Study suggests ORIF yields predictably good functional outcomes

Fractures of the scapular body and neck are traditionally treated nonsurgically with good results. A subset of these fractures, however, respond poorly to nonsurgical treatment, suggesting that some patients may benefit from open reduction and internal fixation (ORIF).

A prospective study examining clinical and functional outcomes after ORIF of scapular body and neck fractures found that surgery for extra-articular fractures of the scapula is associated with excellent functional results and an acceptable complication rate.

Conducted by researchers from the University of Minnesota, the results of “Surgical and Functional Outcomes after Operative Management of Extra-Articular Glenoid Neck and Scapula Body Fractures” were presented by Erich M. Gauger, MD, at the 2010 annual meeting of the Orthopaedic Trauma Association.

Single cohort
The patient cohort comprised 131 patients who were enrolled in a prospective scapula database and surgically treated for a scapular fracture between July 2002 and October 2009. Of these patients, 72 (82 percent male; average age: 45 years) met this study’s inclusion criteria (surgery performed less than 1 month from date of injury; no process fractures or fractures with intra-articular involvement).

In all cases, fractures were caused by high-energy trauma; 61 fractures were of the scapular body (64 percent comminuted) and 11 were extra-articular glenoid neck fractures (91 percent comminuted).

Participating patients had a 96 percent rate of associated injury, most commonly rib or clavicle fractures. Only three patients had an isolated scapula fracture.

Researchers used two- and three-dimensional (3-D) computed tomography (CT) scans and 3-D reconstructions to measure deformity and to determine which patients were candidates for surgery. Indications for surgical treatment included the following:

• medial/lateral (M/L) displacement of the glenohumeral joint greater than 20 mm
• angular deformity in the semicoronal plane greater than 45 degrees
• a combination of angulation greater than 30 degrees plus M/L displacement greater than 15 mm
• glenopolar angle (GPA), formed by lines connecting the inferior glenoid to the superior glenoid to the inferior angle of the scapula, of less than 22 degrees
• double disruption of the superior shoulder suspensory complex (scapula neck, coracoid, clavicle, and acromion) greater than 10 mm
• open fractures

M/L displacement was the most common surgical indication, and 25 patients met two or more of the indications.

“Just having a floating shoulder was not reason enough for surgery; 17 of the 27 patients who had a floating shoulder lesion met the surgical criteria for a displaced double lesion of the superior shoulder suspensory complex,” said Dr. Gauger, a resident at the University of Minnesota.

Surgery on all patients was performed using the posterior approach, most commonly with the Judet incision (Fig. 1).

“More recently, a less-invasive posterior approach has been used, with strategic incisions at the fracture exit points along the perimeter of the scapula that enable direct reduction of the scapula with less muscular dissection and smaller incisions,” said Dr. Gauger.

Good functional outcomes
At mean follow-up of 24 months (range: 6 to 70 months), all fractures demonstrated clinical and radiographic union.

Strength, range of motion (ROM), and Disabilities of the Arm, Shoulder, and Hand (DASH) and Short Form 36 (SF-36) functional outcomes scores were obtained from 82 percent of the patients. At follow-up, nominal differences were found in the surgically treated shoulder versus the uninjured shoulder for both ROM and strength. The mean DASH score at follow-up was 14.1 (range: 0 to 58), which was well within the standard deviation of 14.68 for the normative mean of 10.1, noted Dr. Gauger. The patients’ mean scores for all SF-36 parameters were comparable to those of the normal population.

Complications included hardware removal in five patients, manipulation under anesthesia for shoulder stiffness in three patients, immediate postoperative exchange of intra-articular screws in two patients, and repeat ORIF of one clavicle nonunion.

Dr. Gauger noted that although the study involved the largest series of surgically treated scapular body and neck fractures and the largest series of any type of scapular fracture with significant patient follow-up, it had no nonsurgical or comparative cohort.

“Therefore,” he said, “we cannot definitively state which fractures should be treated surgically, only that highly displaced scapula fractures can be treated surgically with predictably good functional outcomes and acceptable complication rates.”

Dr. Gauger’s coauthor is Peter A. Cole, MD.

Disclosures: Dr. Cole—Investigational Grants from Synthes, Zimmer; Dr. Gauger—no conflicts.

Maureen Leahy is assistant managing editor for AAOS Now. She can be reached at leahy@aaos.org

Bottom line

• Surgical indications for scapular fractures of the body and neck are not clearly defined.
• A certain subset of patients with these fractures may benefit from ORIF.
• Extra-articular fractures of the scapula can be treated surgically with predictably good functional outcomes and an acceptable complication rate.