|
ARTHROSCOPIC RECONSTRUCTION
OF GLENOID FRACTURES
GEORG LAJTAI
Altis -Center for Sportsurgery Austria, Europe http://www.shoulder.org
Introduction:
Fractures of the scapular are relatively uncommon injuries, and most can be treated satisfactorily with nonoperative methods (1-6).
Scapula fractures are often associated with multiple traumatic injuries which may take priority, drawing attention away from a treatment of the scapular fracture (2,3,6).
Fractures of the scapula generally occur in high energy setting of vehicular trauma or fall from height. They are infrequent injuries compromising no more than 5 % of shoulder girdle fractures in most clinical reports. (2,7,8)
This is likely because of a thick protective muscular envelope and recoil of the underlying chest wall on impact.
Another factor is the highly mobile shoulder girdle soft tissue and bony suspensory mechanism where the clavicle and its articulations represent the sites of failure with most accident mechanisms.
Displaced fractures of the acromion, scapular spine and neck have shown poorer outcomes with conservative treatment and for this reason operative reduction and internal fixation are usually recommended (9-11).
Open reduction and internal fixation of displaced glenoid fractures have shown promising results in previous small series (10, 12, 13)
Classification:
Ideberg proposed a detailed scheme for classification that was based on a review of 338 scapula fractures in 322 patients (13). This scheme included fractures of the glenoid rim and the glenoid fossa.
Classification of intraarticular glenoid fractures
Type I:
Glenoid rim fractures
Typ I a:
With anterior fracture fragment
Typ I b:
With posterior fracture fragment
Type II:
Inferior glenoid fracture involving part of the neck
Type III:
Superior glenoid fracture extending through the base of the coracoid process
Type IV:
Horizontal fracture involving both scapular, neck and body. Fractureline always runs inferior to the spine of the scapular
Type V:
Horizontal fracture (as in type IV), with an additional complete or incomplete neck fracture
Type VI:
Type VI fractures are severely comminuted injuries of the glenoid fossa, caused by violent forces.(14)
Arthroscopic reconstruction of displaced glenoid fractures
Requirements:
1. Trained surgeons in arthroscopic shoulder surgery
2. Experienced surgeons in ostheosynthesis and their complications
3. Well presorted OR-Team
4. Having the possibility to do the reconstruction open if necessary (Instruments…)
5. Arthroscopic pump must be available
6. Arthroscopic instruments
7. Cannulated screws
8. Nurse must perfectly use the C- arm
If there is one point not accomplished, you should not try to do this type of procedure.
Positioning:
The patient is positioned in the lateral decubitus position with the arm in 45 degrees abduction and 20 degrees anteversion in a shoulder arm holder.
The C-arm must have the possibility to change the position between the axial and the ap-position, so that surgeons can change the view according to what they need to see.
Good arthroscopic is well as good. X ray pictures must be guaranteed otherwise the procedure can turn into a desaster.
OR-Technique:
• Standard posterior portal to the glenohumeral joint
• Rinse the glenohumeral joint to get good visibility
• Inspection of the joint
• Remove debris and blood clots out of the joint and the fracture line
• Classify the fracture and additional injuries
• Make an anteriorsuperior and midglenoidal portal with the SPS portal system in correct position to the fracture fragments
At this point the C- Arm will put in to the OR field so that an axial as well as an AP-view is possible.
• At the time, when the C- Arm is correct positioned and the arthroscope looks at the fracture, the surgeon starts to make the reposition manoeuvre with the raspatorium - arthroscopically as well as radiologically controlled.
At the beginning of the procedure the aim is to mobilize the fracture parts - to get a perfect reduction later on.
When the fracture fragments are mobilized and it is visiable that the reposition will be possible, next step is to change the portals, so that the arthroscope is viewing from the anterior portal.
• Viewing from the anterior portal the next step will be, to put a Steinmann-pin through the posterial portal into the proximal glenoid fragment.
This Steinmann-pin will be used as a joystick to direct the proximal fracture in correlation to the distal fragment.
If the Steinmann-pin is good in place, reduction can be done on the arthroscopic as well on the radiologic control.
• Put in an orientation needle
With a K-wire you can hold the reduction and it allows a temporary fixation of the fracture fragments.
If you are happy with the result of your reduction:
• Make a skin incision at the Neviaser portal where your K-wire is in place and insert a cannulated screw.
• Controll your manoeuvre with x-ray and arthroscope
Conclusion:
Arthroscopic reconstruction of glenoid fractures can be recommended in dislocated two part glenoid fractures type Ideberg IV and V. It is a technical demanding operative procedure, but minimal invasive and it allows anatomical
reduction under arthroscopical control and stable fixation. Therefore a short postoperative rehabilitation and a good functional outcome can be expected.
References:
1. Aulicino, P. L.; Reinert. Charles; Kornberg, Markus; and Williamson, Sterling: Sisplaced intro-articular glenoid fractures treated by open reduction and internal fixation. J. Trauma, 26: 1137-1141, 1986.
2. Imatani, R.J.: Fractures of the scapula: a review of 53 fractures. J. Trauma, 15: 473-478, 1975
3. Mc Gahan, J. P., Rab, G. T.; and Dublin, Arthru: Fractures of the scapula. J. Trauma, 20: 880-883, 1980.
4. Rowe, C. R.: Fractures of the scapula. Surg. Clin. North America, 43 : 1565-1571, 1963.
5. Ruedl, T., and Chapman, M. W.: Fractures of the scapula and clavicle. In Operative Orthopaedics, edited ba 6. Thompson, D. A., Flynn, T. C.; Miller, P. W.; and Fischer, R. P.: The significance of scapular fractures. J. Trauma, 25: 974-977, 1985.
7. Tscherne H. Christ M: Konservative and operative therapie der Schulterblattbrüche. Hefte Unfallheilkd 126:52-9. 1975.
8. Bauer G. Fleischman W. Dussler B: Displaced scapular fractures: Indication and long term results of open reduction internal fixation: Arch Orthop Trauma Surg 114:215-219. 1995
9. Gagey O. Cury JP. Mazas F: Recent fractures of the scapula. Apropos of 43 cases: Rev. Chir. Orthop. Reparatrice Appar Mot 70: 443-447. 1984
10. Hardegger FH. Simpson LA. Weber BG : The operative treatment of scapular fractures. J. Bone Joint Surg 66B:725-731. 1984
11. Jeanmaire E. Ganz R : Le treatment des fractures de l’omoplute. Indications operatoires : Acta Orthop Belg 30 : 673-678. 1964
12. Aulicino PL. Reinert C. Kornberg M. Williamson S: Dixplaced intraarticular gleonoid fractures retated by open reduction internal fixation. J. Trauma 26: 1137-1141. 1986.
13. Ideberg: Epidemiology of scapular fractures. Acta Orthop. Scand. 1995; 66 (5:395-397)
14. Goss TP: Factures of the glenoid cavity JBJS, 74 A, No 2, 299-305, 1992
|
