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Posterior Scapula Approaches: Extensile and Modified Judet

Cole, Peter A. MD; Dugarte, Anthony J. MD

Author Information
Journal of Orthopaedic Trauma: August 2018 - Volume 32 - Issue - p S10-S11
doi: 10.1097/BOT.0000000000001208

Abstract

INTRODUCTION

Scapula fractures are often the result of high-energy injury mechanisms. Operative planning depends largely on the chronicity, location, and complexity of the fracture. The operative indications established by the primary author are based on radiographical analysis and extensive experience.1–3

As scapula fracture surgery is often delayed to triage other critical injuries, the Extensile Judet has long been useful in the management of scapula fractures.4,5 More recently, variations to the classic approach that minimize soft-tissue trauma have been described.6,7 This is a direct result of an enhanced understanding of fracture patterns.8,9 Avoiding the soft-tissue trauma incurred with the Extensile Judet may expedite postoperative rehabilitation and return to function.

Careful consideration should be taken on a patient-to-patient basis when determining the appropriate approach for fixation of scapula fractures. We highlight the indications and technique for 2 posterior approaches to the scapula: the Extensile Judet and the Modified Judet (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A401).

CASE 1: MODIFIED JUDET

Case 1 illustrates the Modified Judet for a glenoid fracture with an associated transverse scapula body fracture in a 45-year-old man. This approach is ideal for acute fractures with minimal comminution, particularly when exit sites do not require direct visualization of the posterior aspect of the scapula.

Preoperative Management and Patient Positioning

Preoperative evaluation includes anterior–posterior, scapula-Y, and axillary x-rays. Three-dimensional (3D) computed tomography can be helpful in further characterizing fracture patterns.8,9

The patient is situated in lateral decubitus, “sloppy forward” position. The entire forequarter is prepped and draped, and the operative extremity is placed at 90 degrees over a foam wedge.

Surgical Approach

Bony landmarks are palpated and the incision is marked. A “boomerang” incision following the natural curve of the scapula spine and vertebral border is made. The dissection is brought down to the level of the fascia overlying the infraspinatus and posterior deltoid. This fascia is incised in parallel to the opening incision, and a fasciocutaneous flap is elevated, revealing the interval between the teres minor and infraspinatus muscles. With a blunt dissection, reduction and stabilization can occur through this intermuscular window.

Reduction, Definitive Fixation, Wound Closure, and Postoperative Management

A shoulder hook, Cobb elevator, pointed bone tenaculums, and Shanz pins are powerful reduction tools when re-establishing the lateral border and curve of the scapula spine. Generally, fixation can involve 2.7-mm reconstruction and dynamic compression plates for the spine and lateral border, respectively. Minifragment fixation with 2-mm screws may be used for comminution. A 3.5-mm lag screw can be used for acromion process fixation. Wound closure is accomplished with absorbable suture in a layered manner. Postoperatively, patients undergo immediate range of motion for the operative shoulder, without resistive activities. All restrictions are removed after 3 months.

CASE 2: EXTENSILE JUDET

Case 2 illustrates the Extensile Judet approach for a 50-year-old man with a comminuted scapular body fracture sustained 3 weeks before. This approach is best for complex injuries with severely comminuted fractures, multiple exit points, and abundant callus formation.

Preoperative Management and Patient Positioning

Preoperative management and patient positioning are as described for case 1.

Surgical Approach

Bony landmarks are palpated and the incision is carefully marked. A “boomerang” incision that parallels the scapula spine and vertebral border is made. Dissection is taken down to the fascia overlying the infraspinatus and posterior deltoid. The posterior deltoid and infraspinatus are sharply taken from their origins (scapular spine and medial border, respectively). A Cobb elevator is used to elevate a full-thickness, musculocutaneous flap from the posterior aspect of the scapula. Exercise should be cautioned, as the suprascapular neurovascular traverses the spinoglenoid notch.

Reduction, Definitive Fixation, Wound Closure, and Postoperative Management

The reduction techniques, stabilization methods, wound closure, and postoperative care are identical to those described in case 1.

DISCUSSION

Two different posterior approaches to the scapula are described; both include the same incision, reduction goals, wound closure, and postoperative care, but differ regarding management of the musculature overlying the fracture. The Modified Judet lacks the exposure of the Extensile approach, but avoids significant soft-tissue trauma. In contradistinction, the Extensile Judet involves the mobilization of a full-thickness, musculocutaneous flap to gain the exposure necessary for complex fracture patterns.

It is hypothesized that working through intermuscular intervals and sparing the deltoid can expedite postoperative rehabilitation. It is the experience of the primary author that patients treated with the Modified Judet approach can return to function quicker because pain is minimized, and strength and motion normalize earlier when compared with those receiving the Extensile Judet.

CONCLUSIONS

Both the Extensile and Modified Judet approaches are valuable in terms of operative management of scapula fractures, although certain populations may benefit from tissue-sparing procedures.

REFERENCES

1. Cole PA. Scapula fractures: open reduction internal fixation. In: Wiss DA, editor. Fractures. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:15–36.
2. Cole PA, Marek DA. Shoulder girdle injuries. In: Stannard JP, Schmidt AH, Kregor PJ, editors. Surgical Treatment of Orthopaedic Trauma. New York, NY: Thieme; 2007:207–237.
3. Anavian J, Conflitti JM, Khanna G, et al. A reliable radiographic measurement technique for extraarticular scapular fractures. Clin Orthop Relat Res. 2011;469:3371–3378.
4. Judet R. Surgical treatment of scapular fractures. Acta Orthop Belg. 1964;30:673–678.
5. Lantry JM, Roberts CS, Giannoudis PV. Operative treatment of scapular fractures: a systematic review. Injury. 2008;39:271–283.
6. Gauger EM, Cole PA. Surgical technique: a minimally invasive approach to scapula neck and body fractures. Clin Orthop Relat Res. 2011;469:3390–3399.
7. Obremskey WT, Lyman JR. A modified Judet approach to the scapula. J Orthop Trauma. 2004;18:696–699.
8. Armitage BM, Wijdicks CA, Tarkin IS, et al. Mapping of scapular fractures with three-dimensional computed tomography. J Bone Joint Surg Am. 2009;91:2222–2228.
9. Dugarte AJ, Tkany L, Schroder LK, et al. Comparison of 2 versus 3 dimensional fracture mapping strategies for 3 dimensional computerized tomography reconstructions of scapula neck and body fractures. J Orthop Res. 2018;36:265–271.
Keywords:

scapula; fracture; Judet; extensile; modified; posterior approach; glenopolar angle; glenoid; shoulder; forequarter

Supplemental Digital Content

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