66.1 Goals of Procedure

While the majority of scapula fractures can be treated nonoperatively, those involving the glenoid pose a unique set of challenges. ^{1 , 2} The primary goals of open reduction and internal fixation (ORIF) of glenoid fractures are to obtain anatomic reduction, restore joint congruency, and obtain/maintain glenohumeral stability.

66.2 Advantages

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  Early mobilization.

  
  
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  Reduced risk of posttraumatic arthritis.

  
  
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  Improved range of motion.

  
  
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  Improved function. ^{3 , 4}

66.3 Indications

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  Intra-articular fractures: ⁵

  
  
  
  
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    Articular step off ≥ 5 mm. ^{6 , 7 , 8}

    
    
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    Involvement of ≥ 20% of the glenoid.

    
    
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    Failure of the humeral head to remain centered within the glenoid cavity (i.e., glenohumeral instability).

  
  
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  Extra-articular fractures ( Fig. 66.1 ): ^{5 , 9 , 10}

  
  
  
  
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    Angulation ≥ 45 degrees on the scapular Y view.

    
    
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    Glenopolar angle ≤ 20 degrees. ^{11 , 12 , 13}

    
    
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    Lateral border offset of ≥ 20 mm.

In the case of multiple disruptions of the superior shoulder suspensory complex (SSSC), each component should be addressed as separate entities, based on specific indication criteria for each individual injury. The presence of double or multiple disruptions of the SSSC is not in itself an indication for fixation of glenoid fractures.

66.4 Contraindications

Although there are no absolute contraindications to glenoid ORIF, severely comminuted fractures and/or poor bone stock may make rigid fixation difficult to achieve, and may be better treated with nonoperative management, followed by shoulder arthroplasty as needed once the acute injury has recovered.

66.5 Preoperative Preparation/Positioning

Operative planning begins with meticulous evaluation of the fracture. In order to adequately assess the fracture pattern, a true anteroposterior (AP) view of the glenohumeral joint, a true axillary view, and a scapular Y view should be obtained. Furthermore, CT imaging with 3D reconstruction (with humeral and clavicle subtraction) is recommended. ⁸ This can significantly enhance the surgeon’s understanding of both the fracture pattern and the complex anatomy, thereby aiding in choosing surgical approach, and implant positioning.

The choice of approach and positioning is largely influenced by the fracture pattern. The posterior approach is utilized for posterior rim fractures, most glenoid fossa fractures, and glenoid neck fractures, while the anterior approach is useful in the treatment of anterior rim fractures, as well as some fossa fractures (Ideberg III, IV, and Vb). ¹⁴