Nonoperative treatment showed good results for isolated scapular body fractures

BALTIMORE — A retrospective review of 5-year results following nonoperative treatment for isolated scapular body fractures has found that surgery for these injuries may be unwarranted.

Andrew N. Pollak

“While there is evidence that not all scapular fractures result in excellent outcomes, the determination of which injuries might benefit from operative intervention remain unclear,” Andrew N. Pollak, MD, said at the 2010 Annual Meeting of the Orthopaedic Trauma Association, here.

“We conducted a retrospective review of patients treated at our institution for fractures displaced greater than or equal to 10 mm, extra-articular scaphoid body fractures from 2002 to 2007,” he said “These were just isolated injuries. All were treated nonoperatively, as was the protocol for all displaced scapular body fractures consistently during the time of this study.”

Pollak, an Orthopedics Today Editorial Board member, added, “Our hypothesis was that patients with isolated displaced scapular body fractures would have poor outcomes with nonoperative treatment and may therefore benefit from operative treatment.” He later noted that the results of the investigation would not prove that hypothesis.

Types of fractures

Overall, the investigators found 60 patients who met the study criteria and had DASH, SF-36 and functional outcomes scores, as well as range of motion, strength, endurance and return-to-work or activities data available.

According to the study abstract, there were 62 body factures with 39 comminuted and 10 neck fractures, nine of which were comminuted. In terms of published operative indications — greater than 20 mm medialization of the glenohumeral joint; greater than 45° of angular deformity in the semicoronal plane; angulation greater than 30°; double disruptions of the superior shoulder suspensory complex displaced more than 10 mm; glenopolar angle greater than 22° and open fractures — 25 patients exhibited two or more, with 28 patients having double or triple disruptions of the superior shoulder suspensory complex.

At 25 months, the researchers found that all patients had demonstrated clinical and radiographic union of their fractures.

“One-hundred percent of the study patients denied any limitations to their activity due to their shoulder,” Pollok said. “No patient changed occupations as a result of their shoulder injury.”

He said that the average postoperative DASH score was 3.6 with 36% scoring zero out of 100 points — normal. Three patients could not remember which shoulder was injured. “One of those three, agreed to answer the questions but would not agree that he ever sustained a shoulder injury,” Pollok said.

Largest published series

“Other studies have shown that changing the glenopolar angle is associated with disfunction,” he said. “Ours was the largest published series of homogenous fracture patterns plus validated outcomes measures available at a single institution with a single treatment protocol.” He noted that the retrospective nature and small size were limitations.

“We were unable to confirm our hypothesis that nonoperative treatment of scapular body fractures results in poor long-term outcomes.

“Our findings suggest that nonoperative treatment of displaced scapular body fractures leads to excellent long-term results and that displacement alone should not be an indication for operative intervention,” he said. “In the absence of evidence refuting these conclusions, operative treatment of displaced scapular body fractures should not be employed and a prospective randomized comparison of operative vs. nonoperative treatment does not seem justified or otherwise warranted.”

Reference:
Bauer BJ, O’Toole RV, Pollak AN, et al. What is the outcome of a protocol of a nonoperative treatment of all displaced scapula fractures? Paper #25. Presented at the 2010 Annual Meeting of the Orthopaedic Trauma Association. Oct. 13-16, 2010. Baltimore.

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