Scapula Fracture

Treatment &
Management

Author: Thomas P Goss, MD; Chief Editor: S Ashfaq

Hasan, MD
 TREATMENT
Approach Considerations

Most scapula fractures can be managed

effectively with closed treatment.
Because scapula fractures often are associated
with other, sometimes life-threatening injuries,
delay surgery until the patient is medically
stabilized.
Absolute contraindications for surgery are few. In
the case of a major vascular injury, such as an
axillary or brachial artery tear, repair the vessel
first, then follow with fracture fixation.
Recognizing the exact indications for operative
treatment of scapula fractures is a major issue for
the future.
Medical Therapy
Medical therapy for patients with scapula fractures generally
is the same as that for any trauma patient. Perform fluid
resuscitation, stabilize the cardiopulmonary system, and treat
life-threatening injuries prior to operative fixation of scapula
fractures.

Most scapula fractures can be managed with closed

treatment. More than 90% of scapula fractures have minimal
displacement.

Treatment is symptomatic. Short-term immobilization in a

sling and swathe bandage is provided for comfort.
 In some cases, such as intra-articular fractures, close
radiographic follow-up is necessary to ensure that
unacceptable displacement does not occur.

Most scapular fractures heal completely by 6 weeks,

and all external support is discontinued at this time.

Continue ROM exercises until full shoulder mobility is

recovered.

Full functional recovery takes several months.

Ultimately, the prognosis for these fractures is
excellent.
Indications for Surgical Management
The
following Significantly displaced
injuries fractures of the glenoid cavity
(glenoid rim and fossa)
occur with Significantly displaced
enough fractures of the glenoid neck
frequency Double disruptions of the
to merit superior shoulder suspensory
complex (SSSC) in which one
discussion or more elements of the
of scapula are significantly
displaced
operative
treatment:
Significantly displaced fractures of
glenoid cavity (rim and fossa)
Fewer than 10% of glenoid cavity
fractures are significantly
displaced.
Ideberg reviewed over 300 such
injuries and proposed the first
detailed classification scheme.

This classification subsequently

was expanded by Goss
Other indications for surgical management
of these fractures include the following:

Glenoid fossa fractures that result in

significant displacement of the humeral
head such that it fails to lie in the center of
the glenoid cavity, thereby resulting in
glenohumeral instability

Fractures of the glenoid fossa with such

severe separation of the fracture
fragments that nonunion is likely to occur
 Nordqvist and Petersson evaluated 37
glenoid neck fractures treated
nonoperatively and found the functional
results at 10- to 20-year follow-up to be
fair or poor in 32% of cases.

Hardegger et al noted that displaced

glenoid neck fractures result in a functional
imbalance because the relationship of the
glenohumeral joint with the acromion and
nearby muscle origins is altered
 Herscovici et al reported results in nine patients with
ipsilateral clavicular and glenoid neck fractures.
Seven patients were treated surgically with plate
fixation of the clavicular fracture and achieved
excellent results. Two patients were treated without
surgery and were found to have decreased ROM, as
well as drooping of the involved shoulder.
Combined fractures of the distal clavicle and the
superior aspect of the glenoid cavity is another
potentially unstable situation. Each disruption may
lead to displacement at the other fracture site.
If displacement of the clavicular fracture site is
unacceptable, surgical reduction and stabilization is
indicated, usually with a Kirschner-wire (K-wire)
tension-band fixation construct.
 Surgical Therapy
Fractures of glenoid cavity

The approach to glenoid cavity fractures

depends on the type of fracture
Basic orthopedic and shoulder instruments
should be available, and fixation devices
should include 3.5-mm and 4.0-mm cannulated
screws and 3.5-mm malleable reconstruction
plates. Kwires can be used for temporary or
definitive fixation of glenoid fragments
Type II glenoid neck fractures

Temporary fixation can be obtained with K-

wires or interfragmentary screws.
Definitive fixation of the reduced fragment
generally is achieved with a 3.5-mm
reconstruction plate contoured along the
posterior aspect of the glenoid fragment and
the lateral scapular border.
In some type II fractures, severe comminution
of the scapular body or spine may preclude
plate fixation.
In these cases, K-wire or interfragmentary
screw fixation can be used.
Coracoid and acromion fractures

For coracoid fractures that require ORIF, an

anterior deltoid-splitting approach is utilized.
The rotator interval is opened as needed for
optimal exposure of the fracture site. Cannulated
3.5- mm and 4.0-mm compression screws are
useful for fixation of large fragments.
If the fragment is significantly comminuted,
treatment is excision and suture fixation of the
conjoined tendon to the remaining coracoid
process
A deltopectoral approach could also be utilized as
an alternative to a deltoid-splitting approach.
 If surgical reduction and stabilization of an
acromion fracture is necessary, a tension-band
and plate construct usually is chosen
 Postoperative Care
Postoperative management partially depends on
the degree of stability achieved at surgery.
Complete immobilization in a sling and swathe is
used for the first 24-48 hours. After that,
progressive ROM exercises and functional use of
the shoulder out of the sling (within clearly defined
limits) are initiated if fixation is satisfactory.
If surgical fixation was not rigid, immobilization in
a sling and swathe, abduction brace, or overhead
olecranon pin traction may be required for 7-14
days.
Radiographs are taken every 2 weeks to
ensure maintained reduction.
By 6 weeks, healing usually is sufficient to
permit discontinuance of the sling and to
allow progressive functional use of the
extremity.

Physical therapy is continued until ROM

and strength are maximized.
Heavy physical use of the shoulder, such
as athletic activity, is prohibited for 4-6
months.
Patients are encouraged to work diligently
on their rehabilitation programs, as final
motion and strength may not be achieved
for 6 months to 1 year.
 Complications
Complications can result directly from surgical
management.
Neurovascular injury, infection (superficial and
deep), and loss of fixation all can result from poor
surgical technique.
An improper physical therapy rehabilitation program
may lead to unnecessary postoperative

shoulder stiffness.

Finally, poor patient compliance can contribute to

shoulder stiffness and possible hardware failure.
 Long-Term Monitoring
After discharge from the hospital, patients should be
seen for follow-up every 2 weeks for the first 6 weeks.

Radiographs are taken to ensure maintained reduction.

Evaluate the patient's ROM and update his/her
rehabilitation program as needed.
Patients should be seen at 12 weeks for evaluation of
motion and progression of functional use of the shoulder.

Final motion and strength may not be achieved until 6

months to 1 year.
Thank