Fig. 28.1
Anatomic classification (Zdravkovic and Damholt) (a) scapula body, (b, c) glenoid, (d) scapula neck, (e) acromion, (f) scapula spine, (g) coracoid
Type I: Scapula body
Type II: Apophyseal fractures, including the acromion and coracoid
Type III: Fractures of the superolateral angle, including the scapular neck and glenoid
More than 90% of scapular fractures are nondisplaced or minimally displaced and do well with conservative management; however, a specific subset of fractures may lead to poor outcomes after conservative treatment.
28.1.1 Intra-Articular Glenoid Fractures
Intra-articular glenoid fractures generally occur by transmission of force through the humeral head to the glenoid cavity. They are classified according to the Ideberg system with the Goss modification, which includes six fracture types (Fig. 28.2).
Fig. 28.2
Ideberg classification. (Ia) Anterior rim fracture. (Ib) Posterior rim fracture. (II) Fracture through glenoid exiting scapula laterally. (III) Fracture through glenoid exiting scapula superiorly. (IV) Fracture through glenoid exiting scapula medially. (Va) Combination of types II and IV. (Vb) Combination of types III and IV. (Vc) Combination of types II, III, and IV. (VI) Severe comminution
Type I fractures are true glenoid rim fractures, but types II–VI are glenoid fossa fractures with varying extension through the scapular body. Glenoid fractures with minimal displacement and angulation are treated conservatively in 90% of cases. [6].
28.1.2 Extra-Articular Neck Fracture
Glenoid neck fractures are extra-articular, but the mechanisms are similar to that of intra-articular glenoid fractures, most commonly involving humeral head impact on the glenoid after direct lateral impact or a FOOSH injury. They can be classified into two main categories: Type I fractures, nondisplaced which respond to nonsurgical treatment, generally treated symptomatically with early range-of-motion exercises. Type II injuries involve greater than 1 cm of translational fragment displacement or more than 40° of angular displacement and most often require surgical repair. Anatomic neck fractures are inherently unstable and require surgical fixation. Surgical neck fractures can be unstable when they are associated with a clavicular fracture or with coracoclavicular and coracoacromial ligament disruption. This situation denominated by “floating shoulder” compels surgical repair. Internal fixation of the clavicular fracture generally results in adequate stabilization for healing of the glenoid fracture.
28.1.3 Scapular Body Fracture
Approximately 50% of scapular fractures involve the scapular body. The mechanisms include direct impact onto the scapula and sudden muscular contraction. These fractures respond well to conservative management and are usually treated nonsurgically in the acute phase. Operative fixation is rarely indicated, with non-operative measures generally effective. Open reduction may be considered when neurovascular compromise is present and exploration is required. Nonunion or malunion is uncommon but may require delayed surgical fixation if symptomatic, particularly with fragment displacement of greater than 10 mm or if impingement symptoms are present.
28.1.4 Acromion Fracture
Fractures of the acromion are very rare and most often occur due to a lateral impact, a direct strike to the top of the shoulder, or, rarely, impact after superior humeral subluxation. They are classified with the Kuhn system into three types (Fig. 28.3).
Fig. 28.3
Kuhn classification
Type I acromion fractures are nondisplaced and include Type IA (avulsion) and Type IB (complete fracture)
Type II fractures are displaced laterally, superiorly, or anteriorly, but they do not reduce the subacromial space
Type III fractures cause a reduction in subacromial space
(Modified from Kuhn et al. [7])
Type I and minimally displaced type II fractures can be managed with immobilization. Surgical fixation is recommended for markedly displaced types II and III to reduce the acromioclavicular joint and prevent nonunion, malunion, impingement, or rotator cuff injury. Os acromiale must first be ruled out, as well as concomitant rotator cuff injuries. When displaced, acromion fractures lead to subacromial impingement; therefore, they need reduction and fixation by dorsal tension band wiring.
28.1.5 Coracoid Fracture
Coracoid fractures may appear in football injuries as injury mechanisms include a direct blow to the shoulder from a lateral impact, muscle avulsion, direct humeral head impact during anterior shoulder dislocation, and a variant of acromioclavicular joint separation. They are classified into two types with the Ogawa system. Type I fractures are proximal, and type II fractures are distal to the coracoclavicular ligament insertion. There is no clear consensus about the treatment of coracoid process fractures, but nondisplaced and minimally displaced fractures are most commonly type II and can be treated conservatively. Type I fractures are more likely to be markedly displaced. When associated with acromioclavicular separation, displaced acromial fracture, clavicular fracture, or glenoid fracture, these combinations commonly require surgical treatment. Complete third-degree acromioclavicular separation accompanied by a significantly displaced coracoid fracture is an indication for open reduction and internal fixation of both injuries.
28.2 Clavicle Fractures
Clavicular fractures represent approximately 2–4% of all fractures and 35–45% of shoulder girdle injuries [8]. The most common mechanism is fall onto lateral aspect of shoulder that generates compression of shoulder girdle, which translates into compression and distraction at clavicular shaft, resulting in clavicular fracture and tear of conoid ligament. Less common mechanisms are direct impact on the shaft and indirect FOOSH mechanisms. Patients usually present with splinting of the affected extremity, with the arm adducted across the chest and supported by the contralateral hand to unload the injured shoulder.
A careful neurovascular examination is necessary to assess the integrity of neural and vascular elements lying posterior to the clavicle. Most brachial plexus injuries are associated with proximal third clavicle fractures.
The proximal fracture end is usually prominent and may tent the skin. Assessment of skin integrity is essential to rule out open fracture. Up to 9% of patients with clavicle fractures have additional fractures, most commonly rib fractures.
Clavicular fractures are classified according to the Allman system. Group I involves the middle third of the clavicle and comprises approximately 80% of clavicle fractures. Group II (15%) involves the distal clavicle, and Group III (5%) involves the proximal clavicle.
28.2.1 Middle Third (Midshaft) Clavicle Fracture
More than 75–80% of clavicle fractures occur in the midshaft region. Displaced and shortened fractures of the mid-third of the clavicle are common in the young, athletic populations and are frequently high-energy sports injuries. It is this subgroup of patients with displaced and shortened midshaft fractures of the clavicle that often requires operative fixation.
In 2005, Zlowodzki et al. [9] found increasing age, fracture displacement, female gender, and fracture comminution to be associated with the development of nonunion and long-term sequelae after non-operative treatment. In 2006, Nowak et al. [10] found predictable risk factors including lack of osseous contact at fracture site, a transverse fracture, and increasing age that may cause complications in fracture healing and overall recovery and were considered to be indications for operative treatment. Studies of midshaft clavicle fractures with substantial shortening have reinforced these biomechanical findings by demonstrating higher patient satisfaction and improved functional outcomes after operative treatment. The traditional conservative protocol provides positive results in more than 90% of athletes treated with a figure-8 sling [11]. However, recent reports have discussed decreased union rates of displaced midshaft clavicular fractures treated non-operatively. Closed treatment may lead to significant deficits, whereas surgical management results in an earlier and more reliable return to full function [11, 12].
Displaced fractures of clavicle with shortening of 15 mm or more have better results with surgery. Operative fixation allows earlier rehabilitation with a high level of patient satisfaction with respect to shoulder function. Pain relief is faster and there is no need to use shoulder wraps. Rigid internal fixation may also allow patients to return to activities earlier. Reconstruction plates can be contoured best to the three-dimensional anatomy of the clavicle.
Operative management of clavicular fractures includes external fixation, intramedullary fixation, and osteosynthesis with plate and screws (Figs. 28.4 and 28.5).
Fig. 28.4
Midshaft clavicle fracture with intramedullary fixation
Fig. 28.5
Midshaft clavicle fracture fixed with plate and screws
With respect to displaced fractures, plating of 460 patients resulted in a nonunion rate of 2.2% compared with a nonunion rate of 15.1% in 159 patients treated non-operatively [13].
An athlete undergoing traditional treatment of a clavicular fracture would have been immobilized for 3–6 weeks before any range-of-motion exercises were started. However, in the past few years, more aggressive treatment protocols for clavicular fractures have become popular. Success rates of 94–100% with low rates of infections and complications have been reported with plate fixations of acute midshaft clavicular fractures [9]. Fixation with intramedullary nailing using titanium elastic nails has also evolved [13]. With surgical treatment and appropriate rehabilitation, athletes are able to return to competition at 6 weeks without compromising their health or safety [14, 15].
28.2.2 Distal Clavicle Fractures
The distal clavicle fractures (Group II of Allman) were divided into five subtypes according to the Neer classification modified by Craig [16]. Their classification is based on the location of the fracture in relation to the coracoclavicular ligament and their intactness (Fig. 28.6).
Fig. 28.6
Clavicle fractures Neer classification
The Neer type I is a fracture lateral to the coracoclavicular ligament attachment, which has very minimal displacement. Type II is one which is medial to the ligament attachment. It is divided into IIA and IIB. In IIA both the conoid and the trapezoid ligaments are attached to the distal fragment, and in IIB the conoid is detached from the proximal fragment, while the trapezoid is attached to the distal fragment. Type III is one with intra-articular extension. Type IV occurs in children where a periosteal sleeve gets avulsed from the inferior cortex with the attached coracoclavicular ligament, and the medial fragment gets displaced upwards. Type V is similar to type II which involves an avulsion leaving behind an inferior cortical fragment attached to the coracoclavicular ligament. Types II and V are unstable, and there are many controversies about the best management.
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