC space is wider and the relation between the acromion and the coracoid is compromised. Extra-articular fracture of the coracoid base is equivalent to rupture of the CC and CA ligaments.71 In this case, however, distal displacement of the glenoid is less marked, because the neck is not displaced by the muscles attached to the coracoid. Surgical neck fractures may be combined with a fracture of the scapular body or with a clavicular fracture. 
Diagnosis of surgical neck fractures based on a radiograph alone is difficult in most cases. 3D CT reconstruction is very helpful in determining the fracture pattern. 
Displacement of fractures of the surgical neck of the scapula is currently increasingly regarded as an indication for operative treatment. Fixation may be performed via the Judet approach, using plates or a combination of a plate and transspinous screws. 

Transspinous Fractures of the Scapular Neck.

Transspinous fracture of the neck is almost unknown. Gagey et al.58 were the first to publish a drawing as late as in 1984 and called it “fracture transpinale.” Ada and Miller classified a fracture with a fracture line similar to a type IIB scapular neck fracture.1 Cole33 published a 3D CT reconstruction of a transspinous fracture of the scapular neck which he called a scapular neck fracture. The author of this chapter recorded two cases of transspinous fracture of the neck of which one was in combination with a clavicular fracture. 
A definite diagnosis of a transspinous fracture is only possible with the use of 3D CT reconstruction. Displaced fractures can be reduced and fixed to the spinal and lateral pillars from the Judet approach, preferably using plates. 

Author’s Preferred Method of Treatment for Scapula Neck Fractures

 
 

In younger, physically active patients all three types of scapular neck fractures, if displaced, are indications for operative treatment via the Judet approach using plates and lag screws (Fig. 39-17).

 
Figure 39-17
Reduction and fixation of fracture of an anatomical scapular neck fracture.
 
A: Postinjury AP radiograph with typical displacement of the glenoid fragment. B: Reduction and fixation with two 3.5-mm plates and a wire loop.
A: Postinjury AP radiograph with typical displacement of the glenoid fragment. B: Reduction and fixation with two 3.5-mm plates and a wire loop.
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Figure 39-17
Reduction and fixation of fracture of an anatomical scapular neck fracture.
A: Postinjury AP radiograph with typical displacement of the glenoid fragment. B: Reduction and fixation with two 3.5-mm plates and a wire loop.
A: Postinjury AP radiograph with typical displacement of the glenoid fragment. B: Reduction and fixation with two 3.5-mm plates and a wire loop.
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Glenoid Fractures

The goal of treatment of glenoid fractures is to restore congruity and stability to the glenohumeral joint. Undisplaced, minimally displaced, or displaced fractures of the glenoid rim with a small fragment may be treated conservatively.114 Larger, displaced fragments may be reduced and fixed operatively.2,109,122,167 The main indication for operative treatment of glenoid fractures is currently considered to be displacement of more than 3 to 10 mm with a simultaneous involvement of 20% to 30% of the articular surface. 

Fractures of the Superior Glenoid.

Fractures of the superior glenoid are intra-articular fractures of the coracoid base. Displacement is caused primarily by the pull of the muscles attached to the coracoid. Significant displacement of the fragment results in malalignment of the coracoid which may compromise the subcoracoid space and lead to the development of coracoid impingement.63 Fixation is usually performed via the deltopectoral approach, using lag screws, or a small plate. 

Fracture of the Anteroinferior Rim of the Glenoid.

Fractures of the anteroinferior rim of the glenoid are associated with anterior dislocation of the glenohumeral joint. The size of the avulsed fragments varies. There are differing opinions on the treatment of these fractures. Most authors recommend operative treatment especially in cases with bigger fragments or a persisting subluxation of the humeral head.2,27,153,168,177 However, Maquieira et al.127 published very good results in 14 patients with a fracture of the anteroinferior glenoid rim with fragments of more than 5 mm in size and displacement of more than 2 mm, who underwent conservative treatment and were followed up for an average of 5.5 years. Open reduction and fixation with cannulated screws, a small plate, or bone anchors are performed via the deltopectoral approach. Some authors also describe arthroscopic treatment. 

Fractures of the Posterior Rim of the Glenoid.

These rare fractures, resulting from posterior dislocation of the glenohumeral joint, are treated similarly to fractures of the anterior rim of the glenoid. Where reduction and fixation are indicated, they may be performed either by an open procedure from the posterosuperior approach or arthroscopically. 

Fracture of the Inferior Glenoid.

Fracture of the inferior glenoid separates the distal one- to two-thirds of the glenoid fossa. These fractures are caused by a direct impact of the abducted humeral head on the lower half of the glenoid and typically occur in cyclists, or motorcyclists.14 The fracture line extends as far as the lateral pillar of the scapula and mostly involves the scapular body (Fig. 39-18). Mayo et al.,132 Schandelmaier et al.,167 Cole,33,34 Jones et al.,104 and Bartonícˇek and Cronier14 recommend treating displaced fractures via the posterior Judet approach. 
Figure 39-18
Different types of inferior glenoid fractures.
 
A: The intra-articular fragment is formed by the inferior half of the glenoid fossa and by a short part of the lateral border. B: The intra-articular fragment is formed by the inferior third of the glenoid fossa and the whole lateral border. The fracture involves the center of the infraspinous fossa; the medial border of the scapular body is intact. C: The intra-articular fragment is formed by the inferior third of glenoid fossa. The inferior angle of the scapula forms a separate fragment. D: The intra-articular fragment is formed by the inferior half of the glenoid fossa and the whole lateral border. The whole biomechanical body is involved.
A: The intra-articular fragment is formed by the inferior half of the glenoid fossa and by a short part of the lateral border. B: The intra-articular fragment is formed by the inferior third of the glenoid fossa and the whole lateral border. The fracture involves the center of the infraspinous fossa; the medial border of the scapular body is intact. C: The intra-articular fragment is formed by the inferior third of glenoid fossa. The inferior angle of the scapula forms a separate fragment. D: The intra-articular fragment is formed by the inferior half of the glenoid fossa and the whole lateral border. The whole biomechanical body is involved.
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Figure 39-18
Different types of inferior glenoid fractures.
A: The intra-articular fragment is formed by the inferior half of the glenoid fossa and by a short part of the lateral border. B: The intra-articular fragment is formed by the inferior third of the glenoid fossa and the whole lateral border. The fracture involves the center of the infraspinous fossa; the medial border of the scapular body is intact. C: The intra-articular fragment is formed by the inferior third of glenoid fossa. The inferior angle of the scapula forms a separate fragment. D: The intra-articular fragment is formed by the inferior half of the glenoid fossa and the whole lateral border. The whole biomechanical body is involved.
A: The intra-articular fragment is formed by the inferior half of the glenoid fossa and by a short part of the lateral border. B: The intra-articular fragment is formed by the inferior third of the glenoid fossa and the whole lateral border. The fracture involves the center of the infraspinous fossa; the medial border of the scapular body is intact. C: The intra-articular fragment is formed by the inferior third of glenoid fossa. The inferior angle of the scapula forms a separate fragment. D: The intra-articular fragment is formed by the inferior half of the glenoid fossa and the whole lateral border. The whole biomechanical body is involved.
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Author’s Preferred Method of Treatment for Glenoid Fractures

 
 

Displaced fractures of the glenoid, mainly those of its anterior rim and of its lower part, are indications for surgery, mainly in younger or physically active patients. Surgical fixation of a larger avulsion of the anterior rim restores congruity and stability to the glenohumeral joint.

 

Fractures of the inferior glenoid and fractures of the scapular body may be treated from the posterior Judet approach which allows a simultaneous reconstruction of both the articular surface and the biomechanical body of the scapula. The posterolateral approach provides only a limited exposure of the inferior glenoid and lateral border of the scapula and is not suitable for treatment of these cases. Internal fixation is performed using a combination of lag screws and plates, depending on the fracture anatomy (Fig. 39-19). Stable internal fixation allows rehabilitation to start immediately after operation.

 
Figure 39-19
Reduction and fixation of the inferior glenoid and biomechanical body.
 
A: AP radiograph of the injured right scapula, (B)3D CT reconstruction, anterior aspect. For the posterior aspect see Figure 39-18C. C: Anatomical reduction and fixation with four 3.5-mm plates.
A: AP radiograph of the injured right scapula, (B)3D CT reconstruction, anterior aspect. For the posterior aspect see Figure 39-18C. C: Anatomical reduction and fixation with four 3.5-mm plates.
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Figure 39-19
Reduction and fixation of the inferior glenoid and biomechanical body.
A: AP radiograph of the injured right scapula, (B)3D CT reconstruction, anterior aspect. For the posterior aspect see Figure 39-18C. C: Anatomical reduction and fixation with four 3.5-mm plates.
A: AP radiograph of the injured right scapula, (B)3D CT reconstruction, anterior aspect. For the posterior aspect see Figure 39-18C. C: Anatomical reduction and fixation with four 3.5-mm plates.
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Combined Fractures

Combined fractures of the scapula may be divided into two groups. The first group includes fractures resulting from a combination of the four basic patterns of scapula fractures. The second group comprises combinations of one or more basic patterns of scapula fractures associated with injuries to other bones, or joints, of the shoulder girdle. 

Floating Shoulder3

Floating shoulder results from ipsilateral fractures of the scapular neck and the clavicle. It is a rare injury, frequently discussed in the literature mainly in terms of its anatomy and management.43,48,49,60,84,89,100,117,121,148,149,154,158,161,182,183,194 
Floating shoulder results from violation of the integrity of the SSSC. Double disruption of the SSSC, or its single disruption in combination with a fracture of one or both struts, creates a potentially unstable anatomical situation. This may have clinical consequences such as delayed union, nonunion, or malunion. Combination of a fracture of the glenoid neck with another SSSC disruption, for example, an associated fracture of the middle third of the clavicle, may produce a “floating shoulder.” Floating shoulder was defined by Herscovici et al.89 as “ipsilateral midclavicular and scapular neck fractures,” implying a clavicle fracture medial to the attachment of the CC ligament. 
Williams et al.194 pointed out that Goss did not include the CA ligament in the structures of the bone–soft tissue ring. DeFranco and Patterson43 considers this ligament as an important stabilizer in the SSSC. Williams et al.194 also stated that midshaft clavicular and surgical neck fractures alone cannot produce a floating shoulder. Scapular neck fragments are attached to the clavicle by the CC ligament. In the presence of an ipsilateral fracture of clavicular shaft and surgical neck, the glenoid has lost its attachment to the axial skeleton. However, it is still attached to the acromion by the CA ligament and by the osseoligamentous chain consisting of the CC ligament, distal clavicular fragment, and the AC capsular ligaments. As a result, a floating shoulder may develop only after disruption of the CC and CA ligaments. 
Analysis of studies on the floating shoulder revealed a number of problematic issues. Most authors included in their case series not only patients with a midshaft clavicular fracture, but also those with a fracture of the lateral or even medial clavicle and patients with AC dislocation. In all case series, fractures of the scapular neck were diagnosed only by standard radiographs and not by 3D CT reconstruction. Analysis of the radiographs in these studies, however, showed that they were mainly fractures of the scapular body rather than fractures of the scapular neck. DeFranco and Patterson43 and Owens,154 therefore, recommend 3D CT reconstructions to properly define the fracture pattern. In addition, most authors do not describe injuries to individual ligaments constituting the SSSC complex. 
All these deficiencies are reflected in the studies that report good results for both conservative and operative treatment. Some authors perform only internal fixation of the clavicle with the aim of diminishing displacement of the scapular neck. The concept that reduction of the clavicular fracture will also reduce the scapula fracture is in many cases illusory (Fig. 39-20). When better results are reported after internal fixation of the clavicle it has to be taken into account that stabilization of the clavicle allows an intensive rehabilitation of shoulder girdle much sooner than with conservative treatment which may have an impact on the final result. Oh et al.149 described two cases of failure of plating of the clavicle in the treatment of ipsilateral clavicle and glenoid neck fractures. Very good results after simultaneous internal fixation of the clavicle and the scapula were described by Labler et al.,117 Egol et al.,49 and Leung and Lam.121 
Figure 39-20
Combined fracture of the scapular body and clavicle.
 
This fracture is often presented as a floating shoulder. A: 3D CT reconstruction of the right scapula after injury. B: Reduction and fixation of clavicle failed to reduce the fracture of scapular body.
This fracture is often presented as a floating shoulder. A: 3D CT reconstruction of the right scapula after injury. B: Reduction and fixation of clavicle failed to reduce the fracture of scapular body.
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Figure 39-20
Combined fracture of the scapular body and clavicle.
This fracture is often presented as a floating shoulder. A: 3D CT reconstruction of the right scapula after injury. B: Reduction and fixation of clavicle failed to reduce the fracture of scapular body.
This fracture is often presented as a floating shoulder. A: 3D CT reconstruction of the right scapula after injury. B: Reduction and fixation of clavicle failed to reduce the fracture of scapular body.
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The condition of floating shoulder requires careful review on the basis of new studies with identification of the individual types of this injury and their displacement by 3D CT reconstruction. 

Scapulothoracic Dissociation

Scapulothoracic dissociation is a rare, severe, high-energy injury characterized by a wide range of concomitant injuries including those to the shoulder girdle (SC dislocation, clavicle fracture, AC dislocation), tears of the levator scapulae, rhomboids, trapezius, latissimus dorsi, pectoralis minor and deltoid muscles, vascular injuries to subclavian or axillary artery, and partial or complete avulsion of brachial plexus. There is massive soft tissue swelling in the shoulder region while the skin is usually intact. It is caused by a violent lateral distraction or rotational displacement of the shoulder girdle when the upper extremity is caught on a fixed object while the body is moving at high speed.3,65,75,118,198 The mortality is reported to be 11%.198 
The diagnosis is not easy and is based on clinical examination and radiologic findings. The injury may be suspected clinically in the presence of a palpable gap between the medial border of the scapula and the spinous processes. It is important to perform an anteroposterior chest radiograph to show lateral displacement of the scapula. In a hemodynamically stable patient arteriography may determine the extent and localization of the vascular injury. 
The treatment of scapulothoracic dissociation depends on the severity of associated injuries and the general condition of the patient. Zelle et al.198 proposed a system for classifying the severity of scapulothoracic dissociation (Table 39-1). Treatment should focus on the neurovascular injury. Surgical repair should be performed, if necessary. However, there is an extensive collateral network around the shoulder which may substitute for the injured major blood vessel. Vascular repair in patients with a complete brachial plexus palsy is somewhat questionable. Neurologic repair is also controversial. Zelle et al.198 demonstrated that the extent of the brachial plexus injury is the most important predictor of the functional outcome. Patients with partial plexus injuries had a better prognosis. All patients with a complete brachial plexus injury had either an amputation or poor shoulder function. He recommended an immediate above-elbow amputation if upper extremity function is not recoverable. This solution seems to result in better functional outcomes and lower rates of complications. 
Table 39-1
Zelle’s System for Classifying the Severity of Scapulothoracic Dissociation
Type Clinical Findings
1 Musculoskeletal injury alone
2A Musculoskeletal injury with vascular injury
2B Musculoskeletal injury with incomplete neurologic impairment of the upper extremity
3 Musculoskeletal injury with incomplete neurologic impairment of the upper extremity and vascular injury
4 Musculoskeletal injury with complete brachial plexus avulsion
 

Adapted from Zelle BA, Pape HC, Gerich TG, et al. Functional outcome following scapulothoracic dissociation. J Bone Joint Surg Am. 2004;86-A:2–7.

X
The best treatment of associated shoulder girdle injuries is unclear. Goss75 recommended internal fixation of clavicular fractures and stabilization of disrupted AC or SC joints to protect the brachial plexus, subclavian, and axillary vessels, to improve conditions for bone healing and to restore stability to the shoulder girdle. 

Complications of Scapula Fractures and Their Treatment

Both conservative and operative treatments of scapula fractures have a number of early and late complications, leading ultimately to pain, limitation of the range of motion, reduction of muscle strength, or instability of the shoulder. 

Complications of Nonoperative Treatment for Scapula Fractures

Malunion is the most common complication of nonoperative treatment of scapula fractures.36,79,131,137 Healing of extra-articular fractures in a nonanatomical position changes the relationship between the glenoid and the scapular body and consequently the course of the muscles of the rotator cuff. This has an impact on their function. Subjectively, it is manifested by feelings of weakness, pain, and stiffness. Pace et al.155 described in these cases late degenerative changes of the rotator cuff. Malunion may also result in impingement syndrome.63 Fractures of the glenoid that have healed in displacement result in incongruity, instability, or both, and subsequently in degenerative joint disease.167 
Malunion is treated by osteotomy and reorientation of the scapular neck and/or body.36 In intra-articular malunion, one successful case of osteotomy of the glenoid fossa has been described by Haraguchi et al.79 Prominence of a malunited bony fragment may be painful. The solution is excision of the projecting part of the bone.130 
Delayed union was described by Curtis et al.39 in a 15-year-old sportsman with a nondisplaced fracture of the scapular neck. 
Nonunions of the scapular body are rare.56,76,107,137 In 2009, only 15 had been reported in the English literature, all of them treated conservatively.129 Nonunion of the acromion has also been reported.75 The solution is internal fixation or excision of the ununited fragment. 
Injury to the suprascapular nerve can occur in fractures of the scapular neck when the suprascapular nerve becomes entrapped in the fracture line37. This injury is manifested by atrophy of the infraspinatus.22,47,172 
Rib nonunion may be a rare cause of chronic pain after a scapula fracture. In the four reported cases, the situation was successfully treated by internal fixation.5 

Complications of Operative Treatment for Scapula Fractures

Complications of operative treatment may be divided into intraoperative, early postoperative, and late postoperative ones. 
Intraoperative complications include injuries to the suprascapular nerve, malreduction, and intra-articular perforation by screws. In an analysis of 212 cases, Lantry et al.119 found injury to the suprascapular nerve in 2.4%. It is difficult to distinguish whether the injury was caused by the original trauma or during surgery. Reduction of the fragments may be hard to achieve in comminuted fractures of the scapular body, or in significantly displaced fractures of the scapular neck, particularly if surgery is delayed. Screws can be placed into the joint particularly during internal fixation of the scapular neck or of the lateral border of the scapula. 
Early postoperative complications include first of all hematoma, and infection, either superficial or deep.2,80,167 According to Lantry et al.,119 the infection rate is quite high at 4.2%. Hematoma may require evacuation. Most cases of superficial infection may be treated with antibiotics and local care but deep infection requires debridement of the surgical wound, and, where necessary, removal of the implant. 
A relatively common complication is a limited range of motion of the shoulder, requiring manipulation if it persists for more than 6 weeks after surgery.2,167 
Late complications are reported quite frequently. Failure of internal fixation frequently requires reoperation,80,119,167 as does nonunion.129 Oh et al.149 described two cases of failure of plate fixation of the clavicle in the treatment of ipsilateral clavicle and glenoid neck fractures. The authors concluded that where a scapular neck fracture remains displaced even after internal fixation of the clavicle, its reduction and fixation are necessary. 
Residual incongruity as a result of nonanatomical reduction was described by Mayo.132 Hardegger80 reported reoperation for joint instability. Two cases of heterotopic ossification have been described, in one of which there was compression of the axillary nerve requiring surgical decompression.109,119 Heim et al.86 reported postoperative scapular widening. Acromial impingement after internal fixation of the glenoid can be treated by acromioplasty.167 Prominence of implants, requiring their removal, is a problem mainly in fractures of the acromion, scapular spine, or associated clavicular fractures.34,119 One report also describes late infection 11 months after operation, requiring hardware removal.167 In addition, one breakage of a plate was recorded after several years in a healed scapula fracture.167 
Posttraumatic degenerative disease after scapula fractures is reported to occur in 1.9% of cases. If symptomatic it can be managed by arthrodesis2,80,119 but the current treatment of choice is shoulder arthroplasty. 

Summary, Controversies, and Future Directions in Scapula Fractures

The basic problem of the current studies on scapula fractures is that radiology does not always allow proper determination of the fracture pattern leading to unsatisfactory classification, inaccurate determination of fragment displacement, and heterogeneous and nonvalid outcome measurements. Small numbers of scapula fractures are treated in any single department, which results in limited experience of operative treatment for any one treating surgeons. Randomized studies with mid- and long-term results are not available. 
Plain radiographs should be supplemented by 3D CT reconstructions, allowing exact determination of the fracture pattern and a classification must be developed that reflects clinical reality. Indications for conservative, or operative, treatment have to be based on objective evaluation of fragment displacement. Special attention should be given to associated injuries. Evidence-based studies must concentrate on single fracture types, mainly comparing the results of conservative and operative treatments and use validated and specific outcome instruments. 

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