Peter A. Cole MD1 and Lisa K. Schroder BS MBA2 1University of Minnesota, Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, USA 2Orthopaedic Trauma Academic Programs, Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, USA The authors would like to acknowledge Dr. Erich Gauger for his support in preparing this manuscript. In addition, we wish to thank Synthes, Inc. for the research grant funding which supports the research of the Scapula Institute at the University of Minnesota‐Regions Hospital. A chest X‐ray revealed four consecutive left‐sided rib fractures and a pneumothorax, prompting dedicated shoulder X‐rays. A fracture of the scapula in the region of the glenoid neck in addition to a displaced acromioclavicular (AC) joint was diagnosed. Moderate displacement at the lateral scapula border, and a glenopolar angle (GPA) of 63° as seen on the anteroposterior (AP) view, with an angular deformity of 21° measured on the scapula Y X‐ray, prompted a computed tomography (CT) scan. On three‐dimensional (3D) CT, the patient had 20° of angulation, 150% translation and 0.5 cm of displacement of the lateral border. Fracture lines propagated into the spinoglenoid notch, and out the scapular spine, and vertebral border. A two‐dimensional (2D) CT revealed no intra‐articular involvement, however there was significant displacement at the base of the coracoid, and a retroverted glenoid neck of 11°. Scapula fractures account for approximately 1% of all fractures, about the same percent as calcaneus fractures and exceeding that of the talus fractures. Therefore, this injury is quite relevant; particularly for trauma centers, where such injuries are filtered with regularity. A history should render the patient’s job description and recreational activities. The shoulder can compensate adequately for lower functioning individuals; therefore, not every displaced scapula fracture requires surgery. A physical exam should include whether abrasions exist over the shoulder, palpation of the AC and sternoclavicular joints, and a neurovascular exam of the extremity. When the patient can be upright, they must be examined disrobed to appreciate shoulder drooping, which is bothersome in severe cases. There are level IV and level V studies available to answer this question. Shoulder X‐rays yield the detail necessary to determine whether or not there is displacement of a fracture. If on the radiographs, there is displacement of a fracture greater than one centimeter, a 3D CT should be obtained to specifically measure displacement and angulation. In nondisplaced fractures in which nonoperative treatment has been selected, weekly follow‐up films over two weeks should be obtained due to the risk of displacement (level IV).1 Oftentimes, scapula fractures are delayed in referral or workup, either because of missed injury, or treatment of other bodily injuries, or the time it takes to refer to an appropriate medical center (level IV).2 In cases when such delay is greater than two weeks, an EMG and nerve conduction study should be performed due to a high association with nerve injuries (level V).3 This information is helpful for preop planning and prognostication. A 2D CT scan is useful when there is intra‐articular involvement to determine step, gap, and number of fragments. There are multiple opinions on the degree of displacement or angular deformity which warrant open reduction and internal fixation (ORIF). It is important to understand when to operate on patients with scapula fractures. It is important to understand which fractures require surgical treatment. For those which do require operative management, it is also important to understand which surgical approach is optimal. There are level IV and V studies available to answer this question. Though nonoperative treatment of double lesions of the superior shoulder suspensory complex have been shown to eventuate in good or excellent outcomes, it is likely that such series reflected minimally displaced injuries since almost no malunions were reported (all level IV) (Table 76.1).4–7 Nonoperative series to date have not stratified data based on measured displacement, and rigorous outcomes assessment of strength, motion, and function are lacking in those series (all level IV) (Table 76.1).4–8 Furthermore, other authors have reported patients with malunion which eventuated in poor outcomes, indicating that not all malunions are benign (all level IV).9–11
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Scapula Fractures
Clinical scenario
Radiography
Top three questions
Question 1: For patients with a scapula fracture, does CT, compared to plain X‐rays, provide an advantage in terms of diagnosis and management?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
Resolution of clinical scenario
Question 2: In patients with scapula fractures, does operative management, compared to nonoperative management, result in better outcomes?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
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