A meta-analysis of operative versus nonoperative treatment in 463 scapular neck fractures

Sling and forget it? A systematic review of operative versus nonoperative outcomes for scapula fractures

BACKGROUND

The majority of scapula fractures have historically been treated nonoperatively. The current literature describing patient outcomes following scapula fractures is limited. Our objective was to determine differences in outcomes between operatively and nonoperatively treated scapular fractures. The goal of our study was to provide an updated and comprehensive systematic review for scapula body, neck, and glenoid fractures focusing on several outcomes including union rate, return to work, pain, shoulder active range of motion, strength, functional scores, and any recorded complication.

METHODS

The PRISMA methodology was followed for this systematic review. Articles were obtained from the PubMed/Medline database using the following search terms: scapula body OR scapula neck OR intra-articular glenoid AND fracture. Additional articles were obtained by searching the bibliographies of included references. Studies were included if they contained clinical data on one or more of our study objectives and contained participants with a scapular body, neck, and/or glenoid fracture who were at least 16 year old. A total of 35 papers, with 822 total cases were included. Studies chosen were assessed for level of evidence and reviewed for data pertaining to the current study objectives. All cases of scapula fractures found throughout the literature were analyzed for outcome data. Outcomes studied included union rate, return to work, pain, shoulder active range of motion, strength, functional scores, and recorded complications.

RESULTS

The overwhelming majority of scapula fractures go on to union. The majority of patients will eventually return to work. Persistent postinjury pain is unfortunately common. Shoulder range of motion and strength are decreased when compared to the contralateral shoulder. Nonoperative glenoid fractures have the lowest reported functional scores. Malunion, need for additional surgeries, and post-traumatic arthritis were the most common complications.

CONCLUSION

When treating scapula fractures, orthopedic surgeons must consider the specific fracture pattern, as well as patient specific goals. Risks and benefits of both operative and nonoperative management should be discussed with the patient including the exceptionally low nonunion rate regardless of treatment option and that persistent pain following injury is unfortunately common.

Novel Claw-shaped Bone Plate in Complex Unstable Scapular Neck and Body Fractures: Comparison with Reconstruction Locking Plate

OBJECTIVE

For complex and unstable scapular fractures requiring simultaneous fixation of the glenoid neck, the lateral margin of the body, and/or the scapular diaphysis, reconstruction locking plate is difficult to achieve satisfactory fixation. In order to optimize the fixation effect, the newly designed claw-shaped bone plate was designed for fixing such fractures. We also evaluate the clinical effects and follow-up at an average of 1 year after treatment in scapular internal fixation by using reconstruction locking plate and claw-shaped bone plate in complex unstable scapular body and glenoid neck fracture.

METHODS

A retrospective study was conducted from 2018 to 2021, thirty-three patients (27 males and six females) who were defined unstable scapular fractures by Ada-Miller. Fifteen patients (52.86 ± 8.26 years) received claw-shaped bone plate and 18 cases (51.61 ± 11.31 years) received reconstruction locking plate with the intermuscular approach. The clinical effect was evaluated based on the operation time, intraoperative blood loss, surgical complications, clinical healing time and Constant-Murley score (CMS). The data analysis by Student t, Mann-Whitney U test and Pearson's chi squared test.

RESULTS

Compared with reconstruction locking plate, the claw-shaped bone plate showed shorter operation time (102.73 ± 18.43 min vs. 156 ± 37.53, P < 0.0001), higher CMS (94.00 ± 4.07 vs. 89.88 ± 5.42, P = 0.02) and no differences between the two groups regarding intraoperative blood loss (208.00 ± 96.45 mL vs. 269.44 ± 120.21, P = 0.12) and clinical healing times (9.96 ± 1.52 vs. 10.05 ± 1.67, P = 0.87). Follow-up were conducted at first, third, 6 and 12 months after surgery. The operation was successful in all patients with no intraoperative complications.

CONCLUSIONS

For the treatment of complex and unstable scapular neck body fractures, the application of claw-shaped bone plate demonstrated short operation time, better stability of the fracture block, and higher CMS. In the intraoperative and postoperative follow-up showed better clinical results and rehabilitation effects.

Deltoid-Sparing Modified Judet Approach: Technique and Clinical Series

SUMMARY

Posterior approaches provide the mainstay for treatment in most of the scapula body and neck fractures, even those associated with many intraarticular variants. Several posterior approach modifications for minimizing soft-tissue damage and limiting muscular detachment, have previously been described in the literature; however, little or no clinical evidence is available specifically applied to the various approaches.In this study, we describe complete sparing of the deltoid muscle origin during the "modified Judet" approach. The modified approach as previously described detaches the deltoid origin. Deltoid sparing allows for satisfactory visualization and fixation of extra-articular scapula fractures and even some intraarticular variants. The purpose of this article was to describe the deltoid-sparing modified Judet approach and report clinical outcomes for 23 patients after surgical treatment.

Finite element analysis of a novel anatomical locking plate for scapular neck fracture

OBJECTIVES

Reconstruction plates (RPs) are commonly used in scapular neck fractures (SNFs): however, RPs have many defects. In this study, we evaluated a newly designed scapular neck anatomical locking compression plate (SNALCP).

METHODS

An SNF finite element model (Miller-type IIB) was constructed. Plates were subsequently implanted into the scapula and fixed with screws that were grouped according to the plate used: SNALCP (A) and RP (B). Finally, loads were applied to record and analyze performance.

RESULTS

Under lateral, anteroposterior, and vertical compression loads, the maximum von Mises stresses on the scapula and implants of group A were smaller than those of group B. There were some differences in stress distribution between the two groups.

CONCLUSIONS

SNALCP can effectively reduce the stress of the scapula and implant, making stress distribution more uniform and continuous, and has mechanical conduction advantages. Compared to RP, it provides improved stability and more reliable fixation.

Scapula fractures: a review

A consensus is beginning to emerge about the indications for fixation of fractures involving the glenoid fossa of the scapula. The same cannot be firmly said for extra-articular fractures of the blade or the processes of the scapula, with a good deal of reliance on expert opinion from high-volume centres. There are no randomized controlled studies and the systematic reviews that do exist can only pool the data from available case series, making meaningful meta-analysis of limited value. Interest in scapula fractures has increased of late due to the specific association of fractures of the scapular spine and acromion with reverse shoulder arthroplasty.

This review summarizes the available evidence that can assist decision making when faced with a patient with a scapula fracture. Which patients should at least be considered for open reduction and internal fixation, either in the centre where they present or after referral to a more specialist centre? These patients are those with a fracture sufficiently displaced that it interferes with the mechanical function of the shoulder girdle and the aim of fixation is to reduce pain and disability.

Since the majority of scapula fractures heal quickly with non-surgical treatment and do not cause significant disability, decision making can be difficult, and it is perhaps the case that it is easier to err on the side of caution.

However, it seems that there are fracture types, such as significantly displaced double disruptions of the superior suspensory complex, widely displaced lateral column fractures and fractures producing angular deformity of the glenoid process, that benefit from early reduction and stabilization with the expectation of a good outcome for the patient.

Cite this article: EFORT Open Rev 2021;6:518-525. DOI: 10.1302/2058-5241.6.210010

Functional outcomes of internal fixation of scapula fractures due to high-velocity gunshot injuries

BACKGROUND

Open fractures of the scapula are relatively rare and only a few studies are interested in this subject. This study aims to demonstrate the results of internal fixation of open scapula fractures due to gunshot injuries.

MATERIALS AND METHODS

Eight patients who had open scapula fractures and were treated by internal fixation through the conventional Judet approach included in this study. Patients were followed up monthly in the first 6 months and every 2 months in the rest of the follow-up. Shoulder range of motion, Constant Shoulder Score, and Disabilities of the Arm, Shoulder, and Hand score were used for functional evaluation.

RESULTS

The average follow-up period was 34.6 ± 11.9 months. The average time between injuries and the surgery was 10.5 ± 5.1 days. The average shoulder abduction of the patients was 135.6 ± 18.8°, the average forward flexion of the shoulder was 160 ± 19.2°. The average internal and external rotations of the shoulders were 80 ± 14.1° and 63.1 ± 17.3°, respectively. CSS was calculated as 79.8 ± 14.4, and DASH was calculated as 14.1 ± 14.9.

CONCLUSIONS

In the treatment of open scapula fractures due to gunshot injuries, an internal fixation is a reliable option and the results were comparable with previous studies.

Functional Outcome of Open Reduction and Internal Fixation of Displaced Extra-Articular Scapula Fractures

BACKGROUND

Scapular fractures are uncommon injuries of upper extremity resulting mostly from high-energy trauma. Extra-articular fractures form the majority of them. Un-displaced fractures can be managed conservatively with good results. But displaced fracture does not yield satisfactory results and needs surgical fixation. In this case series, we report our experience about such fractures.

METHODS

This was a retrospective study of 12 patients with displaced scapular body and neck fractures treated between 2015 and 2018. Scapular fractures were exposed by modified Judet approach and fixed with either 3.5 mm T buttress or recon locking plate and screws. One case had associated clavicle fracture which was fixed along with scapula. Patients were put on structured rehabilitation and followed up regularly. Functional outcome and range of motion were analyzed.

RESULTS

The patients included 10 males and two females. Mean age was 42 years. Average follow-up was 33 months. Average constant and Murley score was 80. Excellent results were seen in four patients, good results in seven patients and one patient has got fair result. The mean post-operative range of motion of the shoulder at the time of final follow-up was 140° of forward flexion, 136° of abduction, and 34° of external rotation.

CONCLUSION

Displaced extra-articular scapular fractures managed by internal fixation using T buttress locking plates and reconstruction plates give good functional outcome.

Can displaced extra-articular fractures of the scapula be stabilized through a direct lateral-column approach

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.

Functional outcomes of extra-articular scapula fracture fixation with distal humeral Y-type locking plate: a retrospective study

Background

This study aimed to compare the functional outcomes of the Y-type locking plate with the straight reconstruction locking plate for severe displaced scapular fractures.

Methods

This was a retrospective cohort study of 37 patients with severe displaced scapular body and neck fractures treated between July 2013 and October 2016 at the Hanzhong Central Hospital. Treatment selection was based on the surgeon’s experience and discussion with the patient. Sixteen patients received Y-type locking plates and 21 patients received straight reconstruction locking plates. The primary indexes were the Constant Shoulder Function (CSF) and Disabilities of the arm, shoulder, and hand (DASH) scores at 3, 6, and 12 months.

Results

There were 32 males and five females. Mean age was 46.0 ± 10.0 years. The cause of injury included car accident, fall, high fall, and bruising. At 3 months, compared with the straight reconstruction locking plate group, the Y-type locking plate group showed higher CSF scores (82.9 ± 3.5 vs. 79.3 ± 4.4, P = 0.01) and lower DASH scores (9.5 ± 2.5 vs. 12.7 ± 3.9, P = 0.008). There were no differences at 6 and 12 months. There were no differences between the two groups regarding intraoperative blood loss (P = 0.65) and operation time (P = 0.634). There were no complications such as plate rupture and screw prolapse during the 1-year follow-up.

Conclusions

Open reduction using the distal humeral Y-type locking plate can achieve better short-term functional outcomes (3 months) than the straight reconstruction locking plate for severe displaced scapular body and neck fractures, but outcomes are similar at 6 and 12 months. Level of evidence: II-2.

Ring versus non-ring plate for the treatment of displaced scapular body fractures: a retrospective study with a mean follow-up of 5 years

Objective

To compare surgical complications and functional outcomes of the ring plate versus the non-ring plate approach to the surgical repair of scapular body fractures (SBFs; AO/OTA classification: 14-A2.2).

Methods

This retrospective study reviewed data from adults with SBFs who underwent a modified Judet approach combined with non-ring or ring plates between November 2006 and June 2013. The primary outcomes were the Constant and Murley score and the Disabilities of the Arm, Shoulder and Hand (DASH) score. The secondary outcomes were radiographic findings.

Results

A total of 318 patients had a non-ring or ring plate internal fixation, of which 147 patients (ring-treated, n = 72; non-ring-treated, n = 75) were evaluated with a mean follow-up period of 60 months. At the 3-month follow-up, the complication rate was 2.8% and 13.3% for the ring-treated and non-ring-treated groups, respectively. The difference persisted over time, with significantly different rates of 8.3% and 20.0% at the final follow-up for the ring and non-ring groups, respectively. The ring-treated group had significantly higher postoperative Constant and Murley scores and lower DASH scores compared with the non-ring-treated group.

Conclusion

Application of a modified Judet approach combined with ring plate internal fixation for the treatment of SBFs may be the preferred treatment option.

Extra-articular scapular fractures: comparison of theoretical and actual treatment

BACKGROUND

Discrete radiographic thresholds of scapular fracture deformity proposed as a guide for when to utilize operative treatment are a matter of debate. The purpose of the present study was to determine how many patients would have received operative treatment according to these criteria and how many actually received operative treatment.

METHODS

Three hundred and thirty patients with an extra-articular fracture of the scapula at two level 1 trauma centers were retrospectively analyzed. Glenopolar angle, translation, angulation and medial/lateral displacement were measured on computed tomogaphy scans or radiographs to determine the theoretical operative treatment recommendation according to Cole's criteria.

RESULTS

Sixty-two patients (19%) had one or more radiographic indications for operative treatment, half of them had more than 20 mm of lateral displacement, and one fourth of them had substantial translation. No patients had operative treatment of the scapular body. Two patients had operative treatment of an acromion fracture, neither of which met radiographic criteria for surgery.

CONCLUSIONS

At least in our centres, there is a striking discrepancy between theoretical and actual recommendations for surgery. There is clearly a need for more research to determine whether patients are being undertreated or whether the guidelines are too stringent.