Scapular fractures account for 0.5% of all fractures, and while they have traditionally been the result of high-energy trauma resulting in multiple concomitant injuries, an increasing number of elderly patients are sustaining these fractures from low-energy trauma1. Fractures of the scapular body or glenoid neck account for 62% to 98% of all scapular fractures, making these extra-articular patterns the most common types of these injuries2-6. While there has been considerable interest in glenoid neck fractures, particularly floating shoulder lesions7-16, data on the operative management of glenoid neck or scapular body fractures are scarce2,17-24. Current knowledge of the outcomes of operatively treated extra-articular scapular fractures has been derived from small, retrospective case series that included fractures with intra-articular extension or associated process fractures18-20,22-24, analyzed outcomes on the basis of individual fractures in patients with multiple fracture types2, or lacked validated patient-based functional outcomes inclusive of rigorous strength and range-of-motion testing2,17,19,20,22,23.
The purpose of this study was to assess the clinical and patient-reported functional outcomes following open reduction and internal fixation (ORIF) of highly displaced scapular body and glenoid neck fractures. This series of fractures represents a 9-year experience at a level-I trauma center and referral destination for this injury.
Materials and Methods
An institutional review board-approved prospective scapular fracture database was established to record operative data and monitor the clinical and functional outcomes of scapular fractures treated operatively. The operative indications, based on the available literature, were (1) medial/lateral displacement (defined as displacement between the proximal and distal fragments at the lateral border, commonly referred to as “medialization”) of ≥20 mm; (2) angular deformity between the fracture fragments of ≥45° in the semi-coronal plane measured on the scapular Y view; (3) medial/lateral displacement of ≥15 mm and angulation of ≥30°; (4) a glenopolar angle of ≤22°; (5) a double lesion of the superior shoulder suspensory complex as described by Goss25, with ≥10 mm of displacement of both lesions; and (6) open fracture. Patients were excluded if they had sustained a traumatic brain injury from which they were not expected to recover that prevented them from providing informed consent or participating in the postinjury rehabilitation.
Between February 2002 and January 2011, 717 patients presented with a scapular fracture to our level-I trauma center or the private clinic of the senior author (P.A.C.). One hundred and fifty met the operative criteria and were enrolled in the database; 80 (53%) of the 150 had been referred from outside institutions.
The standard preoperative radiographic protocol included anteroposterior (Grashey), lateral (scapular Y), and axillary views of the injured shoulder (Figs. 1-A, 1-B, and 1-C). In addition, computed tomography scans with 3-dimensional reconstructions (3D-CT scans) were ordered when a clearly displaced scapular fracture was diagnosed. The technique for making measurements utilizing 3D-CT was previously validated and reported by the senior author (P.A.C.) and colleagues26. Fractures were classified according to the revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA)27 classification system.
The standard postoperative rehabilitation protocol consisted of full passive and active-assisted shoulder motion with a full active range of motion beginning immediately after surgery, with 3 to 5 lb (1.35 to 2.25 kg) of resistance added between 1 and 2 months. A strengthening program was initiated in the third month and was advanced as tolerated.
At each follow-up appointment, starting at 6 weeks postoperatively, patients underwent comprehensive clinical testing, including measurement of the range of motion and strength, which has been previously reported as a reliable technique28,29. The range of motion of both the injured and the contralateral (uninjured) shoulder was measured with a 14-in (36-cm) goniometer. The forward-flexion starting position was an axis in line with the humeral head and both goniometer arms aligned with the humeral shaft (with the subject’s arm at the side and shoulder internally rotated 90°). The abduction starting position was an axis in line with the coracoid process and both goniometer arms aligned with the humeral shaft (with the subject’s arm at the side and shoulder internally rotated 90°). The external rotation starting position was an axis in line with the olecranon and both goniometer arms aligned with the ulna (with the subject’s arm at the side and elbow flexed to 90°) (Fig. 2).
A handheld dynamometer (microFET2; Hoggan Health Industries) was used to assess shoulder strength (in pounds of force) in forward flexion (forearm pronated and elbow extended), abduction (forearm pronated and elbow extended), and external rotation (arm at side and elbow flexed to 90°) (Fig. 3). Strength measurements for both the injured and the uninjured (contralateral) shoulder were recorded. Patient-reported outcomes were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire30 and the Short Form-36 (SF-36)31, version 1 or 2. Finally, all patients were questioned regarding residual pain, work status, and recreational activities.
All patients who had a fracture of the glenoid neck or scapular body (AO/OTA 14-A3.1 or 3.2 and 14-C1.1 or 1.2) without intra-articular involvement were included in the study. Those with an isolated fracture of the coracoid or acromion were not included. All were operated on within 20 days after the injury. The functional outcomes of fractures of the acromion or coracoid process, intra-articular glenoid fractures, and fractures for which operative treatment was delayed for >20 days have been reported in separate cohorts and therefore were excluded from this study32,33. There was also a previously published study of the early results of the treatment of scapular fractures but it focused on surgical results, not functional outcomes; had limited follow-up; and included all fracture types treated early or late22.
Our review of the cases of 150 patients who underwent ORIF of a scapular fracture revealed that 61 (49 male and 12 female) with a glenoid neck or scapular body fracture met our inclusion criteria. The patients had a mean age of 44 years (range, 18 to 68 years), and 27 (44%) of the injuries were on the dominant side. The mechanism of injury was considered to be high-energy in all but 3 patients (5%), who sustained the fracture in a fall from a low height. Two open fractures resulted from penetrating injuries: 1 was a gunshot wound and the other, a boating propeller injury. According to the revised AO/OTA classification, there were 51 scapular body fractures (14-A3), 32 (63%) of which were comminuted, and 10 glenoid neck fractures (14-C1), 9 (90%) of which were comminuted. Twenty-six patients (43%) sustained a double (n = 25) or triple (n = 1) disruption of the superior shoulder suspensory complex (see Appendix). Only 4 patients (7%) had injuries isolated to the scapula. The remaining 57 patients sustained at least 1 associated injury, with rib fractures (n = 44, 72%), clavicular fractures (n = 23, 38%), and pneumothorax/hemothorax (n = 18, 30%) being the most common (Table I).
Nineteen (31%) of the patients had ≥2 indications for surgery. In 43 (70%) of the patients, medial/lateral displacement was the operative indication, with a mean displacement of 26.6 mm (range, 20 to 40 mm). For 8 patients (13%), the operative indication was angular deformity combined with medial/lateral displacement, with a mean angulation of 34.4° (range, 31° to 41°) and a mean displacement of 23.6 mm (range, 16 to 34 mm). Twenty-six patients (43%) sustained a double disruption of the superior shoulder suspensory complex, with 14 (23%) of the patients having double disruption as the operative indication because both lesions were displaced ≥10 mm. Thirteen patients (21%) had a fracture deformity with a glenopolar angle of ≤22° (range, 15° to 22°), 2 patients (3%) had an angular deformity of ≥45° (46° in both) seen on the scapular-Y view, and 2 patients (3%) had an open fracture of the scapula. One patient did not meet the radiographic criteria for operative fixation, but operative management was deemed appropriate given his strong preference for stabilization, his age (32 years) and occupation (sheet metal worker), the fact that the scapular fracture had progressively medialized from 10 to 16 mm over a period of 9 days, and his dissatisfaction with the “slumped” appearance of the shoulder (see Appendix).
The mean time from the injury to the surgery was 11 days (range, 1 to 20 days). All index procedures were done through a posterior approach. Fifty-four patients (89%) had a Judet skin incision34, which was followed by elevation of a muscular flap consisting of the infraspinatus, teres minor, and deltoid in 44 of them; in the other 10, the surgeon worked through the interval between the infraspinatus and teres minor35. Five patients (8%) had a 2-incision minimally invasive approach36, 1 patient had a straight posterior approach, and 1 patient had an intramuscular approach through an open fracture. Of the 23 clavicular fractures, 17 (74%) were operatively fixed. A mean of 2.8 plates (range, 1 to 6) were used for the scapula. Two patients had supplemental fixation with 2.7-mm cortical screws from the acromial spine into the glenoid neck/lateral border.
Of the 61 patients, 49 (80%) were followed for ≥1 year (mean, 33 months; range, 12 to 138 months) following the surgery and were included in the outcomes analysis. Patients with <1 year of follow-up (n = 4) or no follow-up (n = 8) were not included in the outcomes analysis, although at an average of 7 months the 4 patients with <1 year of follow-up were noted to have radiographic and clinical evidence of healing.
The postoperative range of motion and strength were measured by a single examiner (P.A.C.) for all patients. The mean range of motion of the injured shoulder at the time of final follow-up was 154° (range, 60° to 188°) of forward flexion, 106° (range, 70° to 160°) of abduction, and 66° (range, 18° to 103°) of external rotation. The mean range of motion of the uninjured, contralateral shoulder was 159° (range, 126° to 188°) of forward flexion, 108° (range, 78° to 160°) of abduction, and 70° (range, 18° to 106°) of external rotation (Table II).
The mean postoperative strength of the injured shoulder was 20 lb (89.0 N) of force (range, 7 to 37 lb [31.1 to 164.6 N]) in forward flexion, 14 lb (62.3 N) (range, 6 to 28 lb [26.7 to 124.6 N]) in abduction, and 19 lb (84.5 N) (range, 9 to 39 lb [40.0 to 173.5 N]) in external rotation. The mean strength of the uninjured, contralateral shoulder was 23 lb (102.3 N) (range, 4 to 39 lb [17.8 to 173.5 N]) in forward flexion, 16 lb (71.2 N) (range, 4 to 29 lb [17.8 to 129.0 N]) in abduction, and 23 lb (102.3 N) (range, 9 to 41 lb [40.0 to 182.4 N]) in external rotation (Table III).
The mean and median DASH scores at the time of final follow-up were 12.1 and 4 points, respectively (range, 0 to 54 points; normative mean, 10.1 points37). For all 8 parameters, the mean SF-36 scores of the study patients were comparable with those of the normal population. The mean scores for the study population across all parameters were 63 to 81 points (version 1) and 48 to 56 points (version 2). The control mean scores according to Ware et al.31,38,39 are 61 to 84 points (version 1) and 50 ± 10 points (version 2).
Of the 49 patients, 36 (73%) returned to their preinjury work and activities, 6 (12%) were unable to return to work and/or activities for reasons unrelated to the scapular fracture (most commonly associated injuries), and 1 patient (2%) receiving Workers’ Compensation for a prior ipsilateral rotator cuff injury repair at the time of the scapular fracture reported being unable to return to work because of the injured shoulder (see Appendix). Data were missing for the remaining patients.
Complications or Reoperations
There were no intraoperative or incision-related complications. There were also no infections or nonunions. However, 8 patients had a total of 9 postoperative complications or secondary surgical procedures, including scapular implant removal (n = 3), shoulder manipulation under anesthesia (n = 3), screw removal due to possible intra-articular involvement (n = 1), scapular refracture not requiring a second operation that eventually healed (n = 1), and removal of exostoses (n = 1) (see Appendix).
A recent systematic review of operative treatment of scapular fractures identified only 63 operatively treated extra-articular glenoid neck or scapular body fractures40. The two largest series included one (n = 15) that focused on double disruptions of the, superior shoulder suspensory complex8 and one (n = 14) on isolated glenoid neck fractures41.
Investigators evaluating the results of operative and nonoperative treatment of scapular fractures have infrequently reported radiographic fracture characteristics such as displacement and angular deformity, making their conclusions difficult to interpret10-12,42-45. This inability to link quantifiable fracture characteristics with outcomes is one of the key obstacles to making recommendations regarding treatment of scapular fractures. In the current study, we reported the quantitative clinical and patient-reported outcomes of 49 (80%) of 61 surgical procedures for extra-articular glenoid neck or scapular body fractures that we thoroughly described utilizing validated radiographic measurements. The mean postoperative range of motion and strength were comparable between the injured and contralateral shoulders. In addition, the difference between the injured and contralateral sides with respect to the standard deviations for the range of motion and strength was small, providing evidence that the surgical results are consistent. Of the 49 patients followed for ≥1 year, 36 were able to return to their preinjury work and activities and had excellent functional outcomes as evidenced by nearly normal DASH and SF-36 scores. There were no additional postoperative complications or reoperations since the time of a previous report on the early radiographic and surgical results in these patients22.
Few studies have documented fracture measurements and patient-reported outcomes of patients with nonoperatively treated extra-articular scapular fractures. Pace et al. assessed radiographic data on 9 patients with a glenoid neck fracture and found that the 2 patients without evidence of glenoid neck malunion had the best Oxford scores, a full range of motion, and good or excellent outcomes46. However, no patient was completely free of pain, and the authors concluded that pain was associated with glenoid neck malunion and evidence of subacromial bursitis or rotator cuff tendinopathy, or both. The authors of other reports have also concluded that glenoid neck fractures with malalignment, as indicated by a glenopolar angle of <20°, are associated with less favorable outcomes47,48. Additionally, van Noort and van Kampen49 followed 13 (54%) of 24 patients with a nonoperatively treated glenoid neck fracture and reported that 11 had an excellent outcome according to the Constant score. Ten of the 13 patients had ≤1 cm of glenoid neck shortening and no patient had a glenopolar angle of <20° as measured on radiographs, illustrating the difficulty in comparing operative and nonoperative outcomes.
More recently, in a study of nonoperative management of scapular fractures in 50 patients, Schofer et al.44 demonstrated a significant difference in the Constant score between the injured and uninjured shoulders as well as a significantly decreased range of motion in all planes. Although they did not provide any radiographic measurements, the authors believed that, despite quantifiable differences between the injured and uninjured sides, the functional outcomes were still good. Another study, which included 22 patients with a scapular body fracture, compared the functional outcomes of patients who had an isolated scapular fracture with those of patients with multiple injuries and concluded that the assumption of a satisfactory outcome after conservative treatment is not always true45. Dimitroulias et al.50 evaluated 32 (65%) of 49 displaced scapular body fractures at a minimum of 6 months postinjury. The authors defined displaced fractures as those that were 100% translated and/or displaced >1 cm, although they provided no explanation of how these measurements were obtained and stated that medial/lateral displacement was not measured. They also did not present any strength or range-of-motion data. Dimitroulias et al. reported satisfactory outcomes, primarily based on the change in the DASH score, but did not report the absolute DASH scores for the injured arms.
Although there has been a recent trend toward presenting specific operative indications for glenoid neck and scapular body fractures18,19,22-24, older reports provided inconsistent evidence on when surgical treatment is appropriate, with many of them lacking clearly defined surgical indications7-14. We are not aware of any study comparing operative and nonoperative management of scapular fractures with similar deformity. Jones and Sietsema21 did conduct a retrospective review of 31 operatively treated scapular fractures in patients matched by age, occupation, and sex to 31 patients treated nonoperatively. Although the outcomes were comparable in the 2 groups, the authors demonstrated a much greater severity of injury with respect to medial/lateral displacement, shortening, and angulation in the operatively treated group.
A recent epidemiologic study highlighted scapular fractures resulting from low-energy trauma in the elderly, especially women1. Low-energy trauma caused the fracture in only 3 patients (all male) of the 61 patients in our series. This may be a result of high-energy trauma being overrepresented in patients presenting to a level-I trauma center. It may also be that high-energy trauma is more likely than other mechanisms to produce the force necessary to displace the scapular fragments sufficiently to meet our operative criteria.
A limitation of our study is the lack of a nonoperative control group. Without a control group, we could not prove that surgery yields better outcomes than benign neglect of these fractures—rather, only that patients with certain accepted operative indications can be successfully treated by an experienced surgeon. It should also be emphasized that we do not recommend operative management of even moderately displaced scapular fractures. This series represents a particular subset of patients with highly displaced fractures meeting relatively conservative operative indications, as evidenced by the fact that, during this study period, only 70 (9.8%) of 717 scapular fractures that presented acutely at our institution were treated operatively.
Another limitation is that all measurements were performed and documented by the senior author, which could have created detection bias. However, we believe that the value of a single examiner was the provision of consistency due to a critical eye familiar with this patient population. Perhaps more importantly, we believe that our measurements of the range of motion and strength of the contralateral extremity provided a useful internal control with which to compare postinjury and posttreatment functional levels. Furthermore, the DASH form is completed independently by the patient, adding objectivity to the survey. The DASH results corroborated the improvements in strength and range of motion over time, which we believe supports those results.
Finally, we recognize that this series represents diverse patients and injuries and, although we excluded intra-articular fractures and isolated process fractures, there was heterogeneity regarding patient demographics, concomitant shoulder girdle trauma, and other associated injuries. Nevertheless, the cohort was uniform with regard to the fact that all fractures involved the neck or body without intra-articular involvement.
In conclusion, we report what we believe to be the largest single-center consecutive series of operatively treated scapular body and glenoid neck fractures in the English-language literature with clinical follow-up consisting of detailed range-of-motion measurements, strength analyses, and patient-reported outcome instruments including the DASH and SF-36. The results of our study suggest that severely displaced scapular body and glenoid neck fractures can be treated operatively with predictably good functional outcomes and a low rate of complications.
Tables showing demographics, fracture classifications, and operative indications as well as range of motion, strength, functional outcomes, and complications at the time of follow-up for the individual patients are available with the online version of this article as a data supplement at jbjs.org.
Investigation performed at the Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, St. Paul, Minnesota
Disclosure: Research grant funding for this study was provided by Synthes, Inc., but Synthes did not play a role in this investigation with regard to patient management, data analysis, or manuscript preparation. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work.
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