One article to get a broken shoulder blade, dry goods!

1.
Overview of fractures

Scapula fractures are less common clinically and are usually the result of blunt high-energy trauma, often caused by direct high-energy injuries to the shoulder girdle and falls from heights, 80% to 96% of shoulder blade fractures are accompanied by ipsilateral limb, shoulder girdle, or chest injuries, and the most common combined injuries include rib fractures, pulmonary contusion, head injuries, and clavicle fractures
.

A scapula fracture is associated with an ipsilateral clavicle fracture

Second, applied anatomy

The scapula is a flattened wide irregular bone located posteriorly on both sides above the thoracic cage, and consists of
three sides, three horns, three processes, and two sides.

The three sides are the upper edge, the lateral edge (axillary margin), and the medial edge (spinal margin);

The three corners are the upper corner: about the second rib, the lower corner: about the seventh rib or the seventh intercostal space, the lateral angle: the glenoid, the upper and lower glenoid tubercles;

three processes: coracoid process, acromion, glenoid;

Two sides: front, rear;

It can be seen that there are a large number of muscles attached around the shoulder blade, with the subscapularis muscle in front and the supraspinatus and infraspinatus muscle attached behind, which plays a stabilizing effect
on the fracture area.

Glenoid angle (GPA)

Shoulder suspense ligament complex (SSSC)

The angle between the upper and lower poles of the scapula and the supracapular and the distal line of the scapula is normally 30 to 45°
.
The focus here is on shoulder suspension ligament complex (SSSC) and floating shoulder injuries
.
Superior shoulder suspensory complex anatomy (SSSC): The shoulder suspension ligament complex consists of a ring-shaped structure and two bony protrusions, upper and lower:

The annular structure consists of
the coracoid process, the coracoclavicular ligament, the distal clavicle, the acromioclavicular ligament, the acromion, and the glenoid.

The upper bony protrusion includes the middle 1/3 of the clavicle;

The underlying bony protrusion includes the outermost junction of the scapula and the innermost junction of
the scapular neck.

The shoulder suspension ligament complex is the link between the upper limb and the axial bone, and is an important structure
for maintaining the stability of the upper limb and axial bone.

SSSC injuries and floating shoulder injuries
.

In the annular structure of the shoulder suspension complex, a single tear or fracture has little effect on the stability of the shoulder suspension complex, and the treatment effect is good
.

When more than two annular structures are damaged, the stability of the annular structure is damaged, and surgical repair of the annular structure is required, otherwise it will cause delayed healing of the fracture; Decreased strength in the upper extremities; and other long-term complications
.

The traditional definition of floating shoulder injury is that a fracture of two bony pillar structures of SSSC results in the loss of contact between the glenohumeral joint and the axial bone; William et al.
(2001) defined floating shoulder as the loss of bony and ligament connections
between the scapular neck and the glenoid and glenohumeral joints.

Therefore, the following three conditions can be referred to as generalized floating shoulder injuries:

Fracture of the scapula anatomical neck;

scapular surgical neck fracture + coracoid ligament rupture + coracoid shoulder ligament rupture± acromioclavicular ligament rupture;

Scapula surgical neck fracture + clavicle fracture + coracoidal ligament rupture + acromioclavicular ligament rupture
.

Third, the mechanism of injury

Scapula fractures are often caused by
high-energy trauma.
Usually with local and distant bone and soft tissue injuries (90%)
.
When the humeral head hits the edge of the shoulder and spleen glenoid, it can lead to a glenoid margin fracture
.
This fracture is a true fracture, not an avulsion fracture
caused by indirect violence.
When the humeral head hits the center of the glenoid fossa, it can lead to a fracture
of the glenoid fossa.
Depending on the direction of the force on the humeral head, the fracture can be displaced
in multiple directions.

4.
Diagnosis

Clinical manifestations: local pain and swelling of the shoulder with limited mobility, such as inability to lift the arm
.
Deformity, fracture of the shoulder blade predisposes to changes in the shape of the shoulder blade, such as shortening, angularization, or rotational deformity
.
Bone fricative sound or bone rubbing sensation, when the two fracture ends rub against each other after fracture, bone fricative sound or bone rubbing sensation
can be produced.

Clinical examination shows that the shoulder joint on the injured side has local deformities, usually the shoulder blade is displacement towards the caudal and medial sides, and some patients may have anterolateral rotation deformity
.
In some patients, severe subcutaneous bruising of the shoulder should be noted for dispossession injuries and dissociative injuries
to the scapula-thoracic wall.
Some patients may present with only localized pain or tenderness with no overt deformities or abnormalities
.

X-ray and CT scan

A series of X-ray examinations for scapula fractures that require a complete series of trauma include: scapula position, lateral scapula (or Y-position) and axillary position; Involvement of the scapular glenoid requires three-dimensional CT to identify intra-articular fractures
.
Imaging measurements include step size of the articular surface, glenoid angle, anterior and posterior body angle, and degree
of displacement of the fracture end of the lateral edge of the scapula in the coronal plane.

5.
Fracture classification

1.
Zdravkovic-Damholt classification

Classification of scapula fractures: The shape of the scapula is very irregular, the significance and treatment indications of each part of the fracture are different, it is difficult to carry out a comprehensive classification to cover all fractures, so most scholars tend to classify
according to anatomical parts.

Type I: scapular fracture;

Type II: fracture of the bony process, including acromion and coracoid process;

Type III: fracture of the superior lateral area of the scapula, including the scapuloneck and glenoid;

1.
Scapula; 2, 3.
Glenoid; 4.
Scapular neck; 5.
Acromion; 6.
Scapula; 7.
Coracoid process

Zdravkovic-Damholt classification

2.
Glenoid fracture Goss-Ideberg classification

Type I: anterior edge of the glenoid; Type Ib: posterior edge of the glenoid;

Type II: inferior glenoid; Type III: superior glenoid edge;

Type IV: transverse fracture of the body; Type V: mixed fracture (type II.
~IV.
);

Type VI: crushing fractures
.

3.
Acromial fracture (Kuhn classification)

This classification indirectly determines the degree of
displacement of acromial fractures through changes in the subacromial space.
After a scapromial fracture, it shifts downward under the traction of the deltoid muscle, etc.
, and the acromial space becomes smaller
on imaging.
Type I.
a

Type I.
b Type II

Type III

Type III

Type I acromion was not displaced, and the subacromial space did not change; Type II acromial fracture is displaced, but the subacromial space is not reduced;

Type III acromion displacement, narrowing of the subacromial space, can be the downward displacement of acromial fractures, or upward displacement of shoulder swollen blade neck fractures;

4.
Croak process fracture (Ogawa classification)

This classification is based on fractures that occur proximal to the coracoidal ligament, often with injuries
to SSSC components such as acromioclavicular dislocation and clavicle fractures.

Ogawa classification

Type I is a fracture near the attachment point of the coracoclavicular ligament;

Type II is a distant fracture of the coracoclavicular ligament attachment point;

6.
Treatment

1) Conservative treatment: including suspension and fixation of the triangle scarf of the upper limb on the affected side, early cold or ice compress, later heat compress, physiotherapy, etc
.

1.
The shoulder blade body fracture triangle scarf hangs the affected limb, and shoulder joint function exercise
can be performed 3 weeks after the injury.

2.
If there is no obvious displacement or small displacement of the shoulder blade neck and scapular glenoid fracture, the triangle scarf hangs the affected limb for 2-3 weeks, and functional exercises
are carried out as soon as possible.
For severe displacement, the abduction frame is fixed for 4 weeks
after the traction technique is restored.

3.
Acromial fracture: no displacement or inconspicuous displacement, the triangular scarf is suspended; displacement of the distal fracture end,

Adhesive tape or cast strips are cross-fixed
through the elbow shoulder on the affected side and the chest wall on the healthy side.

4.
Fracture of the scapular coracoid process: the cubital joint is flexed above 90 degrees of triangular scarf suspension
.

2) Surgical treatment:

1.
Purpose of surgery: The purpose of surgical treatment is to preserve the function of the shoulder joint as much as possible and avoid poor alignment, arthritis, scapulothoracic dyskinesia and impingement syndrome
.

2.
Timing of surgery: If the scapula body fracture is often combined with multiple injuries, and the condition is serious, it can only be carried out when the patient with stable life indications can tolerate the operation, and it is advisable to operate within 1 ~ 2 weeks after the injury, and the scapula fracture of more than 3 weeks is generally not advocated for surgery
.

3.
Indications for surgery:

(1) The fracture is angular deformity ≥ 45° on the Y-position;

(2) Fracture medial/lateral displacement ≥ 20 mm, shortening displacement > 30 mm;

(3) Angular deformity ≥ 30° combined medial/lateral displacement ≥ 15 mm;

(4) Glenoid angle (GPA) ≤ 22°;

(5) Upper shoulder suspension complex (SSSC) two-part tear, that is, complete acromioclavicular joint dislocation with lateral scapula displacement ≥ 10 mm, or clavicle fracture with lateral scapula displacement ≥ 10 mm;

(6) Open scapular body fracture
.

4.
Choice of surgical method: The surgical method depends on the patient's general condition and the local condition of
the fracture.
Conventional approaches include: anterior approach, posterior approach, upper approach and joint approach, and a reasonable surgical approach should be selected according to the type of fracture
.

(1) Anterior approach: deltoid muscle, pectoralis major space approach

This approach fully exposes the coracoid process, anterior to the glenoid margin, and lower glenoid
margin.
It is suitable for patients with scapular glenoid fractures accompanied by anterior fractures, coracoid fractures and anterior glenoid limbus fractures
.
Cut the skin along the anterior edge of the deltoid muscle from the coracoid process, pay attention to protect the cephalic vein, retract the deltoid muscle downward and outward, cut the subscapular ligament, in order to increase exposure, the coracoid process can be chiseled, and the coracoid process is drilled before osteotomy to facilitate postoperative fixation
.

(2) Posterior approach: Judet surgical approach

It is used for posterior upper scapuloid fractures, glenofossa fractures, scapular neck fractures, scapular fractures, suprascapular and lateral fractures and partial acromion fractures
.
Generally, only a connecting incision from the acromion to the lower corner of the scapula is used, and the scapula is exposed between the infraspinatus muscle and the small round muscle, and if necessary, the skin can be cut from the acromion along the scapula to the inner edge of the scapula, and the deltoid muscle, the teres minor, and the infraspinatus together with the skin are drawn downward and outward, revealing all the scapula, and the suprascapular nerve innervating the infraspinatus muscle is found at the notch to protect it, and there is a posterior incision sac sac
.

(1) The upper approach is suitable for fracture fixation above the scapular glenoid, the incision is located in the middle of the collarbone and the scapula, extend outward as much as possible, split the trapezius muscle fibers, and retract the supraspinatus muscle backward or forward according to the position of the fracture block
.
Carefully identify suprascapular notches to prevent accidental injury to the suprascapular nerve
.
The posterior part of the lateral border of the clavicle may be partially removed to facilitate screw retention
parallel to the glenohumeral joint surface.

The upper approach of simple acromial fracture: an incision is made along the acromion, subperiosteal peeling exposes the upper side of the acromion, and the anatomical reduction fracture is directly viewed under the view

Scapular approach: adapted to fractures of the upper edge of the scapula; The skin incision is located in the middle of the collarbone and shoulder blade, splitting the trapezius muscle fibers and retracting the supraspinatus muscle forward or
posteriorly depending on the position of the fracture piece.

Note: Carefully identify the suprascapular notch and do not damage the suprascapular nerve
.

VII.
Summary

There are many muscles around the shoulder blades, the blood supply is abundant, and the fracture healing rate is very high
.

The scapula body has the supraspinatus muscle behind it, the infraspinatus muscle is attached, and the subscapularis muscle is in front of it, forming a muscle splint to maintain the stability of the fracture and play a protective role
.

The special muscle splint and high healing rate of the shoulder blade determine that most patients can obtain better results through conservative treatment, but what is the most accurate surgical indication for shoulder blade fracture, there is no unified conclusion, each doctor will choose different treatment methods
according to their own understanding.

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