Scapular body fractures: results of operative treatment

The authors operated on 22 patients with scapular body fractures, with a mean age of 35 years. The minimal follow-up was 12 months. All patients were treated from the Judet posterior approach. The study included 14 cases of an isolated body fracture, three of scapular body fracture combined with fracture of the scapular neck and five of glenoid fossa fracture. In all 14 cases where a 3D computed tomography (CT) reconstruction was performed prior to operation, intraoperative findings corresponded to this reconstruction. In eight cases without preoperative 3D CT reconstruction, the correct type of fracture was identified in only two cases. We also identified three basic types of fractures of the lateral border of the scapula. The anatomical relationship between the glenoid fossa and scapular body, congruency and stability of the shoulder joint was achieved in all cases. The average constant score was 94.     

外侧切口入路桥接组合式内固定治疗肩胛骨骨折

目的:探讨采用外侧切口入路桥接组合式内固定系统治疗肩胛骨骨折的临床效果。方法:2012年10月至2016年12月,采用外侧切口入路桥接组合式内固定系统治疗20例肩胛骨骨折,男15例,女5例;年龄21~52岁,平均31.6岁。肩胛体骨折14处,肩胛颈骨折10处,肩胛冈骨折6处,肩峰骨折1处,喙突骨折1处,盂缘骨折4处,盂窝骨折3处。手术时间为伤后4~15 d,平均10 d。结果:所有患者获得随访,时间3~24个月,平均15个月。术后2例发生伤口感染,经伤口清创、换药后愈合,无骨髓炎、医源性神经损伤、内固定松动断裂、骨折再移位、关节僵硬等并发症发生。术后3个月骨折部位可见骨痂生长,骨折愈合时间为4~7个月,骨折愈合良好,无延迟愈合或畸形愈合。肩关节功能评定采用Hardegger评定标准:优12例,良6例,可2例。结论:肩胛骨外侧切口入路术中操作方便,显露清楚,该切口可任意向两边延长,能为骨折的复位固定提供有利条件。桥接组合式内固定系统术中操作灵活,固定强度可靠,是一种治疗肩胛骨骨折的良好选择。     

手术治疗肩胛骨骨折23例疗效分析

目的探讨手术治疗肩胛骨骨折的内固定方式及其疗效。方法手术治疗23例肩胛骨骨折患者,14例采用后方Judet入路,2例采用前后方联合入路,1例喙突骨折与2例盂部前方骨折采用前方入路,2例肩峰骨折采用骨折处直接切开,2例盂部后方骨折采用后方肩胛骨外缘直接切开。16例伴有肩胛骨多处骨折采用钢板螺钉固定,1例喙突骨折及2例关节盂骨折采用拉力螺钉固定,2例肩峰骨折分别采用克氏针和钢丝环扎,2例关节盂骨折采用可吸收螺钉固定。结果 21例获得随访,时间9～55个月。骨折均愈合。采用体格检查及肩关节Constant评分标准进行疗效评价:优11例,良7例,可2例,差1例。术后并发浅表感染1例,外展>90°时轻微疼痛2例,肩胛上神经卡压1例。结论对于达到手术指征的肩胛骨骨折,适合的手术入路及内固定可以达到满意治疗效果。     

Dislocation fractures of the shoulder. Special status and therapeutic concepts]

Shoulder dislocations associated with a displaced fracture of the humeral head or glenoid require different treatment than shoulder dislocations without fracture. If the humeral head is fractured, two possible complications must be considered:impairment of the subacromial gliding mechanism and insufficient blood supply to the humeral head. In glenoid fractures, instability may be induced. The degree of instability depends on the size of the fragment. In fractures of the humeral head, in particular of the greater tuberosity, we differentiate between the so-called en bloc fracture and the so-called supra-spinatus avulsion fracture. In "en bloc" fractures, one has to be aware that displacement of the fragment can occur not only in the superior direction but in the posterior direction as well. Posterior displacement is displayed radiologically by the "tangential" view. Both the duration of pain and range of motion depend on the amount of displacement of the fragment. Displacement exceeding 3 min in one direction should be reduced surgically in the active patient. For operative treatment of a displaced "en bloc" fracture, we recommend closed reduction and percutaneous screw fixation performed under regional anesthesia. "Supraspinatus avulsion fractures" ought to be treated like rotator cuff tears because there is no possibility of the small fragments healing due to their placement on the joint cartilage. In fracture dislocations, the blood supply of the humeral head is seriously jeopardized if the fracture is situated in the anatomical neck, whereas this is not the case in a fracture of the surgical neck. The number of displaced fragments allows a prediction concerning the survival of the articular segment of the humeral head.(ABSTRACT TRUNCATED AT 250 WORDS)     

The subscapular and subcoracoid bursae: descriptive and functional anatomy

The subscapularis and subcoracoid bursae, as well as the subscapularis muscle, were studied in 42 fresh cadaveric shoulders. Fibrous bands were found in the medial part of the muscle; they were intercalated with the distal tendon-like bands. The superior distal fibrous band was always found to be thicker than the others. Strong fibrous attachments of the subscapularis muscle were found along the lateral border of the scapula as well as along the medial third of the bony crests in the subscapular fossa. Between the crests, the muscle bundles were directly attached to the bone. In the lateral part of the scapula, the subscapularis muscle had only weak connective links with the bone. The subscapularis bursa was found in all cases as a pouch strongly attached to the scapular neck and the adjacent part of the joint capsule. The top of the bursa was linked to the coracoid process by a fibrous attachment called the suspensory ligament. The subcoracoid bursa had only weak connective links with the coracoid process. In 28% of cases, the subscapularis and subcoracoid bursae merged into a unique wide bursa. The subscapular bursa had two types of links with the muscle: (1). weak connective links with the superficial muscle bundles and (2). at least 2 fibrous arcs joining the lateral tendon-like bands, the bursa, and bony crests of the subscapularis fossa. These arcs allow the bursa to follow the course of the muscle exactly. During movements of the glenohumeral joint, the subscapularis muscle sustains huge changes of orientation, particularly the upper part of the muscle that coils around the coracoid process. The strong superior fibrous band enables the muscle to maintain contact with the coracoid process. It is the function of the subscapularis and subcoracoid bursae to manage the friction of the superficial fibers against the scapular neck, the humeral head, and the coracoid process.     

Fractures of the scapular neck: diagnosis,classifications and treatment

Purpose

Fractures of the scapular, or glenoid, neck are strongly debated in the relevant literature. Analysis of the respective studies, however, revealed a considerable confusion in terms of definition, terminology and diagnosis. In addition, there are few studies, primarily case reviews, dealing in detail with these fractures. The aim of this article is to present detailed information about fractures of the scapular neck, based on the analysis of our own experience and of the published literature.

Material and methods

Our group of 17 fractures of the scapular neck comprised 14 men and three women, with a mean age of 38 years (range, 24–55). The authors diagnosed four fractures of the anatomical neck, nine fractures of the surgical neck and five trans-spinous fractures of the neck. Of these 17 scapular neck fractures, six fractures were treated non-operatively, and 11 fractures were operated on via the posterior Judet approach. The mean follow-up was 4.9 years (range, 1–11).

Results

Fractures in all six non-operatively treated patients healed without complications in the anatomical position and with full function of the shoulder. In 11 operatively treated patients, all fractures of the scapula and clavicle healed within three months. In nine cases the function of the shoulder was subjectively and objectively assessed as normal, and in the remaining two cases as fair.

Conclusion

The term “scapular, or glenoid, neck” covers three different types of fractures, i.e., fracture of the anatomical neck, fracture of the surgical neck and trans-spinous neck fracture. Fractures of the surgical neck are divided into stable, fractures with rotational instability and fully unstable fractures, depending on the integrity of the coracocacromial and coracoclavicular ligaments. Accurate diagnosis of fractures of the scapular neck requires 3D CT reconstructions. Undisplaced or minimally displaced fractures may be treated non-operatively, markedly displaced fractures constitute an indication for osteosynthesis via the Judet approach.     

多层螺旋CT多平面重建及三维重建在肩胛骨骨折中的应用

目的 探讨多层螺旋CT（Multi-slice Spiral CT，MSCT）多平面重建和三维重建技术在肩胛骨骨折中的应用及临床价值。方法 26例肩胛骨骨折病人行MSCT扫描，图像经工作站处理后进行多平面重建和三维重建，由三位有经验的放射科医师共同阅片分析，统一评定。结果 本组26例均可以通过多平面重建和三维重建明确判断骨折情况。其中发现肩胛骨体部骨折18处，肩胛颈骨折8处，盂缘骨折9处，盂窝骨折5处，肩峰骨折11处，肩胛冈骨折4处，喙突骨折3处；同时合并肩关节脱位6例，合并锁骨骨折7例，合并多发肋骨骨折13例。多平面重建可多方位更全面地显示肩胛骨骨折的情况。三维重建能立体形象地显示肩胛骨骨折的范围和方向。结论 多层螺旋CT多平面重建及三维重建技术能清晰、直观地显示肩胛骨骨折情况。有利于临床诊断及治疗方案的确定。     

Glenoid hypoplasia. Description of a clinical case and analysis of the literature

Glenoid hypoplasia, or dysplasia of the scapular neck, is a relatively rare alteration that in most cases involves the pectoral girdle in a bilateral and symmetrical manner. In general, glenoid hypoplasia is associated with skeletal changes such as hypoplasia of the humeral head, or changes in the morphology of the acromion and of the coracoid. The authors describe a case of unilateral glenoid hypoplasia, which was symptomatic for a few years, reporting the clinical-radiographic findings and based on the data published in the literature reporting how this disease, which often goes unrecognized, is much more frequent than is imagined.     

Quantitative anatomy of the scapula

Thirty adult bony scapulae were used to report detailed bony dimensions of the scapula. The measurements of bony dimensions of the scapula included the glenoid, coracoid, spine, and body. The results of the measurements showed that the thickest bony stock (posteroanterior diameter), with a mean value of 13 mm to 23 mm in the glenoid process, was found in the middle third of the area within 1 cm medial to the glenoid rim. In the scapular spine region, the greatest superoinferior diameter of the bone was noted in the lateral portion of the spine, followed by the medial portion. It was also found that smallest superoinferior diameter (2 mm to 7 mm) of the spine was located at the middle portion between the base and ridge along the whole spine. On the lateral border of the scapula, the posteroanterior diameter of bone was relatively greater for the upper portion (8 mm) than for the lower portion, including the inferior angle (6 mm). This information may be helpful in open reduction and internal fixation of significantly displaced scapular fractures.     

不稳定肩胛骨骨折的手术治疗

目的探讨肩胛骨不稳定骨折的手术治疗。方法随访分析1999年1月至2004年1月收治的经手术治疗的16例不稳定肩胛骨骨折患．根据Hardegger分类方法，肩胛盂窝骨折4例、解剖颈骨折6例、外科颈骨折4例、粉碎性骨折2例。结果16例患有12例获得完整随访资料．随访时间3个月～4年，平均21月，采用Hardegger肩关节功能评定标准，优4例，良6例，可2例。优良率83．3％．平均骨折临床愈合时间8周。结论a)不稳定肩胛骨骨折畸形愈合严重影响肩关节功能，需行手术切开复位内固定治疗。b)对肩胛骨骨折治疗前需要进行全面的X线摄片检查和CT检查，以全面了解骨折情况，判断骨折的稳定性及有无手术指征。c)对有手术指征的不稳定肩胛骨骨折应根据不同骨折的部位和形态，选择相应的手术人路和内固定物进行手术治疗。     

肩胛骨颈部骨折合并肱骨头脱位的外科治疗

目的　探讨肩胛骨颈部骨折合并肱骨头脱位或半脱位的解剖学基础及外科治疗方法。方法　 1 992年 7月～ 2 0 0 1年 1 1月收治肩胛骨颈部骨折合并肱骨头脱位或半脱位 7例。骨折部位 :解剖颈骨折 2例 ,其中 1例合并喙突骨折 ;外科颈骨折 5例 ,合并肩胛冈骨折 2例 ,合并体部骨折 1例。 7例中合并肱骨头脱位 1例 ,合并肱骨头半脱位 6例 ,7例均行切开复位 ,钢板螺丝钉内固定术。结果　本组随访时间为 1个月～ 8年 ,7例肩胛骨颈部骨折愈合时间在 6～ 9周。 6例术后功能恢复优良。结论肩胛骨颈部构造特殊 ,手术切开复位内固定适用于不稳定性骨折 ,钢板螺丝钉可有效地对骨折进行固定     

The posterior two-portal approach for reconstruction of scapula fractures: Results of 39 patients

The purpose of this study was to describe the so-called posterior two-portal approach to the scapula in detail and to investigate the clinical outcome of patients with displaced glenoid and scapular neck fractures who were surgically treated using this approach. From February 1992 to August 2008, 39 patients (30 men and nine women; mean age: 53 years) with scapular fractures underwent surgical fixation at our institution. Thirty-three patients had glenoid fractures and six had unstable scapular neck fractures. All patients were treated via the two-portal approach. The reduction was evaluated radiographically, and the clinical results were analysed using the Constant score. The mean follow-up period was 78 months (range: 6–168). In 24 of the 33 glenoid fractures, the reduction was anatomical. The mean Constant score was 82.3 (range: 35–100) points. In one case, an early postoperative wound infection was cured by local revision, and one patient developed posttraumatic osteoarthritis of the acromioclavicular joint after 2 years. Only one patient developed specific glenohumeral degeneration after non-anatomical reduction. The posterior two-portal approach allows for a good visualisation of the posterior scapular neck and the glenoid area, facilitating the reduction and safe internal fixation of dislocated scapular neck and glenoid fractures.     

Bony avulsion of the supraspinatus origin from the scapular spine

We describe a case of an avulsion of the scapular spine at the origin of the supraspinatus muscle, with successful conservative treatment. An isolated avulsion is rare, as most avulsions occur in combination with other (more severe) injuries such as fractures of the scapula body or neck, coracoid process, glenoid or humerus. These injuries are mostly seen in high-energy trauma cases and need their own specific treatment. One should therefore always rule out concurrent trauma before treating conservatively.     

Fractures of the scapula

The scapula connects the arm with the chest wall and is therefore of great importance for a free range of shoulder of motion. For a long-term scapular fractures had been treated predominantly conservative. However, clinical studies of the past decades revealed that some fracture patterns deserve operative treatment to prevent unfavorable functional outcome and chronic state of pain. Scapular fractures are predominantly acquired during high-energy trauma and these patients' presents with a mean of 3.9 associated injuries in the emergency department. Injuries to the head, chest and ipsilateral upper extremity are most common. As some of these injuries are possibly life threatening they are treated first. Scapular fractures are only very seldom surgical emergencies. Therefore they are treated during the phase of reconvalescence in polytraumatized patients. Decision-making should be based on a thoroughgoing diagnostics, including conventional x-rays and a CT-scan, epically in cases of glenoid neck or cavity fractures. All fracture patterns should be identified to there full extend and put into the context of the scapular suspensory complex. The OTA lately presented a new and comprehensive system for classification of the scapular fractures. It is divided in two levels. Level one for the general orthopedic or trauma surgeon and Level two for the advanced upper Extremity or Shoulder surgeon. This classification scheme allows an easy access to understanding of the severity and prognostics of scapular fractures. As a general guideline surgery is indicated if a double disruption of the Scapula suspensory system, a relevant malposition or dysintegrity of the glenoid (articular surface) or a displacement of the lateral column is present.     

Der dorsale Zwei-Portal-Zugang zur Osteosynthese von Skapulafrakturen

Zusammenfassung Operationsziel Zugang zur dorsalen Skapula (Skapulahals und Schulterpfanne) zur Osteosynthese. Indikationen Instabile Skapulahals- und Schulterpfannenfrakturen des Typs Ideberg, II, III, IV und V. Kontraindikationen Minimal dislozierte und stabile Frakturen des Skapulahalses. Frühphase nach Polytrauma mit respiratorischer Insuffizienz. Persistierende Blutgerinnungsstörung. Operationstechnik Bogenförmige Hautinzision vom Akromion entlang der Spina scapulae bis zum Angulus inferior scapulae. Erstes Portal oberhalb des Musculus infraspinatus unter Rücksichtnahme auf den Nervus suprascapularis; damit können die oberen Anteile des Skapulahalses und der hinteren Gelenkpfanne dargestellt werden. Zweites Portal zwischen Musculus infraspinatus und Musculus teres minor, um die unteren Anteile des Skapulahalses und der Gelenkpfanne zu erreichen. Die beiden Portale werden durch Unterfahren des Musculus infraspinatus verbunden, sodass die gesamte Rückfläche des Skapulahalses und der Gelenkpfanne eingesehen werden kann. Ergebnisse 19 Patienten - 6 mit instabilen Skapulahalsfrakturen, vier davon mit zusätzlichen Klavikulafrakturen - und 13 mit Schulterpfannenfrakturen vom Typ Ideberg II bis V wurden behandelt. Bei allen wurde eine stabile Osteosynthese erreicht. Bei den Schulterpfannenfrakturen gelang die Reposition sechsmal anatomisch. Sechsmal verblieb ein interfragmentärer Spalt von weniger als 2 mm. Keine intra- oder postoperativen Komplikationen. Alle Patienten wurden nach durchschnittlich 26 Monaten (sechs bis 39 Monate) nachuntersucht. Nach dem Constant-Score [1] fanden sich folgende Punktzahlen: für den Schmerz 12,8 von 15, für die Alltagsfunktionen 16,6 von 20 und für die Kraft 21,5 von 25. Die Gesamtpunktzahl lag bei 79,9 von 100 möglichen bei einem Wert für die gesunde Gegenseite von durchschnittlich 94,3 Punkten. Ein Patient wies nach zwei Jahren eine geringgradige AC-Gelenk-Arthrose auf. Summary Objectives Wide approach to the posterior aspect of the scapula for internal fixation of unstable fractures of neck of scapula and glenoid. Indications Unstable scapular neck and glenoid fractures of Ideberg types II, III, IV and V. Contraindications Minimally displaced and stable fractures of scapular neck. Immediate intervention in polytrauma patients with respiratory insufficiency. Uncontrolled coagulopathies. Surgical Technique Curvilinear skin incision from acromion to inferior scapular angle. The first portal is made at the cranial border of the infraspinatus muscle avoiding injury to the suprascapular nerve. This allows access to the superior scapular neck and posterior glenoid. The second portal is made between infraspinatus and teres minor to reach the inferior parts of the scapular neck and glenoid. The 2 portals are connected by undermining the infraspinatus, thus exposing the entire posterior surface of the scapular neck and of glenoid fossa. The scapular fractures can then be reduced and stabilized. Results The two-portal approach was used in 19 patients, 6 of whom had an unstable scapular neck fracture. The remaining 13 patients had a glenoid fracture of Ideberg types II to V. The fixation was stable in all patients allowing an early functional treatment. The reduction of glenoid fractures was anatomical in 6, and in 6 a gap of < 2 mm remained. No intra- or postoperative complications occurred. All patients were followed up for an average of 26 months (6 to 39 months). The following Constant point count was recorded: pain 12.8/15, activities of daily living 16.6/20 and strength 21.5/25. The overall point score was 79.9/100. One patient had developed a minor arthritis of the acromioclavicular joint.     

The operative treatment of scapular fractures

Fractures of the scapula occur mainly from direct trauma involving considerable violence and associated injuries of the shoulder and thorax are common. In most cases early functional treatment gives good or excellent results. Operative treatment may, however, be indicated, especially with displaced intra-articular fractures, fractures of the glenoid rim associated with humeral head subluxation, or unstable fractures of the scapular neck. Between 1967 and 1981, we treated 37 such fractures by open reduction and stable osteosynthesis. We were able to follow up 33 cases (89%), of which 21 (64%) had complete functional recovery. The other 12 had varying degrees of pain, loss of mobility, and weakness. Overall, however, 79% of the patients had good to excellent results.     

CT三维重建技术对肩胛骨骨折的诊断价值

目的：探讨螺旋CT三维表面遮盖法重建(surface shaded display，SSD)及容积重建技术(volume rendering technique，VRT)对肩胛骨骨折的诊断应用价值。方法：使用SIEMENS PLUS4螺旋CT机对20例肩胛骨骨折患者进行扫描，全部数据输入工作站进行SSD及VRT处理，并与X线、二维CT(2D CT)检查结果进行对照分析。结果：2D CT扫描的结果经临床与手术证实为临床诊断的重要依据，经统计学分析，X线检查及SSD的诊断准确率分别为94．44％和97．78％，假阴性率分别为17．65％和7．84％，X线检查的假阳性率为0．76％；VRT诊断正确率为100％。SSD、VRT检出骨折创伤的数量与X线、2D CT的结果差异无显著性意义，但是显示损伤的质量优于X线和2D CT。术后对8例进行3D CT复查，VRT能立体显示术后肩胛骨骨质及内固定物的形态与结构。结论：螺旋3DCT是诊断肩胛骨骨折的有效手段，可指导手术计划的制定和内固定物的选择，应作为诊断复杂性肩部骨折的首选方法。VRT对骨折术后内固定物的位置及复位效果的判断有较高的应用价值。     

Scapular neck fracture--the influence of permanent malalignment of the glenoid neck on clinical outcome

A scapular neck fracture is considered unstable if it is associated with an ipsilateral clavicular fracture or an acromioclavicular (AC) joint dislocation. Currently, it is recommended that stabilization of a disrupted shoulder girdle must be achieved through open reduction and internal fixation of the clavicular fracture or by reduction of the AC joint, without addressing the scapular neck. However, if the displaced glenoid neck is not simultaneously reduced, malalignment of the glenoid neck may persist. The purpose of this retrospective study was to analyze the effect of associated shoulder girdle injury on glenoid displacement and the influence of glenoid malalignment on clinical outcome. Nineteen patients with scapular neck fractures were reviewed clinically and radiologically at a mean of 8 years (range 2–21 years) after injury. None of them has developed nonunion of the scapular neck, and only one showed radiological signs of mild degenerative joint disease. The glenopolar angle (GPA), which assesses the rotational malalignment of the glenoid about an anteroposterior axis perpendicular to the scapular plane on plain X-rays was measured less than 20° in six patients. Three of them had sustained an associated clavicular fracture or AC joint dislocation. The other 3 patients had permanent severe malalignment of the glenoid neck in the absence of an associated shoulder girdle injury. Five patients with GPA less than 20° complained of moderate or severe pain, whereas of the 13 patients with mild or no glenoid rotational displacement or medial displacement alone, 11 patients had no or mild pain, and only 2 had moderate or severe pain (P = 0.0095). Five patients presented with reduced activities of daily living, 4 of them had severe glenoid rotational displacement (P = 0.0173). Loss of motion was found in only 2 patients, and both had a severely displaced glenoid neck (P = 0.088). In conclusion, severe displacement of the glenoid neck may occur with or without associated fracture of the clavicle or dislocation of the AC joint and can be identified as a GPA less than 20°. Scapular neck fractures with such malalignment have a less favorable long-term outcome compared with otherwise comparable cases with absence of glenoid malalignment as measured with the glenopolar angle. Received: 16 February 2000     

异形钢板的研制及其在肩胛骨骨折的应用

目的：设计一种用于治疗不稳定肩胛骨骨折的新型内固定钢板，并评价其近期疗效。方法：根据肩胛骨解剖特点以及对18例不稳定肩胛骨骨折患者的X线片和CT扫描及其手术观察，设计出适用于肩胛骨骨折内固定治疗的异形钢板。所有患者按Hardegger的骨折分型：肩胛骨体部骨折9例，外科颈骨折3例，解剖颈骨折1例，盂缘骨折3例，肩胛岗骨折2例。均行新型内固定钢板内固定。结果：18例均获随访，随访时间6～18个月，平均12个月。按Rowe评分系统评价术后功能：优14例，良3例，可1例。结论：本钢板设计合理，生物力学性能良好，适用于各型不稳定肩胛骨骨折。     

手术治疗肩胛骨骨折23例临床分析

目的探讨肩胛骨骨折的手术适应证与手术复位内固定的临床效果。方法回顾性分析2000年11月-2006年10月手术治疗23例肩胛骨骨折患者临床资料,骨折位于肩胛冈6处,肩峰3处,肩胛盂6处,体部12处,颈部11处。采用肩胛骨腋窝缘入路15例,后入路8例。术后早期功能锻炼。结果本组均获随访,平均29.6（12-48）个月,X线片显示所有患者均于11（10-12）周达到临床愈合。肩关节功能评定：优15例,良5例,可2例,差1例,优良率为86.96%。发生创伤性关节炎1例,无切口感染和骨不连。结论手术治疗肩胛骨骨折能及时恢复肩关节的动力平衡和稳定性,是一种安全可靠的治疗方法;合理的运用手术入路和内固定方式,早期行功能锻炼,可取得满意的临床疗效。