Master Techniques in Orthopaedic

Surgery: Fractures
2nd Edition

2006 Lippincott Williams & Wilkins

2
Scapula Fractures: Open Reduction
Internal Fixation
Peter A. Cole

Indications/Contraindications
In 1938, Wils on r ecorded a 1% incidence of scapula fractures in a
comprehensive review of 4,390 br oken bones. It is estimated that
scap ula fractures acc ount for 3% to 5% of all fractures about the
shoulder girdle. The well-endowed parascapular muscu lature, the
oblique plan e mobility of the sc apula on the thorax, and the
surrounding ske letal str uctur es (which usually yield fir st) explain
the relative r arity of scapula fractures. However , incr eased
recognition of shoulder morbidity after high-e nergy trauma as well
as improving familiar ity with surgic al approac hes to the sc apula
have clarifie d the in dications fo r nonoperative versus surgical
tr eatment.
Fractures of th e scapula follow a bimodal patte rn of injur ies based
on the v ector and mechanis m of forc e to th e shoulder. Low-energy
and sporting accidents often lead to partial articular fr actur es that
usually involve the anter ior glenoid proc ess and ar e commonly
associated with anterior shoulder dislocations . T hese fractures are
often referred to as bony Bankar t lesions and may be
char acter ized by anter ior shoulder ins tability. If shoulder
instability is pres ent either clinic ally or on radiographic
examination, then o perative intervention in an appropriate
surgical c andidate is recommended. These criteria are usu ally
present with fr actur es involving mo re than 20% of the ar ticular
sur face.
A second variety of scapula fractures involves the glenoid neck
and body, and they generally occur as a r esult of high -ene rgy
tr auma. These fractures may or may not involve the g lenoid
articular sur face. Because of the mechanism caus ing the fracture,
associated injur ies occur in many of these patients . In ser iously
injured patients, diagnos is and s ubsequent treatment of a scapula
fr actur e ar e often delayed due to tre atment of o the r life-
threatening or limb -threatening conditions. According to a
common misconception, scapulothoracic dissociation fr equently
occurs in the s etting of scapula fractures; however ,
scapulothoracic injury r esults from a violent traction force to the
upper extremity, which is quite the opposite mechanism of a
typical scapula fr actur e.
Displaced scapular fractures that exte nd into the glenoid ar ticular
sur face often r equire surgic al treatme nt. Articular fractures should
be treated with open r eduction and inter nal
fixation (ORIF) if a step off of 3 to 4 mm is encountered and more
than 20% of the joint is in volved (Fig. 2.1). Lesser degre es of
articular step off, gap, and percentage o f join t involveme nt, mus t
be placed into the context of the patients occupation , ag e,
activity leve l, physiologic status, and hand dominance.
The optimal treatment of displaced ex tra- articular scapular
fr actur es remains controversial. Recent studies suppor t internal
fixation of scapula nec k fractures sinc e large displacement or
angulation leads to compromise of shoulder function. Ada and
Mille r have recommended ORIF of scapular neck fractures when
the glenoid is medially displaced more than 9 mm or angular
displacemen t exceeds 40 degr ees. Their r ecommen dation is based
on a re view o f 16 patients treated nonoper atively: 50% had pain,
40% had exertional weakness, and 2 0% had decreased motion at
a follow-up of 15 months or later. Eight patients in this s ame
study were treated operativ ely, and all ac hieved a p ainless range
of motion.
In the experience of other authors, medialization of the glenoid up
to 1 cm has be en well tolerated in most patients. Therefor e, ORI F
should be cons ider ed when medialization of the glenohumer al joint
measures more than 15 mm, angular deformity in the semico ronal
plane is more than 25 degrees, or fracture translation exceeds
100% at the lateral border of the scapula ( Fig. 2.2). The
indications for s urgery are even str onger wh en two or mor e of th e
noted sev erity criteria ar e met.
In 1993, Goss descr ibed the superior shoulder suspenso ry c omplex
(SSSC), an osseo ligamen tous ring made up by the acromion,
cor acoid, c lavicle, and glenoid (Fig. 2.3). Goss theorized that if
two disruptions are found in the rin g structures, including their
caps uloligamentous connections, th en the glenohumeral jo int
would be floating, a conditio n that describes discontinuity
between the axial and appendic ular skeleton (Fig. 2.4). Although
this theor y has been challenged by s ome authors, Goss advocated
surgery if two or mor e components of the SSSC are inju red
simultaneously . Fu rther studies have sugges ted that surgery is
indicated when the SSSC complex structures are displac ed and
unstable. Somewhat arbitr arily, if each SSSC injury c auses
displacemen t of more than 1 cm, the floating s houlder co ndition
warr ants surger y in an appropriate c andidate. Most commonly, the
decision-making proc ess leads to surgical fixation of both injuries,
whic h facilitates early rehabilitation.
Isolated fractures to the acromion or coracoid process are less
common. Acromion process and spine fractures occur as a r esult
of direct and concentrated blows to the super ior shoulder region,
whereas cor acoid pr ocess fractur es r esult from tr action injurie s
through the biceps and coracobrachialis. If either an acromion or
cor acoid fr acture is displaced mor e than 10 mm, ORIF may be
indicated in a physiologically young and active patient. If the
acr omion fracture is displaced, then a supr aspinatus -outlet x-ray
should be evaluated for acromial depr ession, which may contribute
to impingeme nt s yndrome, and therefore warrant oper a tive
correction.
Surgery is contr aindicated when an extra-ar ticular scapular
fr actur e is d isplaced less than 10 mm and angulated less than 25
degr ees because the outcomes of nonoperative tr eatment for even
moderately displace d scapula fractur es ar e uniformly good. Active
mobility of the elbow and wris t are en couraged immediately , but a
sling and r est are indicated for 1 0 to 14 days. Scapula fractures
heal r apidly due to the rich blood supply in the shoulder girdle.
Active range of motion can be started by 4 weeks and maximized
quickly . Resistive exercis es are begun by 8 weeks, and return to
fu ll activities is usually possible by 12 weeks.
Classification
Only a few classifications have been de veloped for scapula
fr actur es. The classific ation of Ada and Miller, as well as that of
Hardegger e t al, are anatomically d efined and comprehens ive. The
classification scheme developed by Mayo et al is a reorgan ized
version of the Ideberg classification and is based on a
cons ider ation of the imaging and oper ative findings of 27 intra-
articular glenoid fr actur es. The latter classific ation is helpful in
directing surgical decision making, and it takes into account the
associated scapula body and process fr actur es ( Fig . 2.5). The
Orthopaedic Tr auma Association (OTA) Classification System is an
alphanumeric sys tem in which both intra -articular and e xtra-
articular variants ar e classified ( Fig. 2.6).
Figure 2.1. A. A 2D- CT view, r efor matted in the semicor onal
plane, demo nstrating the displacement between superior and
inferior glenoid fragments. Most superior is the acromioclavicular
jo int (downward arrow), beneath whic h is the humeral head
articulating with the superior gle noid fragment ( r ightward arrow).
Below the articulating head is the s maller glenoid fr agment
(leftward arrow). B. A 3D- CT image for the same patie nt as shown
in (A). It is easier to interpret relationships of key fr agments with
a 3D- CT; however, the 2D-CT is necess ary because volume
aver aging causes three-dimensional recons tructio ns to miss minor
fr actur e line s.

Preoperative Planning
History
As with man y fractu res, indications for s urgery can be less than
distinct. Manual laborers who work with heavy loads and high-
demand athle tes may need surgery with r elative ly few indications.
Also, if the injury occurs in the dominant extremity of an active
individual, or if a patient requir es engagement in significant
overhead activity, then ORI F may be an attr active alternative
tr eatment. However , inju ries more than 3 weeks old , in elderly
patients, and in indiv iduals with mu ltiple confounding co -
morbidities, nonoperative treatment is likely the best choice.
Figure 2.2. A. Medialization: a 3D-CT AP imag e of a scapula
demonstrating medialization of the glenoid relative to the scapula
body as seen bo th at the later al border (r ightward arrow) and at
the super omedial angle at the vertebr al border (two-way arrow).
B. Angulation: a 3D-CT image of the same scapula in a plan e
parallel to the body mimicking the scapula Y x -r ay view. Here the
two lines mar king the lateral borders on t he two fr agme nts create
a 45-degree angle to each other. C. Translation: a 3D-CT image of
the same scapula and in the same plane as B, but imaging has
been taken fr om the medial side instead of from the lateral s ide.
The amount of translation o f the scapula borde rs, as indicated by
the yellow two-way arrow, is easy to appreciate.

Figure 2.3. This illustration depic ts the SSSC, which is an

osseoligamentous ring made u p of the str uctures along the broken
line cir cle in this illustration. Goss theor ized that if two s truc tures
in the ring ar e disrupted, then a floating shoulder le sion, without
osseous or ligamentous continuity betwe en th e axial skeleton and
the forequarter, would exist. A case of a floating shoulder lesion is
illustr ated at the e nd of this chapte r ( Figs. 2.17, 2.18, 2.1 9, 2.20,
2.2 1, 2.22, 2.23, 2.24, 2.25, 2.26).
Physical Examination
The physical examination in the multiply injured patient should
follow the advanced tr auma life support (ATLS) guide lines. In less
ser iously injured patients, inspection of the shoulder in a standing
or sitting patient is helpful (Fig. 2.7). Medial and caudad
displacement of the sho ulder may be obvious and caus e
asymmetry, and it correlates well with the degree of medialization
and depress ion of the glenoid found on radiogr aphs. Because of
pain, patients with displac ed sc apula fr actures, particularly when
associated with multiple rib or clavic le fractures, cannot
voluntar ily forward elev ate or ex ternally ro tate their shoulders to
any significant degr ee.

Figure 2.4. An AP x-ray o f a shoulder that has sustained a double

lesion to the SSSC, which has r esulted in a floating shoulder. Note
the distal clavicle fr actur e (d ownward arrow) and glenoid neck
fr acture ( leftward arrow), which are both substantially displaced.

Figure 2.5. This image dep icts the I deberg classific ation as it was
modified by Mayo et al. The classification is specific for intr a -
articular glenoid fr actur es, and it allows for consideration of the
commonly associate d fr actures of the body and proc esses. It is
helpful for d etermining the surgic al approach; for example, an
Ideberg I, II fr actur e should be addr essed via an anterior
deltopec toral approach, but th e Ide berg IV and V injur y is best
appr oached poster ior ly because the surgeon needs to stabiliz e th e
lateral border.

Ips ilateral, conc omitant, neurovasc ular injuries, while uncommon,

require a c areful assessment of the brachial plexus and distal limb
perfusion. Brachial- plexus injur ies occur in up to 10% of patients
with sc apula fr actures and may at times be subtle. Axillary nerve
sens ation should b e documented; h owe ver, motor assessmen t is
fr equently impossible with displaced fractures. The integrity of the
skin s hould be assessed becaus e abr asio ns are common after the
typical direc t-blow mechanism to the shoulder that causes sc apu la
fr actur es (Fig. 2.8). If the circulation in the upper extremity is
questionable, vascular surgery consultation and an giogr aphy is
strongly recommended.
Figure 2.6. This fig ure shows the AO/OTA clas sific ation for
scapula fractures. Though it provides a sys tematic way of
classification, I have found it to be inadequate in class ify ing 15
out of 40 fracture patterns on which operations were pe rformed
cons ecutively between 1999 and 2002 . Furthermor e, the types of
A, B, and C assigned to sc apula fr actures do not cor respond with
extra-ar ticular , partial ar tic ular , and complete articular v ariants
as they do for other long -bone articulations. The AO/OTA is
currently reviewing and revising this classification scheme to
addr ess these concer ns.

Radiographic Studies
Thre e plain x-ray views should be evaluated before proce eding to
other s tudies, which inc lude anteroposterior (AP), scapula Y, and
axillary views. The AP x -ray of the scapula s hould be taken 35
degr ees off the sagittal plane to correspond with the same angular
position of the sc apula on the thorax. The orthogonal scapula Y
view is 90 degrees to the AP. The axillar y later al is the mos t
difficult to obtain because of patient discomfort, but it is
extremely important.
If an intra-articular glenoid fracture is detected o n any x -ray
view, then a two-d imensional computed tomography (2D-CT) sc an
with 1 mm axial cuts, together with coronal and sagittal
reconstructions, are helpful to delineate articular displacement,
comminution, and frac ture location ( Fig. 2.9). If more than 1 cm
of fr acture displacement is found at the scapula ne ck in any x -r ay
view, then an opposite shoulder AP r adiogr aph and a three -
dimens ional (3D) -CT scan s hould be o btained to better define the
fr actur e displacement. Being mis led with an AP view of the injured
shoulder is common because the glenoid may be significantly
angulated through the later al border so that visualization of the
glenohumeral jo int (clear space ) is impossible. In thes e
circumstances, a 3D - CT sc an is helpful in e valuat ing angular
deformity and medialization of the gleno id.

Surgical Considerations
The scapula is part of a suspensory mechanism of the shoulder,
whic h attaches the upper extremity to the axial skele ton through
the clavic le. Eighteen muscular or igins and ins ertions on the
scap ula aid in providing a stable bas e for g lenohumeral mobility.
The goal of surgery is to restore this stable base as well as the
relationship of the axial and appendicular sk eleton and thus allow
for ear ly rehabilitatio n.

Figure 2.7. This image illustrates why a patient should be

prop erly disrobed for an examination. The dramatic depress ion
and medialization (black lines) of the forequarter can occ ur with
high-energy injur y.
Figure 2.8. Severe scarring resulted from abrasions that occu rred
during impact of the patients forequarter . The injur y mechanism
was caused by a motorcycle cras h, and one can imagine the
shoulder hitting the gr avel embankme nt at the roadside. To
decr ease the chance of infection, this patie nts oper ation was
delayed 2.5 weeks until the skin r e-epithelialized.
Figure 2.9. This 2D- CT image illustrates the importance o f s uch a
study for the intr a-artic ular var iants. The surgeon can appreciate
the extensiv e comminution of the joint and that best access and
buttress plating will re quire a poster ior appr oach. The top arrow
depicts the ante rior glenoid.
Figure 2.10. A. A patient in the beach-chair positio n has an
incis ion to address a clavicle and ips ilater al glenoid fracture (a
common pattern). The isolated, anterior, glenoid frac tures and
Ideberg II frac tures ar e best approached fr om this approach. In
normal circumstances, a deltopectoral incision runs from the
cor acoid toward the deltoid insertio n , but in this case, it was
curved pr oximally and medially ov er the anterior clav icle. B. T he
same patie nt shown in (A) after fixatio n of the clavic le fracture
with a 2.7- mm dynamic compression plate. The orientation is the
same in ( A) and (C) with the axilla to the left. C. The ex posure of
the glenoid fr acture is shown. The sutures are tagging the
infraspinatus, and a Fakuda retractor is ins ide the joint retr acting
the humeral head. One can see the inter val developed between
the deltoid and the infraspinatus as landmarked by the cephalic
vein ( yellow ar row).

Although frac ture -specific exceptions exis t, two surgical

appr oaches are used in the v ast majority of patients with
displaced sc apula fr actur es: the anter ior deltopectoral and
posterior Judet approaches. Patient positioning and draping,
implant selection, cosmesis, and su rgic al risks are all affected by
the approach.
Isolated, anter ior, glenoid fractures, as well as the assoc iated
tr ansverse fracture extending in a coronal plane from the
superomedial angle or scapula vertebral border thr ough the
glenoid, ar e bes t treated through a deltopec toral approach. I n
these injur ies, the superior glenoid is de tached with the cor acoid ,
as in the Mayo Type II fr actur e. In most other fractures involv ing
the scapula (scapu la neck or body fr acture with or without glenoid
involve ment), a pos terior approach is pr efer red. Rarely, combined
anterio r and posterior approaches ar e necessary; for e xample,
the y may be required in the case of concomitant, anterior articul ar
fr actur es combined with scapula neck and body variants . The
clavic le or acromioc lavicular joint may require a separate
appr oach for fixation when indicated.
Viewed fr om the anter ior perspective, th e cor acoid process is a
curved osseous projection off th e anter ior neck. It is the origin for
five anatomic structures and an important surgical landmark. The
glenoid proc ess, under the acromion, contains the pear -s haped
glenoid fossa, wh ich is appro ximately 39 mm in a super ior -inferior
direction and 29 mm in a n anterior-pos terior direction (in the
lowe r half).
Viewed fr om posterior, the scapula is a tr iang ular flat bone with a
thin translucent body surrounded by thick borders that are well
developed as points of muscular orig ins and inser tions. The later al
bord er of the scapula sweeps up from the infer ior angle, forming
the thickest condensation of bone, which ends in the neck of the
glenoid proc ess. The scapula borders and the glenoid neck pro vide
the best bone for reduction and fixation with plates and screws.

Surgery
Anterior Approach
The patient is placed in a beach-chair pos ition with an ar m board
attached to support the extremity. Positio ning an x -ray plate
behind the shoulder during the setup will help to obtain an
intraoperative film following reduction and fix ation. A small towel
roll under the ips ilater al shoulder h elps thr ust the shoulder
fo rward. Dir ect visualization of the joint will minimize the need for
intraoperative fluoroscopy; however, the surgeon should evaluate
a single, AP, shoulder x-ray after fixation.
An incision is made from the palpable co racoid to a point just
lateral to the axillar y fold, commonly named the deltopectoral
groo ve ( Fig. 2.10). This incision is deepened to the deltopectoral
interval whe re the cephalic vein is ide ntifie d and retr acted
laterally with the deltoid and pro tected in the flap. The interval
between the deltoid and pectoralis major is developed d own to the
clavip ector al fasc ia, whic h covers the coracobrachialis and
subscapularis tendon. This fascia is incis ed and retractors are
placed superiorly and inferiorly. The humerus shou ld be externally
rotated to create tension on the subscapular is tendon and to
improve visualization of the le sser tuber osity. With the humerus in
a neutral position, the subscapularis tendon should be c ut 1 cm
fr om its inser tio n for later repair . F or an accurate closure, the
surgeon should dissect the s ubscapular is fr om the capsule as a
distinct laye r; this appr oach is particularly he lpful for an an terior
glenoid fr actur e because the surgeon needs to wor k on both sides
(intr a-articular and extra- articular) of the capsu le. The anter ior ,
circumflex, humeral vessels are at the inferior margin of the
subsc apularis .

Below this leash of vessels is the axillary nerve. Stay sutures are
placed o n each side of the subscapularis muscle to ass ist in
closure and to av oid damage to the axillary nerve.

Figure 2.11. This image demonstrates appr opriate positioning of

the patient when the s urgeon is performing a posterior approach
to the scapula. Soft -positioning wedges allow for a supportive
working s urface while protecting the downside arm. The body,
positioned on a beanbag, should be allowed to flop fo rward. The
entire arm should be pr epped free to allow for manipulatio n and
motion of th e glenohumeral jo int during the procedure.

The joint capsule is c ut longitudinally just off the palpable glenoid

rim and tagged, or the surgeon can work through the fracture to
wash out the joint (see F ig. 2.1 0C) and then obtain an indir ect
articular reduction by working extra-articularly with the fragment.
Fracture red uction can be improved with a dental pick or small
bone hook, and provision al fixation is obtained with Kirsch ner (K)
wir es. Depending on the siz e of the fr agment or the degr ee of
comminution, implant (scr ew) ch oices may r ange from 2.0 to 3.5
mm. Most fr equently, a mini buttr ess plate on the anter ior -inferior
edge is appropriate.
Closure of the capsule and subsc apular is is done with no. 2
braided suture. The subcutaneo us tiss ue is approximated with no.
2-0 suture. The skin is closed with a monofilament, subcuticular,
absorbable suture.

Posterior Approach
Cerv ical and thor acic spine injuries ar e associated with high -
energy sc apula fr actur es in 10% to 20% of cases. Treatment
requ ires car eful intr aoperative patient position. Whenev er
poss ible, the injured verte bral segments should be internally
stabiliz ed firs t to insure protection of the s pinal cord. However, if
nonoper ative spine management is chosen, halo traction is
preferable to a cervical collar in te r ms of patient safety.
The patient is positioned in the later al decubitus position, flo pping
slightly forward on a be anbag with an axillary roll well placed. The
affected upper extremity sho uld be pos itioned on an arm board or
Mayo s tand to support the extremity in a 90-degr ee forward-
flexed and s lightly abduc ted position (Fig. 2.11). T he entire
shoulder, chest wall, an d neck should be prepped and draped to
allow for manipulation of th e shoulder. The planned incision is
drawn on the sk in with a sterile marker. It is made by following
the prominent posterolateral ac romion and extending medially to
the super omedial angle of the sc apula, and then the in cision turns
caudad along the vertebr al border .

Figure 2.12. The patient is allowed to flo p forward, and the

scapula landmarks ar e detailed along with the fr actur e pattern.
The healed abr asion is directly over the fractured posterior spine
of the acromion. The incision depicted by the black line is slightly
caudad to the acromial spine and lateral to the ver tebral border of
the scapula.
Shuc king the shoulder with one hand, as if to protract and
retract the shoulder to create scapulothor acic excursion, the
surgeon feels the bony land mar ks with h is/her opposite hand. A
Jude t posterior inc ision is planned along these landmarks. The
incis ion should be 1 cm caudad to the acromial spine and 1 cm
lateral to the vertebr al border , which allows closur e over a plate
and improves lateral retraction of the flap during surgery ( Fig.
2.1 2).
The incision is deepened onto the bony r idge of the acromial
spine, splitting the interval be tween trapez ius and de lto id
insertions. The in cision curves distally around the superomedial
angle and down the vertebr al border . For access to the lateral
bord er of the scapula, the incision must be gener ous enough to
allow for flap mobilization should the surgeon requ ire a more
extensile approach. Pr operly ex ecuted, the fascial inc ision along
the acromial spine and medial border should prov ide a cuff of
tissue that is sutured back to its bony origin at the end o f t he
procedure.
The depth of the diss ection depends on the need for limited or
comple te e xposure of the posterior s capula; this should be
determined in the preoper ative plan. Limited windows can be used
to access fractures at the lateral border, acromial spi ne, and
vertebral b order (Fig. 2.13). An extensive appro ach can be
exec uted to expose the e ntire posterior scapula by elevating all
musculature off the infr aspinatus foss a (F ig. 2.1 4). The ex tensile
appr oach pr eser ves the entir e subscapularis -muscular slee ve on
the ante rior surfac e of the scap ula, and of course , the elevated
flap respects vascular planes becau se the surgeon rais es it on its
neur ovascular pedic le (supr ascapular arte ry and nerve) (see Fig.
2.14 B). I find it most helpful to utilize an extensile approach for
fr actur es over a week old by elevating the deltoid, infr aspinatus,
and teres minor in a single flap. Also, for complex patte rns, the
extensiv e appr oach is useful when ther e ar e more than thre e exit
points around the ring of the scapula. The extens ile exposure
allows the surgeon adequate co ntrol of the fracture at multiple
points to effect the reduction and mobilize the fracture by
breaking up intervening callus . I t will no t allo w for exposure o f
the gle noid due to the large flap, which cannot be retr acted
sufficiently lateral for joint exposure .

Figure 2.13. A. An intr aoperative photo of the limite d windows

technique shows that the subc utaneous tissue is elevated with the
deltoid muscle (behind the rake retractor) off the ro tator cuff. The
window depicted by the upward yellow arrow is the superomedial
angle sh own after the infraspinatus has been diss ected fr om the
posterior scapula; the procedur e cr eates an axis for fracture
reduction at th is common loc ation (B). The other two retractors
are in the in terval b etween the infraspinatus and teres minor , and
this interval is us ed to expose the lateral border. B. A 3D- CT scan
shows a common fracture pattern, which le nds itse lf to the
exposure shown in (A). The exposur e allows for reduction and
fixation at two key points: the glenoid neck and the superomedial
angle. Both sites will be pla ted.

If lim ited windows ar e des ired, tactically created intervals around

the scapu la perimeter can be used to access spec ific fracture
locations. The musc le plane entered at the ac romial border is
between the tr apezius and the deltoid, which lies at the infer ior
margin of the spine and is elevated to uncover the rotator cuff
muscles. The deltoid should be dissected off the muscular orig in of
the infraspinatus and tagg ed through its fascial cuff for
reattac hment th rough bone tunnels later. A Key or Cobb elev ator
can be us ed to elevate the infrasp inatus and ter es minor from the
posterior fossa. At th e vertebral border of the scapula, the
intermuscular plane is between the infr aspinatus teres minor and
the rhomboids.
Figure 2.14. A. The poster ior Jude t approach results in a flap
fr om the acro mial spin e and vertebral borders. This e xtensile
exposure will allo w for visualization of the entire infraspinatus
fo ssa (the poster ior sc apula) from the vertebral bo rder to the
lateral border as shown in (B). The surgeons fingers are
refle cting th e entire flap en mass, and a Cobb ele vator is used to
dissect th e flap off the flat, posterior, scapular sur face. This
appr oach is best reser ved for cases in whic h sur gery has been
delayed for mor e than 10 days from the time of injury or for cases
in whic h severe comminu tion is present with sever al displaced -
fr actur e line s exiting multiple scapular borders . It cannot be used
when the surgeon desires intra-ar ticular inspection. B. Image of
same patient shown in (A) after flap elevation and retraction. This
patient has a fracture variant that is char acte rized by a broken
glenoid neck from the lateral border up into the s upraglenoid
notch. Extension of another fr acture line into the body is appar ent
in this image, but the severe medialization and antev ersion of the
glenoid articular surface is not apparent. Note the threat of a
retractor by virtue of tr action on th e supr ascapular neurovascular
bundle ex iting from just below the acromion before it enters the
infraspinatus muscle (black arrow).
Figure 2.15. A. Intraoper ative photo demonstrating the exposure
after a capsulotomy. This image was taken after the articu lar
reduction of the glenoid , which had been in four major fragments.
The rightward broken arrow points to the deltoid muscle taken off
the acromial spine. The sutures are tagg ing and retrac ting th e
jo int capsu le. The leftward arrow points to a fr agme nt of displaced
lateral border (glenoid neck). The upward arrow points to the
infraspinatus, which has been tenotomized for better joint
exposure and is on its neurovascular pedicle; the suprascapular
artery and nerve are d epicted by the white arrow. B. T his image is
of the same patien t dep icted in (A) after undergoing
reconstruction of the later al border and with the joint capsule
retracted to the left over th e joint. Th e downward arro w poin ts to
the lateral border; th e upward arrow points to the infr aspinatus;
the vess el loop is on the suprasc apular nerve and artery; the
rightward arrow points to the deltoid.

The most impo rtant window in an intr a-ar ticular fracture is

between the in fraspinatus and teres minor because it allows
access to the later al border of the scap ula and glenohumeral joint.
Iden tific ation of the correct interval is import ant to avoid
dener vation of the infr aspinatus or injury to the axillary nerv e and
posterior humer al-circumfle x artery in the quadrangular spac e.
Once this important interval is developed, the lateral border of the
scapula is exposed to allow r eduction and cor rection of glen oid
version or medialization. I f the glenoid ar ticular sur face must be
assessed dir ectly, then a transverse c apsulotomy can be made so
a retr actor can be placed on the anterior edge of the glenoid and
the humeral head can be r etrac ted (Fig. 2 .15).
Aids for frac ture reduc tio n at the lateral border of the scapula ar e
impor tant becaus e specific retractors and reduction tools have not
been specifically designed for the scapula. At least two, small,
pointed, bone reduc tio n clamps and two, 4 -mm, Schantz pins with
a small exte rnal fixator s et, as well as a pair of T -handle ch ucks,
are helpful. Often a 2.7-mm, dynamic, compression p late
straddling the lateral bor der frac ture can be helpful for reduction
(as well as definitive fixatio n) because it can be applie d per fectly
straight on this border . Po inted reduction tenacula ar e frequently
inadequate due to interference with the flap, so a Schantz pin in
the prox imal and distal segments can be placed in the proper
orientation with a small external fixator to r educe the lateral
bord er for subsequent plating. If the reduction is still not stable, a
prov isional 2.0-mm plate and screws placed s lightly more medial
can keep the lateral border aligned. Furthermore, a c lamp c an be
placed at an associated fracture at the acromial or vertebr al
bord er to help o ff- load str esses on the late ral border while the
reduction is maintained.
Figure 2.16. A. The superomedial angle postfixation with a 2.7 -
mm reconstruc tion plate. This implant is chos en for its malleability
over a difficult contour. This is the same patient depicted in Figure
2.1 3. A 2.7- mm dynamic-compressio n plate was chos en for the
lateral border becaus e it is relatively strong and requ ires no
contour to lay str aight along the glenoid neck . B. An immediate
postoperative AP c hest x-ray that corresponds to the patie nt in
Figure 2.16A . A c hest x-ray is helpful to appreciate that the
glenoid has been properly o riented r elativ e to the opposite side.

I favor 2.7-mm plates along the scapula borders, which ar e

sufficiently strong and are not associated with breakage. I n
addition, they have a lo wer profile than 3.5 plates, are easier to
contour, and allow for greater screw options . A 2.7 -mm dynamic-
compression plate is used on the lateral bo rder where stresses are
greatest, and 2.7-mm r econstruction plates are used for the
acr omial and v erteb ral borde rs of the scapula because they make
contoured fitting, particu larly around the superomedial angle,
much eas ier (Fig. 2.16). I have found that two pediatr ic Kocher
clamps are useful for this maneuver. Longer plates with more
scr ews sho uld be used at the acromial and v ertebral borders
becaus e eac h scr ew is typic ally 8 to 10 mm.

Figure 2.17. A. AP shoulder x-ray taken at the patients fir st

emergency ro om visit. This image r eveals a minimally displaced
clavic le fractur e with a butterfly fragment, a scapu la body fracture
that ex its the lateral border at the gleno id neck, and rib fr actur es
of at le ast levels 2 through 5. Minimal gle noid medialization is
fo und. B. An axillary v iew of the in jur ed shoulder demonstrating
no acromial n or coracoid process fr actur es, no intr a -artic ular
extensio n of the fr acture, and no subluxation of the glenohumeral
jo int.

In the case of a pos terior gleno id frac ture or an intr a-articular

glenoid fr actur e with glenoid neck involve ment and minimal
displacement or involv ement of the acromial spine and vertebral
border, a direct pos terior approach to th e scapular neck or joi nt
can be employed. In these cases , the p athology c an be
dete rmined and the des ired reduction and fixation can be
acco mplished through the interval between the ter es minor and
the infraspinatus muscles.
Occas ionally, in patien ts with substantial articular comminution,
greater exposur e of the joint can be gained with an infraspinatus
tenotomy where 1 c m of cuff insertion is left at the greater
tuberosity for repair. This allows th e slender musculo tendinous
portion of the infraspinatus to be retr acted off the s uperior
glenoid region for better access to the gleno humer al joint. It is
repaired with two heavy-braided no. 2 sutur es at c losure. Exter nal
rotation against resis tance should be protected for 6 postoperative
weeks in the case of this r epair .
Before wound closure, the surgeon must insure that all extr insic
adhes ions and shoulder stiffness ar e elimin ated prior to waking
the patient; this is espec ially important in cases where surge ry
has been delayed. Th is manipulation at the end of the procedur e
is one reas on the entire extremity is preoperatively p repped. To
insure that the repair is secure and early rehabilitation is possible,
the wound is closed over a suction drain under the flap through
use of braided no . 2 nonabsorbable sutures plac ed through several
drill ho les at the acromion spine and vertebral border. The res t of
the musculofasc ial closure can be p erfor med with a no. 1
absorbable, braid ed suture. For cos mesis, the skin is c lose d with a
subcuticular absorbable stitch.

Postoperative Management
Rehabilitation for the anterior and posterior approaches is bas ed
on an identical principle: stable fix ation to withstand physiologic
stresses of ear ly motion to minimize sho ulder stiffness . After
surgery, full, passiv e range of motion should be instituted dur ing
the first week. Continuous pass ive motion (CPM) is not commonly
used unle ss the patie nt c annot cooperate with rehabilitation
adequately or als o has an ipsilateral pr oximal humerus or elbow
injury. For patien ts with profound br achial plexop athy, CPM may
be used for extended per iods.
The goal during the fir st 4 postoperative weeks is to regain and
maintain shoulder motion. Activities o f daily living ar e
encour aged, but no lifting, pushing, pulling, or carrying is allowe d
fo r 4 weeks. The use of pulle ys, push-pull sticks in the opposite
extremity, and supine assisted motion is helpful. A regional
anesthetic block with an indwelling interscalene c atheter for the
first 48 to 72 postoperative hours is an excellent adjunctive
method to promote early sho ulder motion. Ipsilateral elbow, wr ist,
and hand ex ercises including 3- to 5-lb weights (on a suppor ted
elbow) ar e encouraged. These exercises will pr event muscular
atrophy and promote r eduction of limb edema.
Patients ar e followed at 2, 6, and 12 week intervals
postoperatively, and an AP, scapula Y, and axillary radiographs
are obtained. Follo w- up at 6 months and 1 ye ar is appropr iate to
document return of maximu m function. Patients with associated
brachial plexopathy should be followed by an experienced
spec ialist bec ause some patients may ben efit from br achial plexus
exploration, tendon transfers, or neur al graftin g. For the patient
with a dense or irr ecover able plexus lesion (flail shoulder) an
arthrodes is should be str ongly considered.
For anterior approaches to the shoulder, motion should be
protected against external rotation past neutral. Likewise, motion
against resistance should be avoided for a full 6 weeks to allow
healing of the subscapular is, which had been repaired during
exposure o f the glenohumeral joint. Afte r pos terior approaches in
whic h the infraspinatus and teres minor have be en mobiliz ed from
the ir origins and in wh ich the deltoid is tak en off the acromial
spine, these muscles must be prote cted for 6 weeks. At 6 weeks,
patients begin a weigh t program, begin ning with 3 to 5 lbs and
increas ing as the patients symptoms allow.
On occasion, shoulder stiffne ss develops and does not improve
with therapy. This is mor e common in patients with brachial
plexus injuries, a head injury, halo-ves t protec tion fo r sp ine
injury, or complex associated fractures of th e ipsilater al
extremity. I n these patients, a manipulation under anesthesia to
ju mp-s tart sho ulder motion can be helpful. At 3 months after
surgery, res trictions can usually be lifted, and the pati ent can
res ume a s trength and endurance pr ogram until fu lly c onditioned.

Complications
Poor outcomes are often the r esult of associated injuries to the
ipsilater al extr emity, par ticularly when the br achial plexus is
involved. Other complications include no nunion, malu nion,
degenerative glenohumeral joint disease, and instability. Shoulder
instability and r esultant pain and dysfunction can arise from
severe angular deformity of the glenoid neck. These complications
are far less likely to occur with anatomic restoration of the
scapula and its articular surface.
Extensile, posterior, surgical appr oaches in crease the risk o f
supr ascapular nerve injury. This leads to wasting of the ro tator
cuff musc ulature, which may never r ecover . T he surgeon must
tak e intraoperative care to avoid excessiv e tr action on the
neur ovascular bundle as the infraspinatus flap is retr acted at the
lateral border.
The most common complic ation is shoulder stiffness . Early
aggr essive r ehabilitation, particularly in those patients with
ipsilater al injuries, is recommended. If at the 6 we ek follow -up,
motion is poor, manipulation of the patients shoulder under
anesthesia combined with shoulder ar thr oscopy is very useful in
res toring shoulder motion.

Illustrative Case for Technique

A 42 -year-old man had fallen 10 fe et fro m a ladder wh ile at work.
He was evaluated at a hospital emergency room and subsequently
admitted with severe left -shoulder pain and difficulty breathing.
He was diagnosed with a broken scapula, clavicle, and multiple
fr actur ed left r ibs (Fig. 2.17). After 2 days of pain contro l, the
patient was sent home with a sling. He had been evalu ated by an
orthopedic s urgeon in the hospital who exp lained to the patient
that his broken bones would heal with out additional treatment and
that his prognosis for normal recovery was good .
Figure 2.18. A. This AP x-ray image of the shoulder reveals
substantial displac ement of all fr actured bones, which had not
been evident in the initial films of the injury. T he clavicle is
medialized well over 1 cm; the glenoid h as medialized markedly
and has a caudad- facing attitude; per haps most impr essive, the
marked displace ment of all the rib fr actur es indicates that the
entire for equarter has medialized en mass. B. This is a scapula Y
radiograph taken 3 weeks afte r the injur y showing substantial
tr anslation of th e lateral b order. This border is displaced by
appr oximately 3 cm, and significant angular de formity is evident.
C. A compar ison vie w of the opposite shoulder was used as a
template to evaluate the injur ed shoulder (A). Side by side, these
two images highlig ht the amount of scap ular displac ement, wh ich
is striking, as well as the coronal plan e relationship to the chest
wall.

After 3 weeks of significant pain and with no ability to move his

shoulder, the patient pr esented in my office with a workers
compensation agent who had suggested that he obtain a second
opinion. Physical e xamination revealed that the left s houlder was
markedly depressed and medialized. The neurovascular exam at
the level of the left hand re vealed no abnormality. When the
patient was asked to try and move his shoulder, the patient
simply r eplied, I t wont move even when I want it to . Attempts
at active range of motion were indeed futile; although he was
tak en passively to 30 degre es of forward flexio n before stiffness
could not be overcome. The pain was substantial. His neck was
not tend er, and his cervical motion was full, but he experienced
spas ms in the trapezius muscle.
Figure 2.19. A. This is a 3D-CT reconstructed image of the
scapula in the plane most perpendicular to the scapula body. This
rotational image helps one to apprec iate the medialization and
angular deformity of the glenoid relativ e to the distal scapula-
body fr agment. The displacement of the scapula body at the
superomedial angle c an also be see n as a medialized, super ior ,
scapula segment (attached to the g lenoid). Comminution in the
infraspinatus fossa is marked. The clavicu lar medializ ation is also
confir med in this image. B. A 3D-CT image r epresen ting the plane
most parallel to the body of the scapula. In this view, semicoronal
angular deformity can b e measured off the pr oximal and distal
scapula borders (35 degr ees in this case). Als o appreciated is the
severe an teversion of the gleno id.

New x-rays demonstr ated significant displaceme nt of the sc apula

(Fig. 2.18); this finding was differe nt than that seen on the
original film (F ig. 2.17 ). A CT scan was obtained (Fig. 2.19), and
the patient le arned the risks and benefits of surgery. Two days
later the patient was taken to the operating r oom for surgic al
fixation of the scapula and clavicle. The relative indic ations for
surgery wer e multiple and included medial displacement of more
than 15 mm, angular deformity of gr eater than 25 degrees,
grotesque clinical defo rmity, seven broken bo nes in the
for equarter, and a floating shoulder (double lesion of the SSSC).
The patient was placed in the lateral decub itus position, flopping
slightly forward, and a Judet pos terior approach was used to
mobiliz e the entire muscle flap. The callus was cleaned from the
fr actur e line s so that the reduction could be visualized (Fig. 2.20).
Schantz pin joysticks (with T-handled ch ucks) were used in the
glenoid neck and later al border to achieve the reduction. The
lateral border was plate d first followed by plating of the
superomedial angle ( Fig. 2.21).

Figure 2.20. This intr aoperative photograph was taken from the
vantage point of the surgeo n, who stood on the poster ior side of
the patient. Behind the retr actor is the muscle flap containing the
deltoid, infraspinatus , and teres minor. Fracture callus has been
removed and s aved to pack into fracture lines before wound
closure. The open approac h, in which the entire flap is elevate d,
was used because 3.5 weeks had passed since the time of this
patients injury; thus , this expos ure was necessary to mobilize
callus , and reduction aids we re needed to overcome a static
deformity.

The patient was r e-prepp ed and draped after an intraoperative

shoulder x-r ay revealed marked clavicle-fracture disp lacement.
The clav icle was subsequently fixed with a tension band plate
along the sup erio r border (Figs. 2.22, 2.23, 2.24).
Prior to awaking the patient fr om anesthesia, the surgeon
manipulated the shoulder until full motion was r estor ed. This
manipulation also reliev es the intrinsic and extrins ic contractures
that form in a month. Formal postoperative x -r ays wer e taken in
the recovery room ( Fig. 2.25). The patie nt worked with physic al
therapy immediate ly on full and aggressive , passiv e, r ange -of-
motion exercises. He r emarked (as most patients do) that h is
shoulder felt completely different and restored the day after
surgery and that he was able to mov e it for the first time since his
injury. At 1 month, he was advanced to full, active , r ange -of-
motion activity with light weights (3 to 5 lb) beginning at 6
weeks. By 3 months after surger y, he had returned to wor k, had
no pain, and stated that he had full motio n.
Patients ar e followed in the office at 2, 6, 12, 24, and 48
postoperative weeks. This patients 6 month x- ray is shown in
Figure 2.26. At 6 months , his shoulder was asymptomatic. His
motion was within at least 90% of the mo tio n of opposite shoulder
in all directions, and h e complained of no defic it in strength. His
Dis abilit ies of the Arm, Shoulder , and Hand (DASH) exam scor e
was 1 6 (scale 1100; normative-scale func tional score = 10.1).

Figure 2.21. This intr aoperative photograph shows the fixatio n

cons truc t us ing a nine-hole 2.7-mm dynamic compress ion plate
(Synthes, Paoli, PA) for the later al border , an eight-ho le 2.7-mm
reconstruction plate (Synthes) contoured around the superomedial
angle of the sc apula, and a s even-hole locking, one-third, tubular
plate with loc king screws (Synthes) deployed in the proximal and
distal body fr agme nts. The loc king plate off-loads the other two
nonlocking plates that hav e short screws: 8 to 10 mm on the
vertebral b order and 1 2 to 16 mm on the acromial and lateral
bord ers. Dir ectly b ehind and to the r ight of the Isr ael retractor is
the suprascapular neurovascular bundle as it exits from bene ath
the acromion. Great car e must be ex ercised in retr acting this flap
to preserve the functional integrity of these s tructures .

Figure 2.22. The surgical exposure of the clav icle fracture after it
has been cleaned. The butterfly fr agme nt is not in view; it had
been reduc ed and fixed with 2.7-mm lag screws. The surgeon can
access this site from eith er the anterior or poster ior position. I
have chosen to work from the posterior position (same as for the
scapula) and thus the easiest access was to the s uperior border of
the clavic le, which is more convenient in the patient who r equir es
scapula surgery in the floppy lateral o r forward position. The
scapula and c lavicle procedures can usually be don e with a sin gle
prep and drape, but in this case, the procedures were done
separ ately.
Figure 2.23. A pointed, bone, reductio n forceps was us ed to
reduce the fracture. The photogr aph is taken from the v antage
point of the anesthes iologist.
Figure 2.24. An eight -hole, precontoured, titanium, nonlocking
plate (Acumed, Hillsboro, OR) was used for the clavic le
stabiliz ation.
Figure 2.25. A. Postoperative AP x-ray showing the reco nstructed
scapula and c lavicle in pro per o rien tation. Note the gap at the
lateral border, which is often difficult to de fine and reduce in the
comminuted var iants that undergo delayed surgery. B. A
postoperative scapu la-Y x-r ay image demonstrating proper
alignment and orie ntation o f the later al border . C. A
postoperative , ax illar y, x-ray vie w can be used to ins ure that all
scr ews are in extra-articular p osition.
Figure 2.26. An x-ray image taken 6 months after the operatio n
showing co mplete consolidatio n of fr actur e lines .

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