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SCAPULA FRACTURE
DR JASEEM SHAMSUDEEN
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EPIDEMIOLOGY
Relatively uncommon injury
Only 3% to 5% of all soul!er fractures an!"#5% to $% of all fractures#
e mean a&e of 'atients 35 to (5 years
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ANATOMY
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ANATOMY
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)lat* trian&ular +one lin,s te u''er e-tremity
to te a-ial s,eleton# .rotection from im'act is 'rovi!e! +y te
lar&e surroun!in& muscle mass as /ell as
te mo+ility of te sca'ula on te cest /all*
furter ai!in& in force !issi'ation
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MECHANISM OF INJURY
0ommon cause of injury RA
1n!irect injury occurs trou& a-ial loa!in& on te outstretce!arm 2sca'ular nec,* &lenoi!* intraarticular fracture#
Direct trauma* often i& ener&y* occurs from a +lo/ or fall2sca'ula +o!y fracture or trou& !irect trauma to te 'oint of
te soul!er 2acromion* coracoi! fracture#
Soul!er !islocation may cause a &lenoi! fracture#
Muscles or li&aments may cause an avulsion fracture
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CLINICAL EVALUATION
A full trauma evaluation
Neurovascular assessment# 0om'artment syn!rome overlyin& te sca'ula is
uncommon
0omolli si&n is trian&ular s/ellin& of te 'osterior
tora- overlyin& te sca'ula an! is su&&estive ofematoma resultin& in increase! com'artment
'ressures#
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RADIOGRAPHIC EVALUATION
rauma series of te soul!er* Antero'osterior vie/*
A-illary vie/* Sca'ular89 vie/ 2true sca'ular lateral: e a-illary vie/ may +e use! to !elineate acromial an! &lenoi! rim
fractures furter# A (58!e&ree ce'alic tilt 2Stry,er notc ra!io&ra' is el'ful to i!entify
coracoi! fractures
An acromial fracture soul! not +e confuse! /it an os acromiale*/ic is a roun!e!* unfuse! a'o'ysis an! is 'resent in a''ro-imately3% of te 'o'ulation# ;en 'resent* it is +ilateral in 7"% of cases#
Glenoi !"#o#lasia* or sca'ular nec, !ys'lasia* is an unusuala+normality tat may resem+le &lenoi! im'action an! may +eassociate! /it umeral ea! or acromial a+normalities# 1t as a+eni&n course an! is usually note! inci!entally#
0
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CLASSIFICATION
Anatomic 0lassification 2>!rav,ovic an! Damolt
2A Sca'ula +o!y
2?*0 @lenoi!
2D Sca'ula nec,
2E Acromion2) Sca'ula s'ine
2@ 0oracoi!#
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ANATOMICAL CLASSIFICATION
T"#e I$Sca'ula +o!y
T"#e II$ A'o'yseal fractures* inclu!in& teacromion an! coracoi!
T"#e III$)ractures of te su'erolateral an&le*
inclu!in& te sca'ular nec, an! &lenoi!
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Ie%er& Classi'ica(ion o' In(raar(ic)lar
Glenoi Frac()res
y'e 14Avulsion fracture of te anterior mar&in y'e 11A4ransverse fracture trou& te &lenoi!
fossa e-itin& inferiorly y'e 11?4O+liue fracture trou& te &lenoi! fossa
e-itin& inferiorly y'e 1114O+liue fracture trou& te &lenoi! e-itin&
su'eriorly an! often associate! /it anacromioclavicular joint injuryy'e 1B4ransverse fracture e-itin& trou& te me!ial
+or!er of te sca'ula y'e B40om+ination of a ty'e 11 an! ty'e 1B 'attern y'e B140omminute! &lenoi! fracture
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Classi'ica(ion o' Acromial Frac()res
y'e 14Minimally !is'lace!
y'e 114Dis'lace! +ut !oes not re!uce tesu+acromial s'ace
y'e 1114Dis'lace! /it narro/in& of te
su+acromial s'ace
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Classi'ica(ion o' Coracoi Frac()res
y'e 14.ro-imal to te coracoclavicular
li&ament# y'e 114Distal to te coracoclavicular li&ament
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TREATMENT
Nono'erative
Most sca'ula fractures are amena+le tonono'erative treatment* consistin& of slin&
use an! early ran&e of soul!er motion#
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OPERATIVE INDICATIONS
$# Dis'lace! intraarticular &lenoi! fractures involvin&&reater tan 5% of te articular surface#
# Sca'ular nec, fractures /it &reater tan ("8!e&reean&ulation or $8cm me!ial translation#
3# Sca'ular nec, fractures /it an associate!!is'lace! clavicle fracture#
(# )ractures of te acromion tat im'in&e on te
su+acromial s'ace#5# )ractures of te coracoi! 'rocess tat result in a
functional acromioclavicular se'aration#
7# 0omminute! fractures of te sca'ular s'ine#
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Glenoi 'rac()res *Ie%er&
classi'ica(ion+$
T"#e I$)ractures involvin& &reater tan one fourt of te&lenoi! fossa tat result in insta+ility may +e amena+le to o'en
re!uction an! internal fi-ation /it scre/ fi-ation usin& ananterior or 'osterior a''roac# T"#e II$1nferior su+lu-ation of te umeral ea! may result*
necessitatin& o'en re!uction* es'ecially /en associate! /ita &reater tan 58mm articular ste'8off# An anterior a''roacty'ically 'rovi!es a!euate e-'osure
#T"#e III$Re!uction is often !ifficult an! may reuire su'eriore-'osure for su'erior to inferior scre/ 'lacement* 'artial8tic,ness clavicle removal* or !istal clavicle resection ina!!ition to anterior e-'osure for re!uction# A!!itionalsta+iliCation of te su'erior sus'ensory soul!er com'le-2SSS0 may +e necessary
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Sca'ular +o!y fractures4 Nono'erative O'en re!uction may +e consi!ere! /en neurovascular
com'romise is 'resent an! e-'loration is reuire!# @lenoi! nec, fractures4 ese &enerally may +e treate!
sym'tomatically* /it early ran&e8of8motion e-ercises# 1f te injury is accom'anie! +y a !is'lace! clavicle fracture* an
unsta+le se&ment may e-ist* inclu!in& te &lenoi!* acromion*an! lateral clavicle# 1nternal fi-ation of te clavicular fracture&enerally results in a!euate sta+iliCation for ealin& of te&lenoi! fracture#
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Acromion fractures4 Os acromiale must first +e rule!out* as /ell as concomitant rotator cuff injuries#
Dis'lace! acromion fractures may +e sta+iliCe! +y!orsal tension +an!in&* if !is'lacement causessu+acromial im'in&ement#
0oracoi! fractures4 0om'lete tir!8!e&reeacromioclavicular se'aration accom'anie! +y asi&nificantly !is'lace! coracoi! fracture is anin!ication for o'en re!uction an! internal fi-ation of+ot injuries#
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Floa(in& s!o)ler$
Dou+le !isru'tions of te su'erior soul!er
sus'ensory com'le- 2SSS0#
e SSS0 is a +one8soft tissue rin& tat inclu!es te&lenoi! 'rocess* coracoi! 'rocess* coracoclavicular
li&aments* !istal clavicle* acromioclavicular joint* an!
acromial 'rocess#
e su'erior strut is te mi!!le tir! clavicle#e inferior strut is te lateral sca'ular +o!y an!
s'ine#
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raumatic !isru'tion of t/o or more
com'onents of te SSS0 usually secon!aryto i&8ener&y injury is freuently !escri+e!
as a floatin& soul!er#
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Floa(in& s!o)ler in,)r" #a((erns
P)rel" osseo)s in,)ries4 y'e 1A4 sca'ular nec, fracture com+ine! /it a coracoi! +ase
fracture# y'e 1?4 sca'ular nec, fracture com+ine! /it a clavicle fracture an!
sca'ular s'ine or acromion fracture#
P)rel" li&amen(o)s in,)r" y'e 114 sca'ular nec, fracture com+ine! /it coracoacromial an!
coracoclavicular li&ament !isru'tion#
Com%ine osseoli&amen(o)s in,)ries
y'e 111A4 sca'ular nec, fracture com+ine! /it a clavicular saftfracture 'lus coracoacromial an! acromioclavicular li&ament!isru'tion#
y'e 111?4 sca'ular nec, fracture com+ine! /it an acromion orsca'ular s'ine fracture 'lus coracoclavicular an! acromioclavicularli&ament !isru'tion#
American Aca!emy of Orto'ae!ic Sur&eons
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TREATMENT
O'erative mana&ement as +een
recommen!e! +ecause of 'otential insta+ilityan! !is'lacement of te &lenoi!#
Recent series of nono'erative treatment of
floatin& soul!ers re'orte! &oo! results#
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COMPLICATIONS
Associate! injuries4 Most serious com'lication#
1ncrease! mortality is associate! /it concomitant
first ri+ fracture#
Malunion4 .ainful sca'ulotoracic cre'itus#
Nonunion4 is is e-tremely rare* +ut /en 'resent
an! sym'tomatic it may reuire o'en re!uction an!
internal fi-ation#
Su'rasca'ular nerve injury4 is may occur in
association /it sca'ula +o!y* nec,* or coracoi!
fractures tat involve te su'rasca'ular notc#
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