Abstract
Background
Displaced extraarticular fractures of the scapula are uncommon, and rarely require operative fixation. When managed operatively, a posterior Judet approach with detachment of the deltoid muscle from the scapular spine and elevation of the infraspinatus from its fossa, is often performed. This approach is invasive and involves extensive soft tissue dissection. This paper describes the utility of single-column fixation with a direct lateral column approach, with mobilisation of the deltoid, and elevation of the interval between the infraspinatus and teres minor. Our aim is to assess the functional and radiological outcomes of this alternative approach.
Methods
We performed a retrospective cohort study of all patients who underwent operative fixation of their extra-articular scapula fracture (with at least 12 months follow up), using the direct lateral-column approach. Operative indications included patients with an extra articular scapular neck or body fracture, with medial/lateral displacement of ≥20 mm, angulation ≥45°, double disruption of the shoulder suspensory complex, and glenopolar angle (GPA) ≤ 22°. Functional outcomes were assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Subjective Shoulder Value (SSV), pain score & return to work. Radiological assessment was done by 2 independent assessors.
Results
Between January 2014 and December 2016, 12 patients (11 males and 1 female) underwent fixation of their scapula fracture using this approach. Eleven patients (91.7%) returned their questionnaire at an average of 15.6 months (12–28 months). All fractures had healed at the time of the final follow-up. The scapular neck angulation was corrected from 38.7° pre-operatively (0–74°) to 3.6° post-operatively (0–20°). The mean post-operative GPA was 35.4° (30.2°–42.0°). None of the patients had superficial or deep infections, or post-operative neurovascular injuries. Two patients underwent elective removal of their clavicle hook plates. The mean SSV was 88.9 (70–100) and mean pain score was 1.5 (0–8). The mean DASH score was 11.4 (0–51.6). Ten patients returned back to their pre-injury work, with an average return to work of 3.3 months (2 weeks–8 months). Only one patient had a poor DASH score. He had associated ipsilateral segmental fracture of the humerus, fracture of the lateral clavicle and brachial plexus injury.
Conclusions
The direct lateral-column approach is an alternative technique for fixation of the extra-articular neck and body scapular fracture. Plating of the lateral column of the scapula through this single approach is associated with correction of scapular angular deformity, no complications and good clinical results at more than 12 months’ follow-up.
Keywords: Scapular fractures, Direct lateral approach, Extra-articular, Functional outcomes, Single-column fixation
1. Introduction
Glenoid neck fractures are extra-articular fractures extending from the lateral border to either the superior or medial border of the scapula, and account for approximately 10–40% of scapular fractures.1 Due to the protective soft tissue envelope around the scapula, they are commonly the result of high energy trauma, such as direct blunt force or transmission of force through the upper limb.2 Glenoid neck fractures are generally considered stable fractures if the suspensory ligament complex is intact, however, significant displacement may result in poor functional outcomes.3,4 In such cases, operative fixation may be considered and this is commonly performed via a posterior approach.1,5, 6, 7, 8, 9
In 1964 Judet popularized the posterior approach to the scapula, which involves detachment of the deltoid from the scapula spine as well as the elevation of the infraspinatus from its fossa.6 Whilst offering excellent visualisation of the scapula body, extensive soft-tissue dissection may result in soft tissue damage and worse functional outcomes.3,4 This approach was then subsequently modified to focus more on the glenoid and lateral border of the scapula, whilst preserving the soft tissues. Obremsky described the modified Judet approach,8 which reduces the soft-tissue damage by omitting dissection of infraspinatus free from its fossa; however it does involve an extensile incision and elevation of a skin flap along with release of deltoid from the scapula spine. Brodsky et al.5 described a more direct approach to the lateral border of the scapula utilizing a vertical incision to an abducted arm and the internervous plane between infraspinatus and teres minor. Jones et al.10 recently described the interteres approach between teres minor and teres major. The paper reported good outcomes in 17 patients over a six-and-a-half year period, however there is some question over its potential to injure the branches of the axillary nerve supplying teres minor due to some patients experienced post-operative weakness to external rotation. Minimally invasive approach10 and the posterior deltoid splitting approach9 have also been described.
Our paper describes a direct approach to the lateral column of the scapula, utilizing the superior part of the approach described by Brodsky,5 extended further down the lateral border without release of deltoid insertion or shoulder joint arthrotomy. This potentially offers adequate visualisation of the key components of the fracture as well as limiting the muscle dissection. This approach facilitates plating of the lateral column of the scapula, which has been our preferred method for managing these complex injuries. Our hypothesis is that stabilisation of the scapular neck (lateral column) provides adequate stability and alignment to the shoulder girdle, irrespective of the displacement or alignment of the medial/superior border of the scapula and that fixation via this approach will result in good outcomes.
The aim of this paper was to describe the direct lateral column approach to the scapula utilizing the interval between infraspinatus and teres minor, without detachment of deltoid. We also report on the functional and radiological outcomes of a case series of patients who were treated with this single lateral column technique without stabilisation of the medial column or scapula spine.
2. Methods
This was a retrospective case series review of patients who had undergone scapula fixation at our level 1 trauma centre between January 2014 and December 2016. All patients who had undergone a direct lateral column approach for fixation of an extra-articular scapula fracture were identified through a review of the senior surgeon’s surgical database. The institution’s human research ethics committee provided ethical approval for the study. The following inclusion criteria were used: (1) extra-articular scapula neck fracture; (2) direct lateral approach for fixation; (3) at least 12-months follow-up; (4) contactable and agreeable to inclusion in the study. Patients were excluded from the study if they had intra-articular fractures of the glenoid, isolated fractures of the acromion or coracoid process and extra-articular fractures of the scapula body not involving the glenoid neck.
The indications for surgical fixation included patients with a scapular neck fracture with >20 mm of medial or lateral displacement; angulation of >45°; and double disruption to the shoulder suspensory complex.11 A glenopolar angle (GPA)12 - the angle between a line connecting the superior and inferior poles of the glenoid and a second line from the superior pole of the glenoid to the most inferior tip of the scapular body - of <22° was also used as an indication for surgery. A data collection sheet was formatted and the data was captured from a retrospective review of medical records and imaging studies. This included mechanism of injury, patient demographics, associated injuries, operation details and complications including infection, malfixation or the need for removal of metalware.
The preoperative X-ray and CT scans were reviewed to identify associated injuries and the type of injury categorized according to the AO/OTA fracture classification system.13 Only extra-articular (type 14-A3 and C1) fractures of the scapula body and/or neck were included. Furthermore, the GPA as well as presence of fracture and the amount of angulation were recorded. Radiological assessment was evaluated by two independent reviewers and any differences were discussed until a consensus was reached.
Functional outcomes were measured by the Subjective Shoulder Value (SSV) and the Disabilities of the Arm, Shoulder and Hand (DASH) score, both validated region-specific questionnaires. The SSV is expressed as a percentage of an entirely normal shoulder, which would score 100%. The DASH questionnaire consists of a 30-item upper-extremity disability and symptom scale, scored 0 (no disability) to 100 (maximum disability). Other outcomes included pain score from 0 to 10 and whether the patient returned to work.
Descriptive statistics was used to describe patient characteristics. Continuous data were assessed for normality and expressed as mean (range). Paired T-test was used to determine significance of radiographic measurement corrections.
2.1. Surgical technique
All operations were performed by a fellowship-trained shoulder surgeon (A.M). Patients were positioned in the lateral decubitus position with the affected limb supported on a gutter frame. A single incision over the lateral margin of the scapula extending from the upper glenoid to the inferior angle of the scapula was made (Fig. 1). Dissection is carried down to the level of the deltoid fascia and the deltoid epimysium is split in line with the fibers along its lower border. The deltoid is then retracted laterally with a blunt retractor positioned over the superior aspect of the glenoid (Fig. 2). The dense fascia containing infraspinatus and teres minor is incised and this interval is exposed (Fig. 3). Infraspinatus is then retracted superiorly and teres minor is retracted inferiorly to expose the glenoid neck fracture. Care is taken to not to injure the ascending branch of the circumflex scapular vessels which run close to the inferior edge of the glenoid neck. Once identified, small clamps are used to reduce the fractures, which are temporarily stabilized with K-wires. These are then stabilized using 2.7 mm or 3.5 mm locking plates (Fig. 4). One or two plates may be used depending on the type of fracture or stability attained and position is confirmed using image intensifier. Associated clavicle fractures were fixed with a separate incision using anatomic clavicle plates. Fractures of the lateral end of the clavicle or ACJ disruptions were managed with hook plates. Drains were not routinely used during this approach.
Fig. 1.
Single lateral incision over scapula.
Fig. 2.
Deltoid is preserved and retracted to expose the glenoid.
Fig. 3.
Plane between infraspinatus and teres minor.
Fig. 4.
XR demonstrating pre-op 3-D CT of scapular fracture and post-op XR showing single-column lateral plating.
Post-operative management included non-weight bearing of the affected limb in a broad arm sling for 4 weeks. Passive range of motion (ROM) is started from day 1 and active ROM was started once the patient was comfortable with pain. Strengthening exercises was started after 10 weeks. Serial post-operative x-rays were taken immediate post op, at 6 weeks, 3 months 6 months and at one year.
3. Results
Eleven out of the 12 patients (91.7%) that underwent fixation of their scapula fracture using this approach were agreeable to participation in the study and had their functional outcomes recorded. Majority of the patients were male with a mean age of 45 years (24–67 years). One patient relocated overseas and subsequently wasn’t contactable and was lost to follow-up. Mean follow-up was 15.6 months (12–28 months). Four patients had left sided scapular fractures and the remainder were right sided injuries. Seven of these fractures resulted from a motor vehicle accident, two were the result of a pushbike accident and three of them following falls greater than 3 m in height (Table 1). Associated injuries included ribs fractures (8 patients), spine fractures (3 patients), clavicle fractures or AC joint disruption (5 patients), ipsilateral upper limb injuries (2 patients).
Table 1.
Characteristics of the patients.
| Case No. | Age | Gender | Mechanism of injury | Associated injuries | SSV | Pain score | Dash score |
|---|---|---|---|---|---|---|---|
| 1 | 40 | M | HSMVA | None | 90 | 1 | 5.8 |
| 2 | 24 | M | HSMVA | Rib fractures, spine fractures | 90 | 1 | 5.0 |
| 3 | 37 | M | Pushbike | Rib fractures | 100 | 0 | 0 |
| 4 | 42 | M | MBA | Pneumothorax, midshaft clavicle fracture | 100 | 0 | 0 |
| 5 | 57 | M | MBA | Midshaft clavicle fracture | 90 | 2 | 22.5 |
| 6 | 37 | M | HSMVA | Lateral clavicle fracture, segmental humerus fracture, rib fractures, pneumothorax | 70 | 8 | 51.7 |
| 7 | 67 | M | Ped Vs Car | ACJ dislocation, rib fractures | 70 | 4 | 31.2 |
| 8 | 65 | M | Fall | Rib fractures, spine fractures | 98 | 0.5 | 0 |
| 9 | 57 | M | MBA | Manubrium fracture, rib fractures | 80 | 0 | 0 |
| 10 | 28 | F | Pushbike | None | 90 | 0 | 0 |
SSV, Subjective Shoulder Value; DASH, Disabilities of the Arm, Shoulder and Hand; HSMVA, High Speed Motor Vehicle Accident; MBA, Motor Bike Accident.
The mean SSV was 88.9 (70–100) and mean pain score was 1.5 (0–8). The mean DASH score was 11.4 (0–51.6), which improved to 6.5 (0–34.2) if one patient with an ipsilateral upper limb neurologic injury was discounted. The patient with a poor DASH score was a 37-year-old male who had had sustained the fracture being a driver in a high speed motor vehicle accident. He had associated ipsilateral segmental fracture of the humerus, fracture of the lateral clavicle as well as multiple metacarpal fractures. He also had an associated brachial plexus injury. The remaining ten patients all returned back to their pre-injury work, with an average return to work of 3.3 months (2 weeks - 8 months).
The mean scapular neck angulation was corrected from 38.7° pre-operatively (0°–74°) to 3.6° post-operatively (0°–20°) (Table 2). The mean post-operative GPA was 35.4° (30.2°–42.0°). All fractures healed at the time of the final follow-up. None of the patients had superficial or deep infections, or post-operative neurovascular injuries. Two patients underwent elective removal of their clavicle hook plates after 4 months, however, no patients required removal of their scapular implant.
Table 2.
Radiographic measurements pre- and post-operatively.
| Preop | Postop | p-value | |
|---|---|---|---|
| Angulation (Mean) | 35.8 | 3.5 | <0.001 |
| GPA (Mean) | 34.6 | 35.8 | 0.731 |
GPA, Glenopolar Angle.
4. Discussion
In our series of eleven patients, the single-column fixation of the lateral scapula alone achieved satisfactory radiological correction and functional outcomes. This study further demonstrates that a direct lateral approach to extra-articular neck and body of scapular fractures is a safe alternative to more the commonly used posterior approaches.
Scapular fractures are rare injuries that are often the result of high energy trauma. They are often associated with other more serious and life-threatening injuries and for this reason they are often missed or neglected. Non-operative management has been the dictum in non-articular fractures,14 although mal-unions may cause ongoing symptoms. Nordqvist and Petersson15 reported that 50% of patients with residual scapula deformity had shoulder symptoms. Surgical intervention is advocated in severely displaced fractures, mostly those affecting the lateral column.16
The lateral border cortex is the thickest area of the scapula,17 which has been shown to be the key structure for reduction and internal fixation of the scapular body. Our study hypothesized that stabilisation of the scapular neck (lateral column) alone in these operative candidates provides adequate stability and alignment to the shoulder girdle, irrespective of the displacement or alignment of the medial/superior border of the scapula. We demonstrated good functional outcomes with a mean SSV of 88.9 and mean DASH score of 11.4 at final follow-up. A recent retrospective cohort study demonstrated that a single lateral plate technique achieved good functional outcomes comparable with a dual-plating technique, whilst achieving significantly shorter operating time, less blood loss, and fewer plate-related complications.18 The mean DASH scores were 5.5 (±3.0) in the single-lateral plating technique compared with 6.2 (±3.2) with dual-plating. Another recent study showed the use of Y-type locking plate had better functional outcomes than straight locking plates for displaced extra-articular scapular fractures with DASH scores (9.5 ± 2.5 vs. 12.7 ± 3.9, P = 0.008).19 The medial border is also much thinner than the lateral border and positioned subcutaneously. Therefore, plate prominence may disturb the patient and lead to the need for plate removal. Ao et al.18 had a significantly higher rate of plate removal when comparing dual-versus single-plate techniques (78.3% vs 31.8%; p = 0.009). Other studies have reported lower rates of plate removal between 5 and 16%, likely due to the use of smaller plates.12,20 Our study had no patients requiring removal of metal at final follow-up.
Radiographically, our study showed a significant improvement in correction of mean scapular neck angulation (38.7° pre-operatively vs 3.6° post-operatively; p < 0.001), however there was no significant difference in glenopolar angle post-operatively. A recent study by Yadav et al. showed no correlation between change in GPA and functional outcome.21 We reported union in all patients, likely the result of the excellent blood supply and muscular envelope covering the scapula, along with the minimal disruption required in this approach.
We acknowledge limitations in our study that may prevent generalization of the findings. It was primarily limited by its retrospective nature and the possibility to introduce bias. Furthermore, these results reflect the experience of a single surgeon and weren’t directly compared to another technique or non-operative management. Though operative indications were well-defined in this study, the method of measuring displacement and angulation of scapula fractures has only recently been validated.12 Finally, the relatively small sample size limited the statistical power of some of our results. A prospective study with longer term radiological follow-up and direct comparison with other techniques is required to further investigate.
A single-column technique via a direct lateral column approach is an alternative technique for fixation of the extra-articular neck and body scapular fracture. In our cohort, this was associated with significant correction of scapular angular deformity, no significant complications and maintenance of adequate radiological reduction to union. Good clinical outcomes were seen at medium-term follow-up.
Financial disclosure
“None reported”
Ethics
The institution’s human research ethics committee provided ethical approval for the study with project number 190/17.
Author contribution
Rejith Mannambeth: Literature search, study design, data collection, data analysis, data interpretation, writing, critical revision, Nathan Kirzner: Literature search, study design, data analysis, data interpretation, writing, critical revision, Ash Moaveni: Literature search, study design, data collection, data analysis, data interpretation, writing, critical revision.
Level of evidence
Retrospective case series, level IV.
Declaration of conflicting interests
None declared.
Declaration of competing interest
“None reported”
Acknowledgements
The authors would like to thank Eldho Paul for his assistance.
Contributor Information
Rejith Mannambeth, Email: drrejith@gmail.com.
Nathan B. Kirzner, Email: Nathan.kirzner@gmail.com.
Ash K. Moaveni, Email: ash@moaveni.com.au.
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