Introduction

Scapula fractures comprise approximately 1% of all fractures and 3-5% of upper extremity fractures. 90% of scapula fractures are associated with concomitant injury to the thorax/chest including: pneumothorax, hemothorax, pulmonary contusion, cardiac contusion, aortic injury, rib fracture, flail chest, clavicle fracture, and spine fracture. They are typically due to a high-energy mechanism of injury with a lateral impact to the shoulder girdle and/or traction injury to the arm. Up to 15% of scapula fractures are diagnosed late due to incomplete examination or precedence given to life-threatening injuries. The vast majority of scapula fractures are treated nonoperatively and this chapter will explore indications for surgical consideration.

I. Preoperative

1. 
   

   History and physical examination

   
   
   
   
   1. 
      

      Mechanism of injury—high-energy trauma to chest wall and shoulder girdle.

      
      
   2. 
      

      Location of pain:

      
      
      
      
      1. 
         

         Patients complain of shoulder pain/posterior scapular border pain.

         
         
      2. 
         

         Distinguish between chest wall trauma and scapula/shoulder girdle pain.

      
      
   3. 
      

      Associated injuries:

      
      
      
      
      1. 
         

         Chest wall injuries to thoracic cage.

         
         
      2. 
         

         Ipsilateral clavicle/upper extremity fractures.

         
         
      3. 
         

         Neurovascular injury.

      
      
   4. 
      

      Inspection:

      
      
      
      
      1. 
         

         Asymmetry compared to contralateral shoulder girdle.

         
         
      2. 
         

         Soft tissue swelling/ecchymosis over posterior scapular border.

         
         
      3. 
         

         Associated soft tissue swelling over clavicle/shoulder girdle with associated trauma.

         
         
      4. 
         

         Documentation of dermal abrasions with location, depth, and degree of contamination.

         
         
      5. 
         

         Identification of associated trauma wounds and location of chest tube placement/intravenous (IV) lines.

      
      
   5. 
      

      Palpation:

      
      
      
      
      1. 
         

         Crepitus over posterior shoulder girdle and scapula border.

         
         
      2. 
         

         Tenderness to palpation over fracture site.

         
         
      3. 
         

         Late detection of injury with missed fractures is not uncommon, highlighting the importance of correlation of examination findings with radiographic analysis.

      
      
   6. 
      

      Motor function:

      
      
      
      
      1. 
         

         Difficult to fully assess motor function based on injury pattern and associated life-threatening injuries.

         
         
      2. 
         

         Patients typically demonstrate significantly limited shoulder function.

         
         
      3. 
         

         Careful evaluation of the brachial plexus and sound knowledge of peri-scapular muscular innervation are required to accurately diagnose neurological deficits.

         
         
      4. 
         

         Associated extremity injury or deficits should alert physician to more extensive injury.

      
      
   7. 
      

      Sensory function:

      
      
      
      
      1. 
         

         Assess and document dermatomal sensory function.

         
         
      2. 
         

         Assessment of brachial plexus.

      
      
   8. 
      

      Vascular status:

      
      
      
      
      1. 
         

         Identification of palpable pulses.

         
         
      2. 
         

         Documentation of capillary refill.

         
         
      3. 
         

         Auscultation over proximal vascular tree for audible bruits or palpation of thrills.

   
   
2. 
   

   Anatomy (▶ Fig. 19.1 )

   

   
   
   
   
   1. 
      

      Supraspinatus fossa:

      
      
      
      
      1. 
         

         Origin of supraspinatus muscle.

         
         
      2. 
         

         Suprascapular artery and nerve travel through suprascapular notch over superior border.

      
      
   2. 
      

      Infraspinatus fossa—origin of infraspinatus muscle in fossa and origin of teres major and minor over inferior and lateral border.

      
      
   3. 
      

      Subscapularis fossa—origin of subscapularis muscle.

      
      
   4. 
      

      Glenoid—articular component of scapula enveloped by joint capsule and labrum.

      
      
   5. 
      

      Acromion process:

      
      
      
      
      1. 
         

         Termination of spine of scapula.

         
         
      2. 
         

         Contributes to acromioclavicular (AC) joint complex.

         
         
      3. 
         

         Articulates with distal clavicle.

      
      
   6. 
      

      Coracoid process:

      
      
      
      
      1. 
         

         Bony prominence anteriorly over scapula, with base lateral and cranial to lateral scapular border.

         
         
      2. 
         

         Attachment of short head of biceps brachii and coracobrachialis muscle.

         
         
      3. 
         

         Attachment of coracoacromial and coracoclavicular (CC) ligament complex.

      
      
   7. 
      

      Spine:

      
      
      
      
      1. 
         

         Begins over medial border and terminates as acromial arch and acromion.

         
         
      2. 
         

         Suprascapular artery and nerve enters into infraspinatus fossa, as spine becomes acromial arch.

      
      
   8. 
      

      Lateral border:

      
      
      
      
      1. 
         

         Superficial border posterior deltoid muscle.

         
         
      2. 
         

         Glenoid and glenohumeral joint centrally and superiorly, and quadrangular and triangular space laterally and inferiorly.

         
         
         
         
         • 
           

           i. Quadrangular space defined superiorly by teres minor, medially by long head of triceps, laterally by humerus and lateral head of triceps, and inferiorly teres major.

           
           
         • 
           

           ii. Contents of quadrangular space include axillary nerve and posterior humeral circumflex artery.

           
           
         • 
           

           iii. Triangular space bordered superiorly by teres minor, inferiorly by teres major, and laterally by long head of triceps.

           
           
         • 
           

           iv. Content of triangular space circumflex scapular artery.

      
      
   9. 
      

      Medial border:

      
      
      
      
      1. 
         

         Superficial border trapezius muscle.

         
         
      2. 
         

         Deep border levator scapulae superiorly, and rhomboids centrally and inferiorly.

   
   
3. 
   

   Imaging

   
   
   
   
   1. 
      

      Chest radiograph.

      
      
   2. 
      

      Anteropoterior (AP)/lateral/axillary radiographs shoulder.

      
      
   3. 
      

      Clavicle radiographs when indicated.

      
      
   4. 
      

      CT scapula/shoulder girdles: Three-dimensional reconstruction.

   
   
4. 
   

   Classification

   
   
   
   
   1. 
      

      Classifications are used mainly for research purposes and to guide surgical decision planning.

      
      
   2. 
      

      Ideberg classification with Goss modification describes glenoid fracture patterns with extension into scapular body.

      
      
   3. 
      

      AO/OTA classification distinguishes separately glenoid, body, and process fracture patterns.

      
      
   4. 
      

      Anatomic:

      
      
      
      
      1. 
         

         Anatomic description can be used to describe coracoid, acromion, and spine of scapula fractures.

         
         
      2. 
         

         Location description can be used to identify body fractures involving supra (superior body) or infraspinatus fossae (inferior body).

         
         
      3. 
         

         Extra-articular fractures involve the body or neck, but do not involve the glenoid.

         
         
         
         
         • 
           

           i. Peripheral margins of scapula are thicker than fossae, which are thin and associated with comminution.

           
           
         • 
           

           ii. Important to identify extent of medial involvement, which is often best interpreted or assessed on three-dimensional computed tomography (CT) reconstruction.

         
         
      4. 
         

         Intra-articular (glenoid) fractures:

         
         
         
         
         • 
           

           i. Posterior glenoid fractures can be associated with posterior fracture-dislocation patterns.

           
           
         • 
           

           ii. Anterior glenoid fractures can be associated with anterior fracture-dislocation patterns.

         
         
      5. 
         

         Superior shoulder suspensory complex injuries (SSSC):

         
         
         
         
         • 
           

           i. Osseoligamentous ring contributing to stability about the shoulder.

           
           
         • 
           

           ii. Bone contribution: clavicle, coracoid, acromion, and glenoid.

           
           
         • 
           

           iii. Soft tissue contribution: CC, coracoacromial, and AC ligaments.

           
           
         • 
           

           iv. Disruption of two of these structures is referred to as “double disruption”.

         
         
      6. 
         

         Scapulothoracic dissociation:

         
         
         
         
         • 
           

           i. Limited published data owing to injury rarity.

           
           
         • 
           

           ii. Results from high-energy traction injury to upper extremity.

           
           
         • 
           

           iii. Can present as flail, anesthetic, and pulseless upper extremity.

           
           
         • 
           

           iv. Internal degloving injury with closed forequarter amputation.

           
           
         • 
           

           v. Bone injury:

           
           
           
           
           • 
             

             Laterally displaced scapula.

             
             
           • 
             

             Sternoclavicular (SC) subluxation/dislocation.

             
             
           • 
             

             AC dislocation.

             
             
           • 
             

             Displaced, distracted clavicle fracture.

           
           
         • 
           

           vi. Vascular injury:

           
           
           
           
           • 
             

             Subclavian/axillary artery injury.

             
             
           • 
             

             Dense collateral vascular network rarely results in ischemia.

             
             
           • 
             

             May require urgent/emergent ligation in cases of severe hemorrhage and hemodynamic instability.

             
             
           • 
             

             Revascularization with saphenous vein interposition grafting when indicated.

           
           
         • 
           

           vii. Neurologic injury:

           
           
           
           
           • 
             

             Tend to be proximal root and cord injuries.

             
             
           • 
             

             Result in complete or partial brachial plexopathies.

             
             
           • 
             

             Poor outcome with complete plexus injury despite attempts at nerve grafting.

             
             
           • 
             

             Outcome following TSD depends on extent of neurologic injury.

             
             
           • 
             

             Recommendation for acute above elbow amputation in the setting of complete plexus injury.