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Rockwood and Green's Fractures in Adultes : Chapter 37 Scapular fractures

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 37
SCAPULAR FRACTURES
Arthur van Noort
INTRODUCTION TO SCAPULAR FRACTURES
PRINCIPLES OF MANAGEMENT
MECHANISMS OF INJURY
ASSOCIATED INJURIES
HISTORY AND PHYSICAL EXAMINATION
IMAGING AND OTHER DIAGNOSTIC STUDIES
DIAGNOSIS AND CLASSIFICATION
SURGICAL AND APPLIED ANATOMY AND
COMMON SURGICAL APPROACHES
SURGICAL AND APPLIED ANATOMY
COMMON SURGICAL APPROACHES
CURRENT TREATMENT OPTIONS
INTRODUCTION TO SCAPULAR
FRACTURES
The scapula is an integral part of the connection between the
upper extremity and the axial skeleton. This highly mobile,
thin sheet of bone articulates in three different joints: with the
humerus in the glenohumeral joint, with the clavicle in the
acromioclavicular joint, and with the thorax in the scapulothor-
acic joint. To accomplish a full range of shoulder motion, a
smooth coordination is required of motion in all three articula-
tions. Therefore, a complex interaction of several muscles that
envelope the scapula is necessary.146 Besides its assistance in
the movements of the arm in the shoulder joint, the scapula
has two other functions. It is a mobile platform for the humeral
head and upper extremity to work against, and it serves as a
point of attachment for muscles, tendons, and ligaments.62 No
less than 18 different muscles insert on or originate from the
scapula allowing six basic movements of the shoulder blade over
the posterior chest wall: elevation, depression, upward rotation,
downward rotation, protraction, and retraction.63
Scapular fractures are generally the result of a high-energy
trauma with a high incidence of significant associated (local and
MDC-Bucholz-16918 R1 CH37
GLENOID FRACTURES
SCAPULAR NECK FRACTURE
THE SUPERIOR SHOULDER SUSPENSORY COMPLEX
THE FLOATING SHOULDER
SCAPULAR BODY FRACTURE
ACROMIAL FRACTURE
CORACOID FRACTURE
SCAPULOTHORACIC DISSOCIATION
COMPLICATIONS
FUNCTIONAL OUTCOME
CONTROVERSIES AND FUTURE DIRECTIONS
remote) injuries.3,67,79,115,116,169,184,191 These associated inju-
ries are often major, multiple, and sometimes life-threatening,
therefore needing priority in treatment. The relative infrequency
(prevalence 1 %) and ‘‘benign characteristics’’ of a scapular frac-
ture probably explain the limited attention in the literature.78
Historically, scapular fractures have been treated by closed
means. One of the earliest descriptions of treating scapular frac-
tures was published in 1805 in Desault’s treatise on fractures.
Since then, it has been suggested in the literature that over 90%
of scapular fractures are non- or minimally displaced and do
well with conservative treatment.79,115,184 This observation,
however, has been based on the treatment of scapular fractures
in general and its relevance is therefore very limited. A more
differentiated approach is necessary as good results are not guar-
anteed with exclusively conservative treatment.8 Recent litera-
ture is more focussed on the results of conservative79,115 or
operative treatment41,42,61,66,74,84,98,99,112,132,133,156 with regard
to specific fracture types. This contrasts with publications before
the 1990s which were particularly focussed on the trauma
mechanism and associated injuries.115,116,169,184 Specific types
of scapular fractures are severe injuries that may result in signifi-
cant shoulder dysfunction. There are a few reports on poor
08-31-09 11:35:20
2 UPPER EXTREMITY
prognosis after conservative treatment of displaced glenoid,
scapular neck, coracoid, and acromion fractures.1,77,127 Along
with technical refinement of diagnostic tools, more attention is
currently paid to these fracture types as demonstrated by the
rising number of publications on this subject.
PRINCIPLES OF MANAGEMENT
Mechanisms of Injury
Scapular fractures are caused by different mechanisms, of which
blunt trauma is probably the most common.1,3,8,115,116,169 This
direct force may cause fractures in all anatomic areas of the
scapula. Other mechanisms are indirect injuries: (1) traction
by muscles or ligaments may induce avulsion fractures of the
acromion or coracoid, which in rare cases are caused by a sei-
zure or an electrical shock110,166; and (2) impaction of the hu-
meral head into the glenoid fossa which may induce glenoid
and some scapular neck fractures.
As in general with high-energy trauma, traffic accidents are
the main cause of scapular fractures (occupants of motor vehi-
cles in about 50% of cases1,8,115 and pedestrians in 20%3,115 ).
Other causes are motorcycle accidents, fall from heights, crush
injuries, or sporting activities (horseback riding, skiing, and
contact sports).
Associated Injuries
Usually, high energy is required to fracture a scapula, hence
scapular fractures are commonly associated with concomitant
injuries. Research shows that 61%–98% of scapula fractures
have associated injuries.1,3,17,79,97,115,116,165,169 These associ-
ated injuries may be multiple and may need priority in treat-
ment. As a result, diagnosis and treatment of scapular injuries
may be delayed or suboptimal.
A wide variety of regional and remote injuries have been
reported which may be life-threatening, such as pneumothorax
(9%–38%),3,45,118,169 pulmonary contusion (8%–54%),45,
116,169
arterial injury (11%),45,169 closed head injuries (20%–
79,115
42%), and splenic or liver lacerations 3%–5%.116 Brachial
plexus injury is present in 5% to 13%3,45,79,115,169 and is often
the most important prognostic factor with regard to the final
clinical outcome, whether fracture treatment be conservative or
otherwise. The reported mortality rate of patients with scapular
fractures from the concomitant injuries varies between 2% and
15%.115,169,191
In a recent review article on the operative treatment of scapu-
lar fractures, Lantry97 analyzed the associated injuries of 160
cases in 11 different studies. Rib fractures were the most com-
mon associated injury, followed by head and chest injuries.
Fractures in remote anatomic areas were found in nearly 20%
of patients. To determine the significance of scapular fractures
in blunt trauma, Stephens161 compared two matched groups
of patients with and without scapular fractures. Except for a
significantly higher incidence of thoracic injuries in the group
with scapular fractures, he found no difference in mortality or
incidence of neurovascular injuries. Veysi179 reported in 2003
that patients with scapula fractures have more severe underlying
chest injuries and overall injury severity scores (ISS). However,
these findings, which were confirmed by other authors,161,183
did not correlate with a higher rate of intensive therapy unit
admission, length of hospital stay, or mortality. There is no
MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20
clear correlation between the number and severity of associated
injuries and the type of scapular fracture. Nevertheless,
Tadros165 found in a prospective study that the ISS and abbrevi-
ated injury score for chest injuries are higher and posterior
structure injuries are more frequent in patients with fractures
involving multiple scapular regions.
In summary, scapular fractures should alert the surgeon to
the presence of other, sometimes very severe injuries. Severe
chest injury should also raise suspicion of a possible scapular
fracture.108
History and Physical Examination
A patient with a scapular fracture typically presents with the
arm adducted along the body and will protect the injured shoul-
der from all movements.
Physical examination may reveal swelling, ecchymosis, cre-
pitus, and local tenderness. The ecchymosis is in general less
than expected probably because the scapula is protected by a
thick layer of soft tissue. Active range of motion is restricted in
all directions. Abduction in particular is very painful.
Neviaser126 described in 1956 that the rotator cuff function
is weak and very painful secondary to inhibition from intramus-
cular hemorrhage. This has been described as a ‘‘pseudorupture’’
of the rotator cuff and usually resolves within a few weeks.
When a scapular fracture is diagnosed, it is important to perform
a careful neurovascular examination to rule out arterial injury
and/or brachial plexopathy.
Imaging and Other Diagnostic Studies
After initial assessment, according to Advanced Trauma Life
Support (ATLS) principles, specific radiographic evaluation of
the injured shoulder is indicated as soon as the patient is in a
stable condition. Associated injuries requiring urgent treatment
may force the treating surgeon, particularly in polytrauma pa-
tients, to evaluate the chest only by a routine supine chest radio-
graph. This is the earliest opportunity to identify a scapular
fracture. Harris68 pointed out in a retrospective analysis of 100
patients with major blunt chest trauma that the scapular fracture
was diagnosed on the initial chest radiograph in only 57 of 100
patients and, although present, was not recognized in 43%.
Particularly extensive associated chest injuries may overshadow
the scapula with a delay in diagnosis as a result.164
Scapular fractures are notoriously difficult to visualize radio-
graphically. Except for the chest radiograph, a true anteropos-
terior (AP) view, perpendicular to the plane of the scapula, a
lateral, and an axillary view are recommended. A true axillary
projection of the glenohumeral joint and scapula is ideally per-
formed with the arm in 70 to 90 degrees of abduction, which
might be very painful for the patient in the acute situation.
Alternatives for this view are the Velpeau axillary lateral view12
(see Fig. 39-15) or the trauma axillary lateral view170 which can AQ1
be taken while the patient is supine. In case of a complex shoul-
der injury with a double disruption of the superior shoulder
suspensory complex (SSSC) (Fig. 37-1), a weight-bearing AP
projection of the shoulder is recommended by Goss.60
Most scapular fractures will be diagnosed by the three-view
scapula trauma series, but special views may be necessary for
selected fracture types. The Stryker notch view is useful for
coracoid fractures (see Fig. 39-20) while the apical oblique AQ1
view48 and the West Point lateral view147 are useful for glenoid
rim fractures. In cases of scapular fractures with multiple frac-
 CHAPTER 37: SCAPULAR FRACTURES 3

FIGURE 37-1 A,B. A double disruption of the SSSC (fracture of the coracoid process and
ipsilateral lateral clavicle fracture). C,D. After open reposition and internal fixation of both
clavicle and coracoid process, both fractures healed. Despite the acromioclavicular joint
subluxation, the patient had a maximum constant score of 100.

A B

C D

ture lines and particularly significant displacement, a computed
tomography (CT) scan is recommended, although the additional
value is not clear in every fracture type.113 It is however useful
to assess the size, location, and degree of displacement of frag-
ments in coracoid, acromion, and glenoid fractures. In glenoid
fractures, it is also helpful to evaluate the position of the humeral
head in relation to the glenoid fossa or fracture fragment (Fig.
37-2). Finally, a three-dimensional CT scan can be very helpful
in understanding complex fracture patterns and in preoperative
planning.
Diagnosis and Classification
Scapular fractures are generally classified by anatomic area
(body and spine, glenoid cavity, glenoid [scapular] neck, acro-
mion, and coracoid).
MDC-Bucholz-16918 R1 CH37
Fractures of the body and spine are the most common (ap-
proximately 50%), followed by the scapular neck (approxi-
mately 25%), glenoid cavity (approximately 10%), acromion
(approximately 8%), and coracoid process (approximately
7%).1,79,115,127,184
There are several other classification systems reported in the
literature. Zdravkovic and Damholt191 divided scapular frac-
tures into three types: type 1, fractures of the body; type 2,
fractures of the apophysis (including acromion and coracoid);
and type 3, fractures of the superior lateral angle, including the
glenoid neck and glenoid. Zdravkovic and Damholt191 consid-
ered type 3 fractures, which represented only 6% of their series
to be the most difficult to treat.
Thompson and colleagues169 presented a classification sys-
tem which also divided scapular fractures into three different
classes:
08-31-09 11:35:20
4 UPPER EXTREMITY

Class 1: acromion, coracoid, and minor fractures of the body

Class 2: glenoid and scapular neck fractures
Class 3: major scapular body fractures
In their opinion, classes 2 and 3 were much more likely to
have associated injuries.
Wilber and Evans184 divided scapular fractures into two
groups. Group 1 included patients with fractures of the scapular
body, scapular neck, and spine; group 2 included patients with
fractures of the acromion, coracoid process, and glenoid. They
reported poor functional outcome caused by loss of glenohu-
meral motion and residual pain in patients of group 2.
Finally, the Orthopaedic Trauma Association’s (OTA) classi-
fication, which was originally published in 1996, has been re-
vised for scapular fractures.107 In this new format, the differ-
ences between the OTA and AO classification have now been
FIGURE 37-2 The humeral head is subluxed along with a posterior frac- eliminated by a unified alpha-numeric code (Fig. 37-3).
ture fragment.

BONE: SCAPULA (14)

Types:
A. Extra-articular (not glenoid) (14-A) B. Partial articular (glenoid) (14-B) C. Total articular (glenoid) (14-C)

Groups:
Scapula, extra-articular (not glenoid) (14-A) Scapula, partial articular (glenoid) (14-B) Scapula, total articular (glenoid) (14-C)
1. Acromion 2. Coracoid 3. Body 1. Anterior rim 2. Posterior 3. Inferior rim 1. Extra-articular2. Intra-artic- 3. Intra-artic-
(14-A1) (14-A2) (14-A3) (14-B1) rim (14-B2) (14-B3) glenoid neck ular with neck ular with
(14-C1) (14-C2) body (14-C3)

FIGURE 37-3 The OTA classification of scapular fractures.

MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20

 CHAPTER 37: SCAPULAR FRACTURES 5

Glenoid Fractures
The most commonly used classification scheme concerning gle-
noid fractures is the one devised by Ideberg et al.,77,78 who
described five different fracture types. Goss60 modified this sys-
tem by subdividing type 5 and introducing type 6, a stellate
glenoid fracture with extensive intra-articular comminution
(Fig. 37-4).
The diagnosis of glenoid neck fractures can be made with
the standard three-view trauma series. The axillary radiograph
combined with CT scanning is used to demonstrate any sublux-
ation or displacement.
Scapular Neck Fractures
Scapular neck fractures are extra-articular fractures by defini-
tion. Although three fracture patterns have been described as
scapular neck fractures,62 only two run through the scapular
neck (Fig. 37-5). One fracture pattern runs lateral from the
origin of the coracoid to the lateral border of the scapula (ana-
tomic neck), and the other runs medial from the coracoid to
the lateral border of the scapula. According to the OTA, both
are classified as type 14-C1 (see Fig. 37-3).
Diagnosis of a scapular neck fracture is reliably made by
plain films, in contrast with assessment of the amount of fracture
displacement and angulation.26,113 A common method to deter-
mine angulation deformity and shortening, as described by Best-
ard,10 is on an AP radiograph of the scapula (Fig. 37-6). Three-
dimensional CT reconstruction images may be of more benefit
in assessment of displacement and angulation, in contrast with
the images of a conventional CT scan.113

Ia Ib

II III IV

Va Vb Vc VI

FIGURE 37-4 Classification of fractures of the glenoid cavity: type Ia, anterior rim fracture; type Ib, posterior
rim fracture; type II, fracture line through the glenoid fossa exiting at the lateral scapular border; type III, fracture
line through the glenoid fossa exiting at the superior scapular border; type IV, fracture line through the glenoid
fossa exiting at the medial scapular border; type Va, combination of types II and IV; type Vb, combination
of types III and IV; type Vc, combination of types II, III, and IV; type VI, comminuted fracture. (Goss TP.
Scapular fractures and dislocations: diagnosis and treatment. J Am Acad Orthop Surg 1995;3(1):22–33, with
permission.)

MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20

6 UPPER EXTREMITY
B A
FIGURE 37-5 Line A is a fracture through the anatomic scapular neck.
Line B is a fracture through the surgical scapular neck.
FIGURE 37-6 The GPA is the angle between the line connecting the
most cranial with the most caudal point of the glenoid cavity and the line
connecting the most cranial point of the glenoid cavity with the most
caudal point of the scapular body. It provides a value for the obliquity of
the glenoid articular surface in relation to the scapular body. A GPA ranging
from 30 to 45 degrees is considered normal.10
MDC-Bucholz-16918
Acromion Fractures
Kuhn90 has proposed a subclassification of acromion fractures,
which are classified by the OTA as type 14-A1 fractures, to help
determine the need for operative intervention (see Fig. 37-4).
According to the classification of Kuhn, type 1 are nondisplaced
fractures, type 2 displaced fractures without reduction of the
subacromial space, and type 3 displaced fractures with reduc-
tion of the subacromial space (Fig. 37-7).90
The diagnosis is radiographic. A three-view trauma series,
including an AP view, a lateral view, and an axillary view of
the scapula, will detect most acromial fractures. Caution should
be used to differentiate an acromial fracture from an os acromi-
ale. An axillary radiograph of the contralateral shoulder may be
helpful, because an os acromiale is bilateral in approximately
45% to 62% of the cases.38,101 Occasionally, a CT scan is neces-
sary to define the configuration of the fracture precisely (Fig.
37-8B,C).
Coracoid Fractures
Ogawa,133 who simplified the classification scheme of Eyres,42
classified coracoid fractures into two different types. Type 1 is
situated proximal to the coracoclavicular ligament attachment
and type 2 distal to these ligaments (Fig. 37-9). Ogawa133 sug-
gested that a type 1 fracture may disturb the scapulothoracic
connection (see Fig. 37-1).
The complex anatomy of the scapula makes defining the
fracture type difficult. The coracoid process is not easily visuali-
sed on a radiograph. Apart from the usual three-view trauma
series, an AP tilt view (35–60 degrees),60 a Stryker notch
view,145 and a Goldberg posterior oblique 20-degree cephalic
tilt view53 may be helpful. A CT scan with three-dimensional
reconstruction images will give more insight into the fracture
pattern.
Scapulothoracic Dissociation
Damschen et al.29 proposed a classification system for scapulo-
thoracic dissociation in 1997 based on musculoskeletal, vascu-
lar, and neurologic impairment. Zelle et al.192 modified the
group of neurologic impairment of this classification scheme
and added the group with a complete brachial plexus avulsion
as the most severe type (Table 37-1).
The diagnosis of scapulothoracic dissociation is based on
history, clinical findings, and radiography. The difficulty for the
treating physician is that the severe associated injuries may di-
vert attention away from the sometimes subtle clinical signs of
the scapulothoracic dissociation.94 The clinical signs may vary
between swelling from a dissecting hematoma and a flail and
pulseless extremity.
A well-centered chest radiograph will demonstrate lateral
displacement of the scapula on the injured side, which is pa-
thognomic of a scapulothoracic dissociation. The degree of later-
alization can be quantified using the scapula index (Fig. 37-
10).86,134
SURGICAL AND APPLIED ANATOMY
AND COMMON SURGICAL
APPROACHES
Surgical and Applied Anatomy
A thorough knowledge of the bony contours of the scapula and
its related musculotendinous and neurovascular structures is
R1 CH37 08-31-09 11:35:20

Type IA
FIGURE 37-7 Kuhn’s classification of fractures of the acromion
process. Type I undisplaced: Ia avulsion fractures and Ib true frac-
tures. Type II displaced without reduction of the subacromial
space. Type III displaced with reduction of the subacromial space.
This reduction may be by inferior displacement of the acromion or
by an association with a superiorly displaced glenoid neck fracture
required for adequate treatment of patients with scapular frac-
tures, particularly if operative treatment is considered. The sca-
pula is a large, flat, triangular bone that connects the clavicle
to the humerus. At least 18 different muscles originate from
and insert into this highly mobile bone (Fig. 37-11).
Special attention should be given to neurovascular structures
at risk when surgery (both anteriorly and posteriorly) is under-
taken.
Brachial Plexus
The brachial plexus descends in the concavity of the medial
two thirds of the clavicle, accompanies the axillary artery, and
lies beneath the pectoralis minor muscle. The musculocuta-
neous nerve originates from the lateral cord and penetrates the
conjoined tendon of biceps and coracobrachialis at a variable
distance (average 5 cm) from the coracoid tip (Fig. 37-12).
Suprascapular Nerve
Beneath the trapezius and omohyoid muscle, the suprascapular
nerve enters the supraspinous fossa under the transverse liga-
ment (or suprascapular ligament). The nerve runs beneath the
supraspinatus muscle and curves round the external corner of
the spine of the scapula to the infraspinous fossa (Fig. 37-13).
In the supraspinous fossa, it gives off two branches to the supra-
spinatus muscle, and in the infraspinous fossa, it gives off two
branches to the infraspinatus muscle, besides some filaments
to the shoulder joint and scapula.
The safe zone for avoiding suprascapular nerve injury during
open surgical procedures requiring dissection of the posterior
shoulder joint within 2.3 cm of the superior glenoid rim and
within 1.4 cm of the posterior rim of the glenoid at the level
of the base of the scapular spine (see Fig. 37-13).157
Axillary Nerve
Before entering the quadrilateral space, the axillary nerve runs
together with the circumflex humeral artery overlying the sub-
scapular muscle. The axillary nerve divides in this space and
MDC-Bucholz-16918 R1 CH37
CHAPTER 37: SCAPULAR FRACTURES 7
Type IB
Type II
Type III Type III
sends a posterior branch to the teres minor muscle, together
with a lateral brachial cutaneous nerve (see Fig. 37-13).6 An
anterior branch runs from this space approximately 5 cm below
the edge of the acromion as the nerve passes anteriorly to inner-
vate the anterior two thirds of the muscle.
The innervation of the posterior part of the deltoid is vari-
able. In 70%, it is innervated by the posterior branch, in 27%
by posterior and anterior branches, and 3% only by the anterior
branch.172 One should therefore be careful when performing a
deltoid splitting approach in a posterior surgical approach.
The branch to the teres minor arises from the posterior
branch of the axillary nerve immediately adjacent to the inferior
aspect of the capsule at the level of the glenoid rim (see Fig.
37-13).6
Common Surgical Approaches
Posterior Approach
The most common surgical posterior approach to the scapula
in the last decades was the one described by Judet.83 It is an
extensive approach which involves dissection of the infraspi-
natus muscle from the infraspinatus fossa with the risk of neuro-
vascular damage (suprascapular nerve) and structural muscle
damage. Nowadays, the advocated posterior approaches are less
invasive, since no or minimal infraspinatus detachment is neces-
sary when using the interval between the teres minor and infra-
spinatus muscle.16,36,82,128,129
For the posterior approach, the patient is placed in a prone
or lateral decubitus position. As described by Ebraheim,36 a
skin incision is utilized along the scapular spine and then a
vertical extension at the lateral border of the scapula (a ‘‘reverse
Judet’’ skin incision) (Fig. 37-14). This allows the surgeon to
reflect the complete posterior deltoid, if necessary, off the scapu-
lar spine. A medially-based fascia flap is raised to expose the
scapular musculature. The interval between the infraspinatus
and teres minor muscles is entered with the infraspinatus mus-
cle retracted cranially and the teres minor muscle laterally. This
avoids any injury to the suprascapular nerve supplying the infra-
08-31-09 11:35:20
 B

FIGURE 37-8 The radiograph (A) and CT (B,C) scan of an 80-year-old

woman with a posterocranial glenohumeral luxation with a symptomatic
pseudarthrosis of an acromion fracture. D. The patient underwent a plate
osteosynthesis with bone graft and a reversed shoulder prosthesis. D

TABLE 37-1 The Classification System for

Scapulothoracic Dissociation as
Proposed by Damschen et al.29
and Modified by Zelle et al.192
Type II
Type Clinical Findings
Type I
I Musculoskeletal injury alone
IIa Musculoskeletal injury with vascular injury
IIb Musculoskeletal injury with incomplete neurologic impair-
ment of the upper extremity
III Musculoskeletal injury with incomplete neurologic impair-
ment of the upper extremity and vascular injury
IV Musculoskeletal injury with complete brachial plexus
FIGURE 37-9 Ogawa’s classification of coracoid fractures. Type I is proxi- avulsion
mal to and type II is distal to the coracoclavicular ligaments.
8
MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20
 CHAPTER 37: SCAPULAR FRACTURES 9

FIGURE 37-10 The diagnosis of scapulothoracic dissociation

can be made on a nonrotated AP radiograph by comparing the
distance from the medial border of the scapula with the spinous
processes between the affected (long arrow) and unaffected
(short arrow) sides. Kelbel et al.86 created the scapula index
and reported a normal value to be a ratio of 1.07 Ⳳ 0.04.134

A B
FIGURE 37-11 Muscle insertions onto the scapula. Anterior (A) and posterior (B) views.

FIGURE 37-12 The position of the brachial plexus in relation to the ante-
rior surface of the scapula. The supraclavicular and axillary nerves are also
shown.

MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20

10 UPPER EXTREMITY

Suprascapular nerve

Spine of scapula

Posterior branch of
axillary nerve

Supraspinatus
Humeral head

Superiorlateral
brachial cutaneous
Infraspinatus branch
Deltoid muscle

Lateral head
of triceps

Radial nerve

Long head
of triceps

Teres major

Teres minor
FIGURE 37-13 A posterior view of the course of the suprascapular nerve and posterior branch of the axillary
nerve in relation to the scapula and overlying muscles.

spinatus muscle as well as to the axillary nerve supplying the
teres minor muscle. The lateral border of the scapula and the
glenoid joint are then displayed, with the possibility of open
reduction and internal fixation of scapular neck fractures and
posterior glenoid fractures (types Ib, II, IV, and possibly V) (see
Fig. 37-14).
A disadvantage of the described approach is the release of
the posterior deltoid muscle off the scapular spine. Alternatives
are described by Wirth186 who described a posterior approach
with splitting of the posterior deltoid in line with its fibers dis-
tally to the upper border of the teres minor. Splitting the deltoid
muscle, however, endangers the integrity of the axillary nerve

Trapezius
Spine of scapula

Deltoid

Infraspinatus

Medial margin
of scapula

Teres major
Teres minor

FIGURE 37-14 Posterior approach to the glenohumeral joint/

scapular neck showing the skin incision.

MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20

 CHAPTER 37: SCAPULAR FRACTURES 11

at the level of the dense connective tissue of the subdeltoid
fascia. Furthermore, the intramuscular nerve branches can occa-
sionally be damaged within the lateral deltoid compartment.
Finally, Brodsky et al.16 and Jerosch et al.82 claim excellent
exposure with their described posterior subdeltoid approach to
the posterior aspect of the glenohumeral joint and scapular neck
(Fig. 37-15). After a vertical skin incision, the inferior border
of the spinal part of the deltoid is identified and mobilized by
blunt dissection. By abducting the free draped arm 60 to 90
degrees, it is easier to retract the mobilized deltoid muscle and
enter the interval between the infraspinatus and teres minor
muscle as described above, allowing access to the posterior as-
pect of the glenoid and lateral border of the scapular body.
Care should be taken to avoid injury to the circumflex scapular
artery, which lies directly medial to the insertion of the long
head of triceps, and the axillary and suprascapular nerves.
Anterior Approach
The anterior approach is used for coracoid and type Ia glenoid
fractures. It is performed in the beach chair position, with the

C Deltoid muscle
mobilized

Suprascapular nerve
Infraspinatus muscle

Circumflex scapular artery

and axillary nerve

Triceps muscle, long head

Teres minor muscle

Capsule

Infraspinatus muscle Teres minor muscle

FIGURE 37-15 The posterior approach to the glenohumeral joint and scapula. A. Arm in adduction. B. Arm
in 90 degrees of abduction. C. The underlying rotator cuff muscles. D. The capsular incision.

MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20

12 UPPER EXTREMITY
incision made in Langer’s lines over the coracoid process to
the axillary fold. The deltopectoral groove is opened with the
cephalic vein attached to the deltoid muscle. In the presence
of an anterior glenoid rim (type Ia) fracture, the subscapularis
tendon is dissected off the anterior glenohumeral capsule and
turned back medially. The capsule is opened and a humeral
retractor is inserted behind the posterior aspect of the glenoid to
visualize the entire glenoid cavity. After reduction and internal
fixation of the glenoid fracture, the capsule, which is usually
not stretched by the injury, is closed without performing a cap-
sular shift.
Superior Approach
A superior approach is indicated when a superior glenoid frag-
ment (type III, type V glenoid fracture) or an anatomic neck
fracture of the scapula is difficult to control or stabilize. This
approach can be added to an anterior or posterior approach. It
is performed in a beach chair position with the skin incision
made midway between the scapular spine and clavicle, laterally
over the edge of the acromion. The trapezius can then be split
in the line of its fibers, taking care to protect the accessory nerve
which runs from anterior to posterior. After identifying the su-
prascapular notch, the supraspinatus muscle can either be split
or shifted to the anterior or posterior part of the supraspinatus
fossa depending on whether access is required to the anterosup-
erior or posterosuperior aspect of the glenoid. Care should be
taken to protect and avoid injury to the suprascapular nerve
and vessels that lie medial to the coracoid process.
CURRENT TREATMENT OPTIONS
Glenoid Fractures
Glenoid fractures make up 10% of all scapular fractures. Only
10% of glenoid fractures are significantly displaced,60 meriting
surgical consideration. The majority (90%) are minimally or
undisplaced and should be treated nonoperatively. Fractures of
the glenoid are commonly found in the middle aged, between
40 and 60 years, with a male prevalence,78 and result most
often from high-energy direct trauma.1,57,79,112,115,150 They
occur when the humeral head is driven with a substantial force
against the glenoid fossa. This may be caused by a direct force
on the shoulder or an axial force through the humerus. The
direction of this axial force will predict the fracture pattern.
The most common fracture type is the anterior chip fragment
fracture (type Ia) which is often associated with an anterior
shoulder dislocation.78
Many authors have reported good early functional outcome
in patients treated nonoperatively with intra-articular fractures
without associated instability.20,77,144,151 Since the late 1980s,
operative treatment of glenoid fractures has gained more atten-
tion.4,8,74,84,89,98,156 There is a current trend towards arthro-
scopic techniques of glenoid fracture treatment, particularly in
Ideberg type I fractures.9,22,24,51,138,163,167
Ideberg Type I
Fractures of the anterior or posterior margin of the glenoid
(types Ia and Ib, respectively) may cause instability of the gleno-
humeral articulation. These fracture types are usually sustained
during traumatic glenohumeral subluxation or dislocation.76,77
After injury, the continuity between capsule, labrum, and frac-
MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20
ture fragment is usually maintained. Instability of the glenohu-
meral joint can be expected when the fragment is displaced
more than 1 cm and if at least 25% of the glenoid cavity anteri-
orly or at least 33% of the glenoid cavity posteriorly is in-
volved.32 Although debate exists among surgeons about the
amount of displacement and the size of the fragment that is
acceptable, it is accepted that rim fractures associated with per-
sistent or recurrent instability should undergo open reduction
and internal fixation.32,66,77,159 An axillary radiograph and CT
scan will demonstrate whether the humeral head is centered
exactly in the glenoid fossa or is displaced along with the frac-
ture fragment. The latter is an indication for surgical treatment.
The goal of surgery is to prevent morbidity secondary to gleno-
humeral instability or degenerative joint disease by accurate
reduction of the articular surface. According to the literature of
the last decade, open procedures can be replaced by arthro-
scopic fixation of fragments with promising results particularly
in type I fractures9,22,24,138,163,167 ); most authors reported resto-
ration of glenohumeral stability and good functional results.
Ideberg Type II
Type II fractures occur when the force through the humeral
head is directed somewhat inferiorly, with a fracture line run-
ning from the glenoid fossa to the lateral border of the scapula
body as a result. The amount of articular displacement and the
degree of comminution determines the need for open reduction
and internal fixation. Goss60 advocates open reduction and in-
ternal fixation with displacement of more than 5 mm. This is
based on the findings of Soslowsky et al.,162 who demonstrated
that the maximum thickness of glenoid articular cartilage is
5 mm. Schandelmaier156 reviewed 22 patients with displaced
glenoid fractures after a mean review period of 10 years: 9 had a
type 2 fracture and were treated by open reduction and internal
fixation through a posterior approach. He found a mean con-
stant score of 94.
Ideberg Type III
A type III glenoid fossa fracture occurs when the force is directed
superiorly, causing a fracture that involves the upper third of
the glenoid fossa including the coracoid. The fracture runs from
the glenoid fossa through the superior scapular body in the
proximity of the scapular notch. According to Goss,60,61 type
III,V, and VI injuries in particular are prone to neurovascular
injuries and damage to the SSSC. As with all other glenoid
fractures, a type III injury is usually undisplaced and can be
treated conservatively with good functional outcome in absence
of associated neurologic injury. The indication for operative
treatment is also displacement of more than 5 mm.
Ideberg Type IV
This type is caused by the humeral head being driven centrally
into the glenoid fossa. A fracture line runs from the fossa directly
across the scapula body to exit along its medial border and
splits the glenoid fossa into two parts. Surgery is indicated when
there is more than a 5 mm separation between the two parts.
Surgery may prevent symptomatic degenerative joint disease,
instability of the glenohumeral joint and, although extremely
rare, nonunion of the fracture.
Ideberg Type V
Originally, Ideberg76,77 described type V as a combination of a
type II and IV injury, with a direct violent trauma as the mecha-

nism of trauma in most cases.20 Goss57 subdivided type 5 into
three different subtypes (see Fig. 37-4). Type Va is a combina-
tion of type II and IV, Type Vb a combination of type III and
IV, and type Vc a combination of type II, III, and IV. These
subtypes are caused by more complex and probably greater
forces than those causing the simpler fracture patterns.57
The same indications used for type II, III, and IV should be
applied when determining the need for open reduction.19
Operative treatment of type V injuries does not uniformly lead
to a good functional outcome which is probably mostly relat-
ed to associated neurovascular injuries and postoperative
complications.77,84,98,112,156
Ideberg/Goss Type VI
Type VI fractures, introduced by Goss,60 are caused by the most
violent force and include all fractures with at least two articular
fragments. Even if displacement of the fragments is substantial,
with or without subluxation of the humeral head, open reduc-
tion and internal fixation is not indicated due to the extensive
comminution.60
In general, Ideberg’s experience with fracture type II through
V indicates:
1. Closed reduction under anesthesia is unsuccessful in im-
proving position of the fracture fragment(s)
2. Secondary improvement of position of fracture fragments is
possible after conservative treatment due to moulding of the
fracture by muscle forces across the glenohumeral joint
3. A good result occurred in 75% of the cases after early mobili-
zation
4. Open reduction and internal fixation may also lead to a good
result in the absence of other significant ipsilateral shoulder
fractures, nerve, or muscle injuries76–78
Scapular Neck Fracture
A fracture of the neck of the scapula is the second most common
scapular fracture.3,79,115,116 The suggested mechanisms of
trauma are a direct blow to the shoulder, a fall on the point of
the shoulder, or a fall on the outstretched arm. The fracture line
most often extends from the suprascapular notch area across the
neck of the scapula to its lateral border inferior to the glenoid
(surgical neck fracture) or, rarely, lateral from the origin of the
coracoid to its lateral border inferior to the glenoid (anatomic
neck).
Scapular neck fractures, by definition extra-articular frac-
tures, are sometimes accompanied by a fracture line through
the coracoid process or may remain as an intact unit. If the
scapular neck fracture is not associated with an ipsilateral shoul-
der lesion (of the SSSC), displacement is possible but
rare.31,58,176 According to the concept of the SSSC, isolated frac-
tures of the scapular neck are considered stable fractures.61
The treatment of these fractures has historically been nonop-
erative, mostly with a favorable outcome.79,83,103,115,116,177 Rec-
ommended methods of closed treatment include closed reduc-
tion and olecranon pin traction for 3 weeks followed by a
sling,32 closed reduction and a shoulder spica cast for 6 to 8
weeks,7 and even the use of a traction suspension system for
reduction of a displaced neck fracture.177 Some authors doubt
the usefulness of closed reduction in these fractures, advocating
the use of a sling and suggest mobilizing the affected arm as
soon as possible.117 Lindholm and Leven103 studied a series of
MDC-Bucholz-16918 R1 CH37
CHAPTER 37: SCAPULAR FRACTURES 13
scapular neck and body fractures and concluded that if un-
treated, all fractures healed in the position displayed at the time
of the original injury.
These studies, however, do not present data to justify these
recommendations. A more differentiated approach is necessary
as conservative treatment does not uniformly lead to a good
result. Several authors noted fair to poor results after conserva-
tive treatment of severely displaced scapular neck frac-
tures.1,3,49,127,135,148 Displacement is defined as at least 1 cm
of translation or 40 degrees of angulation (or a glenopolar angle
[GPA] ⬍20 degrees) in the AP plane of the scapula and separates
minor from major injuries according to Zdravkovic,191 Nordq-
vist and Petersson,127 and Geel.50
Ada and Millar1 reported on 24 patients with displaced scap-
ular neck fractures. Of the 16 patients treated conservatively,
50% complained of pain at night, 40% had weakness of abduc-
tion, and 20% had decreased range of motion. Whether transla-
tional displacement of at least 1 cm remains a good criterion
for surgical treatment of scapular neck fractures is controver-
sial.148,176 The criterion of angulation greater than or equal to 40
degrees (or a GPA ⬍20 degrees) is probably less questionable.
Several authors reported less favorable long-term outcome after
conservative treatment of angulated scapular neck fractures,
compared with scapular neck fractures without angular dis-
placement.15,88,148,173Good to excellent results have been re-
ported on open reduction and internal fixation of patients with
displaced scapular neck fractures.9,67,88,100 In these series, how-
ever, displaced scapular neck fractures are in most cases associ-
ated with ipsilateral clavicle fractures. According to Zlowod-
zki,194 who performed a systematic review of 520 scapular
fractures in 22 case series, excellent or good results can be
achieved with nonoperative treatment of isolated neck fractures
in 77% of the cases and in 88% of the cases with operative
treatment. Universal guidelines for conservative or operative
treatment are difficult to establish empirically because the
available literature does not include randomized or non-
randomized comparative studies. Treatment should, therefore,
be individualized.
The Superior Shoulder Suspensory Complex
Goss61 described the SSSC, consisting of the glenoid, coracoid,
acromion, distal clavicle, coracoclavicular ligaments, and
acromioclavicular ligaments (Fig. 37-16). This bone–soft tissue
ring maintains the normal, stable relationship between the
upper extremity and the axial skeleton. Single disruptions of
the SSSC, such as an isolated scapular neck fracture, are usually
anatomically stable because the integrity of the complex is pre-
served, and nonoperative management yields good functional
results. When the complex is disrupted in two places (double
disruption), such as a scapular neck fracture with an acromi-
oclavicular joint disruption, a potentially unstable anatomic sit-
uation is created. Because the SSSC includes the glenoid, acro-
mion, and coracoid, many double disruption injuries involve
the scapula. In the presence of a displaced fracture of the acro-
mion, coracoid process, glenoid, or scapular neck, the possibil-
ity of another lesion of the SSSC (i.e., a double disruption)
should be considered. According to Goss,61 open reduction is
indicated for double disruptions that are accompanied by signif-
icant displacement, which may lead to delayed union, mal-
union, or nonunion as well as long-term functional deficits.
08-31-09 11:35:20
14 UPPER EXTREMITY

A B

FIGURE 37-16 The SSSC A. Clavicle–acromi-

oclavicular joint–acromion strut. B. Clavicle–cora-
coclavicular ligament–coracoid linkage. C. Three
process-scapular body junction. (From: Goss TP.
Fractures of the scapula. In: Rockwood CA, Matsen
FA, Wirth MA, et al., eds. The Shoulder. 3rd ed.
Philadelphia: Saunders; 2004:413, with permis-
C sion.)

The most common described double disruption of the SSSC The rarity of the floating shoulder is also illustrated by the
is the ipsilateral glenoid surgical neck and midshaft clavicle complete lack of well-performed, prospective studies with com-
fracture. This injury, although the terminology is criticized,91 parison of different treatment options. The literature on this
is also defined as a floating shoulder. subject is limited to data provided only by case reports and
retrospective studies of small patient series.
The Floating Shoulder Good clinical results are reported for both conservative and
Ganz and Noesberger46 were the first authors who described operative treatment (Table 37-2). Traditionally, floating shoul-
this injury in 1975. They suggested a loss of the stabilizing ders were treated nonoperatively. However, over the last two
effect of the clavicle in the case of a combination of these two decades, there has been increased interest in open reduction
fractures. In contrast to isolated scapular fractures, they found and internal fixation of these fractures.40,66,69,71,93,99,141 Hers-
more severe displacement of the scapular fracture when com-
bined with an ipsilateral clavicle fracture. The weight of the
arm and the combined contraction of the biceps, triceps, and
coracobrachialis muscles may cause inferior and rotational
displacement of the distal fragment resulting in a change in
the contour of the affected shoulder, the so-called drooping
shoulder (Fig. 37-17). Apart from this possible caudal and rota-
tional displacement, it is also suggested, although criticized
by some,129,175 that the glenoid fragment is displaced antero-
medially by contraction of the rotator cuff muscles (Fig.
37-18).46,66,71 Translational displacement of the scapular
neck will result in shortening of the lever arm of the rotator
cuff musculature and threaten the functional balance of the
glenohumeral joint.66,158 This may result in loss of abduction
strength,1,20,66 although this is not necessarily synonymous with
limitation of range of motion, as demonstrated in a biomechani-
cal analysis.25 Williams and colleagues185 conducted the only
cadaver study on this subject to determine the stability afforded
by specific structures. They concluded that ipsilateral fractures
of the scapular neck and the shaft of the clavicle do not produce
a floating shoulder without additional disruption of the coracoa-
cromial and acromioclavicular capsular ligaments. These find-
ings have not yet been confirmed in clinical studies. FIGURE 37-17 Drooping aspect of the left shoulder.

MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20

 CHAPTER 37: SCAPULAR FRACTURES 15

A B C
FIGURE 37-18 A,B. Radiographs of an ipsilateral scapular neck and midshaft clavicle fracture. C. The glenoid
fossa is still not reduced despite open reduction and internal fixation of the clavicle.

covici71 reported on 9 patients: 7 had been treated operatively
(with osteosynthesis only of the clavicle) and the remaining 2
had been treated nonoperatively. Their good results led them to
recommend open reduction and internal fixation of the clavicle
only, in order to prevent malunion of the scapular neck. The
authors presumed that the glenoid neck fracture would usually
reduce and be stabilized indirectly. Rikli141 retrospectively ana-
lyzed 12 cases, 11 with osteosynthesis of the clavicle alone,
whereas one had both the clavicle and the glenoid neck fractures
fixed. The findings of Leung and Lam99 are based on the treat-
ment results in 15 cases in whom simultaneous fixation of the
displaced scapular and clavicle fractures had been performed.
All but one patient had a good, or excellent, functional result,
according to the scoring system of Rowe.151 All fractures healed
at an average of 8 weeks postoperatively. Good results in 7
operatively treated patients, by fixation of both the scapular
neck and clavicle fractures, or disrupted acromioclavicular joint,
have also been described in a retrospective study by Egol et

TABLE 37-2 Reported Results of Conservative and Operative Management of the Floating
Shoulder
Outcome Outcome
ORIF ORIF Clavicle Conservative Operative
Number Conservative Clavicle and Scapula Outcome Measure (mean score) (mean score)

Edwards39 20 20 — — Constant28 96
40
Egol 19 12 — 7 American Shoulder and 80.2 88.7
Elbow Surgeons119
Hashiguchi69 5 — — — University of California, 34.2
Los Angeles41
Herscovici71 9 2 — 7 Herscovici 1 good; 7 excellent
1 poor
Labler93 17 8 6 3 Constant28 90 66
93 (ORIF both)
Leung99 15 — — 15 Rowe151 84
Ramos139 13 13 — Herscovici71 11 excellent;
1 good
Rikli141 12 — 11 1 Constant28 Constant: 96%
173 28
van Noort 35 28 7 Constant 76 Constant: 71%

ORIF, open reduction and internal fixation.

MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20

16 UPPER EXTREMITY
al.40 Finally, in a study of Labler et al.,93 6 patients were treated
with internal fixation of only the clavicle and 3 with fixation of
both clavicle and scapular fractures.
Routine operative treatment of a floating shoulder without
regard to displacement has recently been questioned. Edwards39
reported excellent results in 17 and good results in 3 patients
in whom all ipsilateral fractures of the scapula and clavicle had
been treated nonoperatively by a shoulder immobilizer, until
the associated injuries allowed mobilization of the shoulder.
They recommend conservative treatment, especially in patients
with less than 5 mm displacement. In a retrospective study, van
Noort et al.173 reported fair to good results in 28 patients treated
conservatively (mean constant score: 76), with a well-aligned
glenoid. The authors concluded that these rare shoulder lesions
are not unstable by definition and that conservative treatment
leads to a good functional outcome in the absence of caudal
displacement of the glenoid. Caudal displacement was defined
as an inferior angulation of the glenoid of at least 20 degrees.174
Ramos et al.139 in 1997 reviewed 13 patients with ipsilateral
fracture of the clavicle and scapular neck treated conservatively.
The average follow-up was 7.5 years. Using Herscovici’s scoring
method,71 they reported 84.6% excellent, 7.7% good, and 7.7%
fair results.
Based on both clinical and biomechanical studies, it remains
unclear under which criteria a floating shoulder should be
treated operatively. Current experience indicates that an undis-
placed, or minimally displaced, ipsilateral clavicle and scapular
neck fracture can be treated conservatively, with a good func-
tional outcome. The amount of displacement that is accept-
able at the fracture sites of the glenoid neck and clavicle is
controversial.
Scapular Body Fracture
Approximately 50% of scapular fractures involve the scapular
body and spine.61 This fracture type is correlated with the high-
est incidence of associated injuries.19,169 They are generally
caused by indirect forces or by direct trauma. Wyrsch and co-
workers190 reported a scapular body fracture in a professional
boxer who sustained the injury during an attempted punch.
More rare causes are seizures, electrical shock treat-
ments,11,70,110,166 or stress fractures.136 Scapular body fractures
heal readily and do not merit operative intervention,115,116,184
regardless of the number of fracture fragments. The fact that
these fractures heal well without significant clinical symptoms
is probably directly related to the protection of a thick layer of
muscles surrounding the scapula. Several series of conserva-
tively treated patients with scapular body fractures have been
reported with union of the fracture and a good functional out-
come.3,79,103,115 Zlowodzki194 reported in a systematic review
of 520 scapular fractures in 22 case series, that 99% of all scapu-
lar body fractures had been treated nonoperatively. Excellent
or good results were achieved with nonoperative treatment in
88% of the cases.
Nonetheless, painful scapulothoracic crepitus caused by
malunion of the scapular body may have adverse mechanical
and functional effects on shoulder movement. Excision of the
bony prominence in these cases is usually curative.44,45 Other
clinical symptoms are pain, limited range of motion, and wing-
ing of the scapula by loss of the serratus anterior muscle.64
Nordqvist and Petersson127 found poor long-term results in
MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20
some patients with more than 10 mm of displacement. Non-
unions are extremely rare. Two cases have been reported which
were both treated successfully by open reduction, rigid internal
fixation, and bone grafting.43,64
Acromial Fracture
The acromion provides one side of the acromioclavicular joint
and serves as the point of attachment for the deltoid muscle
and a number of ligaments. By forming the roof of the glenohu-
meral joint, it lends posterosuperior stability. Approximately
8% to 9% of all scapular fractures involve the acromion.3,115,184
There are four causes described for an acromial fracture:
1. A direct blow from the outside, in general a significant force.
2. A force transmitted via the humeral head from the inside.
Traumatic superior displacement of the humeral head,
which may also result in an associated rotator cuff tear, can
cause an (superiorly displaced) acromial fracture. Another
mechanism is rotator cuff arthropathy, in which an acromial
fracture may occur by superior migration of the humeral
head.20
3. An avulsion fracture is usually caused by an indirect force.
Heyse-Moore and Stoker,72 Rask and Steinbergh,140 and
Russo et al.153 reported forceful contraction of the deltoid
muscle resulting in an avulsion fracture of the acromion.
4. Stress fractures of the acromion have been reported, particu-
larly in sports.65,178,181 Subacromial decompression with sig-
nificant thinning of the acromion may also lead to a stress
fracture.106,111,152,182
A diversity of associated ipsilateral shoulder lesions with
an acromion fracture is described. The brachial plexus is at
risk particularly with an inferiorly displaced acromion frac-
ture.114,123 Other associated lesions, as reported earlier, are
rotator cuff lesions.104,145 Finally, ipsilateral acromioclavic-
ular joint lesions, coracoid, clavicle, glenoid, and proximal
humeral fractures and shoulder dislocations have been re-
ported.58,92,95,102,114,122,193
Independent of the mechanism of trauma, when a fracture
does occur, it is usually non- or minimally displaced. Nonopera-
tive treatment in these cases will lead to union of the fracture
with a good to excellent functional outcome.61 Most acromion
fractures are successfully treated simply by immobilization with
a sling or Velpeau dressing until the pain has subsided, which
is usually within 3 weeks.1,81,90,92,102,114,120 Some authors have
advocated the use of a spica cast with the shoulder in abduc-
tion.122,184 Omission of a sling or another form of immobiliza-
tion may cause secondary displacement of the fracture.59
According to the classification of Kuhn,90 the group of non-
or minimally displaced fractures are type I fractures and caused
by indirect force (avulsion fracture-type Ia) or a direct trauma
(type Ib). Nonoperative treatment is also advocated by Kuhn90
in dislocated acromial fractures in which the subacromial space
is not compromised (type II fracture). However, a poor clinical
outcome or a symptomatic pseudarthrosis of patients with a
type II fracture has been reported.34,90 In type III displaced
fractures in which the subacromial space is diminished by the
inferior pull of the deltoid on the acromial fragment, open re-
duction with internal fixation is advocated by Kuhn90 and
Ogawa132 to prevent secondary impingement. Most authors rec-
ommend open reduction and internal fixation for markedly dis-

placed acromion fractures to reduce the acromioclavicular joint
and prevent nonunion, malunion, and secondary impinge-
ment.124,151 When surgery is performed, a variety of surgical
techniques may be employed, including the use of tension band
wiring, sutures, Kirschner-wires, staples, lag screws, and
plates.8,30,61,66,81,182 Excision of the acromial fragment has been
reported but is generally not recommended for fragments larger
than half an inch because it can result in substantial weakness
of the deltoid muscle.90,120,123,130
Coracoid Fracture
The most common mechanisms that have been described as a
cause of a coracoid fracture are:
1. A direct blow to the superior point of the shoulder
2. A direct contact between the humeral head and coracoid
process in case of an anterior shoulder dislocation47,168
3. An avulsion fracture by a forceful contraction of the short
head of the biceps, pectoralis minor, or coracobrachialis
muscle5,149
4. As part of an acromioclavicular dislocation180
5. Stress fractures have been reported: medial migration of the
humeral head from rotator cuff arthropathy may result in a
coracoid fracture14
Coracoid fractures may be isolated, but in many cases are
accompanied by ipsilateral shoulder injuries. Ogawa133 re-
ported acromioclavicular dislocations as the most common as-
sociated lesion, seen in 60 of the 67 described patients. Other
common associated lesions are lacerations or abrasions over the
posterolateral or lateral deltoid muscle, (lateral) clavicle frac-
tures, shoulder dislocations, and rotator cuff tears.
Fractures in adults are most common at the base of the cora-
coid, whether or not with extension in the upper border of the
scapula and/or the glenoid.42,80,131,188 Other reported sites are
the middle portion33,137 and the tip.75,121,193
Many methods of treatment of coracoid fractures have
been described. There is, however, no consensus in the litera-
ture about the preferred treatment of coracoid fractures. Many
authors suggest that non- or minimally displaced fractures
can be successfully treated by conservative treatment.42,52,109,193
On occasion, however, these injuries may be significantly
displaced and of functional importance, thus making surgical
management a consideration. Fractures of the coracoid tip are
avulsion injuries (Ogawa type 2) which may displace consider-
ably. Despite the chance of nonunion,117 this type of fracture
can be treated conservatively with good functional out-
come.23,42,52,109,132 On occasion, operative treatment is indi-
cated when the fractured coracoid tip impedes the reduction
of an anterior dislocated humeral head.42,189 Other indications
for surgery include a painful nonunion after anterior shoulder
dislocation.47,85
Treatment of fractures of the coracoid base (type 1) follow
the same reasoning described for fractures of the coracoid tip.
However, displacement of the fracture is more common which
may be due to accompanying ipsilateral shoulder injuries (dou-
ble disruptions of the SSSC). In these circumstances, or in cases
with extension of the fracture into the glenoid fossa (with dis-
placement), open reduction and internal fixation with screw
fixation of the coracoid fracture is advocated.42,61,133 Martin-
Herrero,109 however, described satisfactory outcome in conserv-
MDC-Bucholz-16918 R1 CH37
CHAPTER 37: SCAPULAR FRACTURES 17
ative treatment in 7 patients despite displacement of the fracture
and associated ipsilateral shoulder injuries in 6.
Scapulothoracic Dissociation
Scapulothoracic dissociation is characterized by a complete loss
of scapulothoracic articulation and lateral displacement of the
scapula, while the skin is usually intact. It is classically 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.2 It is a rare,
severe injury of the shoulder girdle with a high mortality rate
(10%).29 Some authors describe this injury, which is almost
always associated with severe vascular injuries (prevalence
88%–100%), as an internal forequarter amputation.96,154,187,192
As well as lesions of the subclavian and axillary artery, associated
complete or partial disruptions of the brachial plexus (preva-
lence up to 94%)29 are frequent and well described in the litera-
ture. Other described associated lesions are osseous injuries
to the shoulder girdle (particularly clavicle fractures, but also
acromioclavicular or sternoclavicular dislocation), injury to
muscles (deltoid, pectoralis minor, rhomboids, levator scapulae,
trapezius, and latissimus dorsi), and massive soft tissue swelling
in the shoulder region. Approximately 50% of the reported cases
are the result of a motorcycle accident.18
The management of patients with scapulothoracic dissocia-
tion should follow the ATLS principles with cardiopulmonary
stabilization and resuscitation being of paramount importance.
Treatment recommendations have focused on the care of the
accompanying neurovascular injury. In a hemodynamically sta-
ble patient, arteriography is used to determine the vascular in-
tegrity, followed by surgical repair if necessary. However, it
should be appreciated that an extensive collateral network
around the shoulder can protect against limb-threatening is-
chemia.54,100,171 Sampson et al.154 presented a series of 11
cases). They questioned the need for vascular repair in these
patients, all of whom had a complete brachial plexus palsy,
no radial pulse, and subclavian or axillary artery occlusion on
arteriography. Of these 11 cases, 6 were revascularized and 5
were not. All 11 limbs remained viable, although none of the
11 patients regained any function. Zelle et al.192 demonstrated
that the extent of the neurologic injury is of paramount impor-
tance in predicting the functional outcome. All of their patients
with a complete brachial plexus avulsion either had an amputa-
tion or had poor shoulder function at the time of follow-up.
Partial plexus injuries, however, have a good prognosis, and
most patients achieve complete recovery or regain functional
use of the extremity.60 If upper extremity function is not restora-
ble, an immediate above-elbow amputation seems to result in
better functional outcomes, lower complication rates, better re-
lief of causalgia, and more successful return to work than a late
amputation.13,18,192 Many patients refuse a secondary amputa-
tion despite a flail, anesthetic upper extremity.27,35,54,171
The recommended treatment of associated osseous lesions in
patients with scapulothoracic dissociation is unclear and should
therefore be individualized. Nevertheless, Goss61 advised open
reduction and internal fixation of clavicle fractures and stabilisa-
tion of disrupted acromioclavicular or sternoclavicular joints
for three reasons: to avoid delayed or nonunion, to restore as
much stability as possible to the shoulder complex thus reduc-
ing long-term functional problems, and to protect the brachial
08-31-09 11:35:20
18 UPPER EXTREMITY

plexus, subclavian, and axillary vessels from further injury

caused by tensile forces.

A U T H O R ’ S PR E FE R R E D T R E A T M E N T

Scapular Neck Fractures

Reduction of translational displacement (⬎1 cm) in an iso-
lated scapular neck fracture is not necessary to obtain a good
functional outcome with conservative treatment. One should
be aware of the possibility of ipsilateral shoulder lesions (e.g.,
fractures, rotator cuff lesions, and intra-articular glenohu-
meral damage), which may influence the final functional
outcome.155,176 Symptomatic local care in a shoulder immo-
bilizer followed by passive exercises as soon as the pain al-
lows will not interfere with fracture healing and will result
in a good to excellent functional outcome.
In case of an associated ipsilateral clavicle fracture (float-
ing shoulder), there is a chance of further displacement of
either or both of the fractures. Current experience indicates
that undisplaced, or minimally displaced, ipsilateral clavicle
and scapular neck fractures can be treated conservatively
with a good functional outcome. In relatively young patients
without comorbidities, open reduction and internal fixation
by plate osteosynthesis should be considered in displaced,
shortened, midshaft clavicle fractures because of the chance
of nonunion (prevalence 15%)73,142 or malunion. Fixation FIGURE 37-19 A scapular neck fracture which has been reduced and
of the clavicle fracture may allow reduction of the glenoid stabilized with a plate.
neck fracture and restoration of the shoulder contour. How-
ever, despite anatomic reduction of the clavicle fracture, dis-
geon but also on the size and comminution of the fracture
placement of the scapular neck fracture may persist. In par- fragment.
ticular, rotational displacement of the scapular neck will Types II through V have poorly defined indications for
compromise the functional outcome. In case of caudal angu- operative treatment. However, on the basis of available re-
lation of the glenoid fossa of more than 20 degrees (or a ports, it seems reasonable to conclude that surgery has a
GPA angle ⬍30 degrees) (see Fig. 37-6), operative treatment definite role in the treatment of glenoid fossa fractures. When
should be considered through a posterior approach with the humeral head is not centered in the major portion of
plate osteosynthesis along the lateral border of the scapula the glenoid fossa and is subluxed along with the fracture
(Fig. 37-19). However, caution should be employed to avoid fragment, open reduction and internal fixation of the fracture
surgical overtreatment in the absence of data to support an is indicated. Type II fractures are approached posteriorly,
aggressive approach. and type III by either a superior or combined posterior and
superior approach. A cannulated interfragmentary compres-
Glenoid Fossa Fractures sion screw (3.5 mm) is placed after a Krischner-wire posi-
For type Ia fractures, surgical treatment is preferred where tioned in the superior fragment is used to manipulate and
there is subluxation of the humeral head or in fractures likely reduce the fracture. A posterosuperior approach is usually
to cause glenohumeral instability, which can be predicted if required for the treatment of types III, IV, Vb, and Vc, so
the fracture is displaced more than 5 mm or if a quarter or that the superior glenoid fragment can be reduced and fixed
more of the glenoid cavity is involved. Exposure is performed relative to the inferior aspect of the glenoid cavity. Care
should be taken when using the posterosuperior approach
through a standard deltopectoral approach with mobiliza-
which places the suprascapular nerve in some jeopardy as the
tion of the subscapularis muscle. A large fragment can be
nerve passes through the scapular notch, the supraspinatus
fixed with two screws, but smaller or comminuted fragments
muscle, the spinoglenoid notch, and the infraspinatus
may require a buttress plate with smaller screws.
muscle.
The same indications for surgery as for a type Ia fracture
Type VI fractures are managed nonoperatively. Passive
should be applied for a type Ib fracture except that the size
exercises should be started as soon as possible in order to
of the posterior fragment which will predict instability is a prevent the development of a stiff painful shoulder. These
third or more of the glenoid cavity. For posterior fractures, injuries have the highest chance of posttraumatic arthritis.
a posterior glenohumeral exposure is advocated with access
to the glenohumeral joint through the interval between
the infraspinatus and teres minor muscles. In both types
Ia and Ib, there are possible advantages of arthroscopically COMPLICATIONS
controlled operative treatment using percutaneous screw The available information with regard to the complications of
fixation. This is typically dependable on the skill of the sur- scapular fractures and their treatment is very sparse. One should
MDC-Bucholz-16918 R1 CH37 08-31-09 11:35:20

make a distinction between the complications of treatment and
concomitant injuries of scapular fractures. The latter are some-
times life-threatening and may have more consequences with
respect to the priorities of treatment and the overall functional
outcome. On the other hand, regional complications such as
nerve injuries may influence the functional outcome of the af-
fected shoulder dramatically. An example is a brachial plexus
injury, which is described by Rockwood,143 after coracoid frac-
ture. Suprascapular nerve injuries are reported following scapu-
lar neck fracture with extension into the suprascapular
notch37,160 and from coracoid base fractures.143 Axillary nerve
and brachial plexus injuries have been described in association
with an acromion fracture.114,115
Reported complications after conservative treatment are in
general uncommon and variable. Malunion and particularly
nonunion of scapula fractures are very rare. In a recent search
of the medical literature, Marek105 discovered only 15 cases of
scapula nonunion after nonoperative management. Malunion
of particularly scapular body fractures is well tolerated, although
painful scapulothoracic crepitus is described.1,3,127 Displaced
glenoid fractures may lead to glenohumeral arthritis and insta-
bility,1,66 pain (in rest and with exertion), limitation in range
of motion, and weakness.1,3,127,191 Some authors suggest that
displaced fractures of the glenoid neck can lead to altered me-
chanics of the surrounding soft tissues, giving rise to glenohu-
meral pain and dysfunction.1,3,49,127,135,148
With regard to complications of operatively treated patients
with scapular fractures, Lantry97 analyzed the postoperative
complications of 212 cases described in 15 retrospective case
series. The overall reported complication rate in these studies
was fairly low. The most common complications were removal
of implants in 7 % due to metal failure or local discomfort and
infection in 4 %. Other mentioned complications were nerve
injuries (2%), mostly involving the suprascapular nerve (4 out of
5), reoperation other than hardware removal for posttraumatic
arthritis (2%), rotator cuff dysfunction (1%), and heterotopic
ossification (1%). Nonunion after operatively treated scapular
fractures is not cited as a complication except for one reported
case by Marek.105 Finally, an improper physical therapy rehabil-
itation program or a poor patient compliance may contribute
to unnecessary postoperative shoulder stiffness.
FUNCTIONAL OUTCOME
In general, more than 90% of scapular fractures are non- or
minimally displaced and do well clinically after conservative
treatment.79,115,184 This observation has been based on treat-
ment of scapular fractures in general, and its relevance is there-
fore very limited. A more differentiated approach turned out to
be necessary as conservative treatment does not uniformly lead
to good results.1,9,135 Literature regarding outcome of treatment
of specific fracture types, however, is mostly comprised of case
reports and small series and is therefore scarce. There is particu-
larly concern about poor functional outcome after conservative
treatment of displaced acromion, coracoid process (base), scap-
ular neck, and glenoid fossa fractures.1,3,49,127,135,148 With re-
spect to functional outcome after operative treatment, most se-
ries concern glenoid fossa fractures57,66,84,98,112,156 and scapular
neck fractures with or without an ipsilateral clavicle frac-
ture.1,8,40,66,69,71,93,99,141,173 In a systematic review of 243 cases,
MDC-Bucholz-16918 R1 CH37
CHAPTER 37: SCAPULAR FRACTURES 19
Lantry97 pointed out that good to excellent functional results
were obtained in approximately 85% of cases which mainly
consisted of displaced glenoid fossa and scapular neck fractures.
Limitations of interpreting these study results are the retrospec-
tive character of the case series (level IV) and the various out-
come scales and scoring systems. In the above mentioned stud-
ies, the following shoulder scoring systems were used: American
Shoulder and Elbow Surgeons,40 constant score,8,39,93,141,
156,173,176
Herscovici score,39,71,139 Neer score,131,133 Rowe
98,99
score, University of California, Los Angeles, score,69 or sub-
jective scores based on the surgeon’s assessment mainly based
on pain and range of motion.1,3,66,112,116,127
CONTROVERSIES AND FUTURE
DIRECTIONS
The problem with the management of scapular fractures in gen-
eral is the lack of evidence-based treatment. The scientific
knowledge is based on case series and expert opinion (level IV
and V). The available literature includes neither randomized nor
nonrandomized comparative studies. Apart from the different
nonvalidated and nonspecific outcome measures and methodo-
logical limitations of many studies, the influence is of associated
injuries on the final outcome is unclear.
The challenge for the future is to complete well-documented,
methodologically correct, comparative studies on the fracture
types that may benefit from surgical treatment, such as displaced
glenoid and scapular neck fractures.
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