Near-normal function seen after operative treatment of severely displaced scapula fractures

Issue: December 2010

Open reduction and internal fixation of severe and severely displaced extra-articular fractures of the scapula can yield near-normal function and a low complication rate, data from a prospective, single-surgeon study suggest.

Peter A. Cole, MD, chief of orthopedic surgery at Regions Hospital and professor at the University of Minnesota in St. Paul, Minn., and Erich M. Gauger, MD, an orthopedic Surgery resident at the University of Minnesota, assessed 72 patients who were treated surgically between July 2002 and October 2009. Gauger presented the results at the 2010 Annual Meeting of the Orthopedic Trauma Association (OTA).

“It is important to mention that we only treated and studied what most would agree to be severe and severely displaced scapula fractures,” Cole told Orthopedics Today. “For example, 98% of the patients in this study had at least one associated injury, including 15% [of the patients having] associated nerve injuries.”

Researchers classified the fractures according to the revised OTA classification as scapula body (n=61, with 39 comminuted) or extra-articular glenoid neck fractures (n=11 with 10 comminuted).

“Technically however, there is much confusion and a lack of clarity in the field as to what constitutes a neck and a body fracture” Cole said.

Complete indications for operative treatment included: greater than 20 mm medial/lateral displacement — medialization — of the glenohumeral joint in relation to the lateral border of the scapula; greater than 45° of angular deformity in the semicoronal plane; angulation greater than 30° and medialization greater than 15 mm; double disruptions of the superior shoulder suspensory complex displaced greater than 10 mm; a glenopolar angle less than 22°; and open fractures.

Twenty-five patients met two or more of these criteria, and medialization was the most common criterion met, according to Gauger. Twenty-nine patients had a double or triple disruption of the superior shoulder suspensory complex with 17 patients meeting operative criteria.

Gauger reported 100% union rate and 82% of patients having at least 6 months of follow-up at a mean of 24 months (range, 6 to 70 months). The mean Disabilities of the Arm, Shoulder and Hand score was 14.1, and mean Short Form-36 scores were comparable to those of the normal population at all parameters.

The researchers found little difference in range of motion between the injured and uninjured shoulders. Forward flexion was 154° in the operated shoulder vs. 158° in the uninjured shoulder; abduction was 104° vs. 106° in the uninjured shoulder; and external rotation with the arm at the side and elbow flexed to 90° was 66° vs. 71°.

The patients demonstrated similar results for strength measured with a dynamometer: 18 lb of force in the operated shoulder vs. 23 lb of force in the uninjured shoulder for external rotation; 19 vs. 23 for forward flexion; and 14 vs. 16 for abduction.

According to the study abstract, eight patients were unable to return to work and activities because of reasons unrelated to the scapula fracture. The researchers reported five patients who underwent removal of scapula hardware, three patients with shoulder stiffness requiring postoperative manipulation under anesthesia, two patients who required removal of intra-articular screws immediately postoperatively, one patient who had a scapula malunion and a scapula fracture after fixation that was treated nonoperatively.

Because of the lack of a comparative or normal nonoperative cohort, “we cannot say what fractures should be operatively managed; only that if you have a highly displaced scapula fracture, it can be treated operatively with good functional outcome and an acceptable complication rate,” Cole said. – by Tina DiMarcantonio

Reference:

Gauger EM, and Cole PA. Surgical and functional outcomes after operative management of extra-articular glenoid neck and scapula body fractures. Paper 026. Presented at the 2010 Annual Meeting of the Orthopaedic Trauma Association. Oct. 13-16, 2010. Baltimore.

Erich M. Gauger, MD, and Peter A. Cole, MD, can be reached at the University of Minnesota, 640 Jackson St., St. Paul, MN 55101; 651-254-2815; e-mail: egauger@umn.edu and Peter.A.Cole@HealthPartners.com. Gauger has no direct financial relationships with any products or companies mentioned in this article. Cole is a paid consultant for Synthes and receives research support from Synthes, and DePuy, a Johnson & Johnson Company.

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