CONSERVATIVE MANAGEMENT OF SHOULDER INJURIES
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FRACTURES ABOUT THE SHOULDER
Conservative Management
Brodie E. McKoy MD
Christopher V. Bensen MD
Langdon A. Hartsock MD
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Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
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Address reprint requests to
Brodie E. McKoy, MD
Department of Orthopaedic Surgery
Medical University of South Carolina
96 Jonathan Lucas Street
Charleston, SC 29425
Fractures about the shoulder are common occurrences. Of the three bones in the shoulder region, the clavicle is most often broken followed by the proximal humerus and less commonly the scapula. Each of these bones is unique in its fracture patterns and mechanism of injury. A thorough history and physical examination along with selective radiographs can lead to an accurate diagnosis and appropriate treatment plan. Most of these fractures may be treated conservatively with good functional results.
FRACTURES OF THE CLAVICLE
The clavicle is the most commonly fractured bone during childhood, and it has been estimated that it is involved in 1 of every 20 fractures in adults. [2] It is almost entirely subcutaneous along its anterior course and is exposed to a variety of traumatic insults, including motor vehicle accidents, sports injuries, and falls. Fractures of the clavicle easily are diagnosed, and most can be managed by conservative, closed means. Complications are rarely encountered, and clavicle fractures unite uneventfully in most cases. Despite the fact that major neurovascular structures and the apical lobes of the lungs lie in close proximity to the clavicles, injuries to these structures are uncommon. Because of the prevalence of clavicle fractures, the orthopedic surgeon must have a thorough understanding of their evaluation and management as well as the possible associated injuries, which, although uncommon, can be limb-threatening or even life-threatening.
Anatomy
The clavicle is a long, S-shaped bone that is tubular throughout its medial and central portions but assumes a flatter shape at its lateral end, where it articulates with the acromion. The middle third is the thinnest, and it is untethered by ligamentous structures, causing it to be the most commonly fractured segment. It is made up primarily of dense trabecular bone, but it lacks a true medullary canal. The clavicle is bound at both ends by strong ligaments forming the sternoclavicular and acromioclavicular joints, which play a major role in stability of the clavicle.
The clavicle is an important structure for two reasons: (1) It serves as the only bony connection between the axial skeleton and the upper extremity, and (2) several vital neurovascular structures lie directly beneath it. The clavicle contributes to motion and stability of the upper extremity. The combination of the lateral curvature of the clavicle and longitudinal rotation contributes approximately 30° to the range of motion of the shoulder girdle and is important for complete shoulder elevation. The cords of the brachial plexus as well as the subclavian artery and vein pass between the medial curvature of the clavicle and the first rib and, consequently, are at risk with displaced clavicle fractures.
Evaluation
Patients with clavicle fractures resulting from low-level and moderate-level trauma who present soon after injury are easily diagnosed on physical examination. The exact location of the fracture can usually be identified by close inspection and palpation. There is usually a clearly defined history of the traumatic event, and common symptoms on presentation include pain, swelling, and tenderness over the injury. Additionally, patients who have sustained clavicle fractures usually hold the ipsilateral upper extremity next to the trunk and avoid unnecessary movement because this exacerbates the pain. The head may also be tilted toward the fractured side to relax the sternocleidomastoid or trapezius and reduce the forces acting on the fracture site.
Radiographs
A routine anteroposterior (AP) view of the clavicle is the only radiographic study required to identify and classify most fractures. The film should include the sternoclavicular joint as well as the entire shoulder girdle to rule out associated injuries. In cases in which the diagnosis is in question, 45° cephalad and caudad views can facilitate the evaluation. [41] Stress radiographs may be required in distal-third fractures to identify degree of displacement and associated injuries of the coracoclavicular ligaments.
Classification
Although fractures of the clavicle have been classified on the basis of fracture pattern and degree of comminution, the most commonly used method today is based on location of the fracture (Table 1) . Most authors have divided the clavicle into thirds, primarily determined by radiographic interpretation. [2] [32] [43] Although this method may be somewhat arbitrary and inexact, it appears to provide the most useful information with respect to treatment options and prognosis.
TABLE 1 -- CLASSIFICATION OF CLAVICLE FRACTURES Group 1 Group 2 Group 3
Middle-third fractures Distal-third fractures Proximal-third fractures
Type I--minimal displacement Type I--minimal displacement
Type II--fracture medial to coracoclavicular ligaments Type II--significant displacement
Type III--articular surface fracture
Conoid and trapezoid attached Type IV--epiphyseal separation
Conoid torn; trapezoid attached Type V--comminuted
Type III--articular surface fracture
Type IV--ligaments intact to periosteum with displacement of proximal fragment
Type V--comminuted with ligaments not attached proximally or distally
Data from Rockwood CA, Green DP, Buchloz RW (eds): Rockwood and Green's Fractures in Adults, ed 4, vol 2. Philadelphia, Lippincott-Raven, 1996, p 1116
Fractures of the medial third of the clavicle are relatively uncommon. There is usually excellent ligamentous stability in this region, and displacement is usually minimal. Fractures to the middle third segment are the commonest, constituting about 80% of all clavicle fractures. [2] [43] Although these fractures are not typically subclassified, they can be differentiated on the basis of displacement and degree of deformity, which can help determine treatment options.
Distal-third fractures of the clavicle are the most complex, in terms of fracture pattern and in treatment options. Neer [33] described fractures occurring distal to the trapezoid ligament as distal-third fractures and further subdivided them into three types. Type I fractures, the commonest, are relatively stable because the conoid and trapezoid ligaments remain intact. In type II fractures, the trapezoid ligament is ruptured, and there is loss of stabilization of the medial fragment. This loss of stabilization can result in severe displacement and an increased risk of nonunion. Type III fractures extend into the acromioclavicular joint and typically do not involve ligamentous injury.
Associated Injuries
Several injuries associated with clavicle fractures have been described, including neurovascular injury, hemothorax, and pneumothorax. [10] [19] [28] [29] The brachial plexus and subclavian vessels are directly below the medial segment of the clavicle. The subclavius muscle is the only intervening structure and, despite its relatively small size, is probably responsible for the rather low number of injuries to these structures.
The incidence of pneumothorax associated with clavicle fractures has been estimated at approximately 3%. [43] It would seem plausible that pneumothorax and hemothorax would be more likely to occur with fractures that are the result of high-energy mechanisms, although this has not been studied. Consequently, a thorough investigation should be undertaken if the orthopedic surgeon has clinical suspicion of either of these injuries.
Nonoperative Treatment
Most clavicle fractures have historically been treated by closed means, and operative intervention has been discouraged. Fractures of the medial third, as previously mentioned, are uncommon, and there is a relative paucity of reports in the literature regarding these injuries. Although internal fixation has been advocated by some authors, most are managed nonoperatively with a sling and swathe or a figure-of-eight dressing. [8] [12] [23] Several of these techniques are illustrated in Figure 1 (Figure Not Available) . If there is considerable displacement of the fracture fragments, CT may be necessary to ensure that the underlying neurovascular structures are not at risk.
Figure 1. (Figure Not Available) Types of figure-of eight bandages intended to maintain closed reductions of the clavicle: Stockinette padded with sheet wadding and held in place with safety pins ( A), padded stockinette with upper and lower borders tied to one another ( B), commercial bandage ( C), superior view showing bandage pulling shoulders up and backward ( D), figure-of-eight bandage with sling ( E), and figure-of-eight with collar and cuff ( F). ( From Dameron TB Jr, Rockwood CA Jr: Fractures and dislocations of the shoulder. In Rockwood CA Jr, Wilkins KE, King RE (eds): Fractures in Children. Philadelphia, JB Lippincott, 1984, p 618; with permission.)
Middle-third fractures that are not displaced respond well to closed treatment. Neer [34] reported that only 3 of 2235 patients (0.1%) with midclavicular fractures failed to heal after treatment by closed methods. This treatment usually is accomplished with a sling and swathe or a figure-of-eight dressing. Some authors have indicated that these injuries uniformly result in deformity; however, loss of function is minimal, and they could be treated symptomatically. [23] [43] Operative intervention is usually reserved for the rare cases of delayed union or nonunion.
Nondisplaced fractures involving the distal third, as with inner-third and middle-third fractures, can be treated conservatively. Displaced fractures of the distal third segment are the only group of clavicle fractures for which most authors advocate routine operative intervention. [35] [39] Neer [35] reported that 22% to 33% of these fractures went on to nonunion after conservative treatment. Additionally, Edwards et al [11] and Neer [35] reported that 100% of cases treated operatively healed within 10 weeks with a relatively low rate of complications.
Complications
Although a variety of complications after nonoperative management of clavicle fractures have been reported, the overall incidence is low. Nonunion rates of 0% to 2.2% have been reported by a number of authors. [12] [34] [43] [46] Several risk factors for nonunion have been identified, including the extent of initial trauma, [21] fracture comminution, [51] fracture displacement, [21] inadequate immobilization, [43] distal-third fractures, [42] and refracture. [51] There is a general consensus in the literature that degree of fracture comminution and displacement are the risk factors of greatest consequence.
Neurovascular complications associated with nonunion, including subclavian artery and vein compression, [22] thoracic outlet syndrome, [4] and brachial plexus palsy, have also been reported. Patients with clavicular nonunions may present with symptoms years after initial injury. Treatment of these complications is aimed at resection of the hypertrophic callus, which compresses the underlying structures, and restoration of anatomic position and alignment of the clavicle. This treatment is often accomplished by rigid internal fixation with bone graft, and results usually are excellent.
PROXIMAL HUMERUS FRACTURES
Most proximal humeral fractures occur in the elderly, but in young adults, these injuries are primarily caused by high-energy trauma. Overall, approximately 85% of proximal humeral fractures can be treated without surgery with successful results. An understanding of the anatomy, muscle forces around the shoulder, classification, and treatment options is essential in providing proper care to each patient with a proximal humerus fracture.
Anatomy
The articular surface of the proximal humerus articulates with the glenoid and is retroverted approximately 30°, whereas the neck-shaft angle of the proximal humerus is approximately 140°. The proximal humerus is made up of trabecular bone in the metaphysis, which has a thin cortical shell. As the aging process progresses, the trabecular density in the proximal humerus decreases, and this osteoporosis potentiates the possibility of fracture with low-intensity trauma.
The greater tuberosity is the insertion point for the rotator cuff tendons, which are essential for abduction of the shoulder, and the lesser tuberosity is the insertion site for the subscapularis tendon. Between the two tuberosities is the bicipital groove. The biceps tendon travels in the bicipital groove and over the humeral head, where it inserts on the superior glenoid rim and acts as a humeral head depressor. In addition to the rotator cuff and subscapularis, numerous other muscles control shoulder motion. These muscles can cause deformity of a fracture, and these forces must be neutralized for successful nonoperative treatment. The deltoid and rotator cuff muscles frequently cause the proximal fragment to be abducted and externally rotated. The deltoid muscle can cause shortening through the fracture site, whereas the pectoralis and latissimus can cause medial translation of the shaft.
The axillary nerve is close to the shoulder joint as it travels inferior to the shoulder capsule going from anterior to posterior. It can be injured by the fracture leading to a deltoid muscle palsy. The anterior humeral circumflex artery supplies the humeral head; however, the humeral head can survive on collateral vessels from the posterior medial capsule if the circumflex artery is disrupted.
Evaluation
Most proximal humerus fractures occur as a result of a fall from a standing height. In young patients, high-energy trauma is the most frequent cause. Treating a patient with a proximal humerus fracture requires a complete history and physical examination. Important features of the history include the age of the patient, associated medical conditions, work status, handedness, recreational activities, and expectations. The physical examination should allow complete visualization and examination of the shoulder. The skin may have extensive ecchymosis and swelling, but lacerations and open fractures are rare. Palpation at the fracture site is painful, and crepitation may be noticed. An anterior bulge just below the coracoid can be due to an anterior dislocation of the humeral head, and a posterior dislocation may be associated with a posterior bulge and a sulcus on the anterior aspect. Most often the neurovascular examination is normal. This examination should be documented carefully. Axillary nerve function usually is unable to be tested because of pain from the fracture; however, the presence or absence of sensation over the lateral portion of the shoulder can give some information on the integrity of the axillary nerve. In the elderly, a preexisting rotator cuff tear may be present, or the injury may cause a rotator cuff tear. Ipsilateral fractures of the humeral shaft, elbow, forearm, or wrist can occur. Examination for injuries to the peripheral nerves of the upper extremity must be performed and documented.
Radiographs
A high-quality set of radiographs is the next step in evaluation. Correct classification depends on being able to visualize the amount of displacement or angulation of fracture fragments. A standard series of radiographs includes an AP view, a scapular Y view, and an axillary lateral view. The axillary lateral view is useful for determining if there is posterior or anterior displacement of the humeral head in the glenoid and displacement of the greater tuberosity fragment. For stable fractures, internal and external rotation views help visualize the proximal humerus. The external rotation view is useful for seeing the anatomic neck and the greater tuberosity. Occasionally, CT scans are useful to determine the size and location of Hill-Sachs lesions of the humeral head.
Classification
The Neer classification is the most commonly used system for classifying proximal humeral fractures (Fig. 2) (Figure Not Available) . A fracture fragment is considered displaced if it is angulated 45° or displaced 1 cm. A two-part fracture can include greater tuberosity fractures or fractures of the surgical neck. Three-part and four-part fractures are more complex injuries, and these often require surgery, including internal fixation or hemiarthroplasty. The Neer classification system has been shown to have about a 66% interobserver agreement. Another classification system is the AO Classification, which is an alphanumeric system and has multiple subtypes. The proximal humerus is designated the number 11 bone segment. Type A fractures are extraarticular unifocal fractures. Type B fractures are extraarticular bifocal fractures. Type C fractures are articular fractures. Although this scheme is complex, it has been adopted by the Orthopaedic Trauma Association.
Figure 2. (Figure Not Available) Neer's anatomical classification of proximal humerus fractures. Group I includes all proximal humerus fractures in which no segment is displaced more than 1 cm or angulated more than 45°. Group II includes displacement of the head segment. Group III includes displacement of the shaft with the rotator cuff intact. Group IV and V blend as the four-part fracture in which both tuberosities are displaced. Group VI implies damage outside of the joint space. ( From Neer CS II: Displaced proximal humeral head fractures: I. Classification and evaluation. J Bone Joint Surg Am 52:1079, 1970; with permission.)
Nonoperative Treatment
Approximately 85% of proximal humeral fractures are minimally displaced. These fractures are amenable to nonoperative treatment, which is successful in most cases. Treatment is initially performed by placing the patient's arm into a sling. Radiographs can be obtained to document reduction. Any significant displacement or instability of the fracture can be an indication to switch from nonoperative to operative treatment. Once pain and swelling subside, physical therapy can be initiated with gentle active and passive range of motion. Physical therapy usually begins with pendulum exercises. The exercise program is slowly advanced to obtain motion in all planes, including flexion, abduction, and internal and external rotation. This program usually can be initiated approximately 2 to 3 weeks after the fracture occurs. Increasing range of motion can be obtained as the fracture heals and as the patient tolerates. After approximately 6 weeks, the fracture should be healed sufficiently to allow for strengthening exercises. Gentle resistive exercises can be initiated. The goal is to obtain a full range of motion with satisfactory strength.
Outcomes
Reports on outcomes of treatment of proximal humerus fractures have concentrated on operative results. A study from Sweden, however, reported the results of 15 elderly patients treated nonoperatively with a minimum 10-year follow-up. [54] The mean Constant score was 59 for three-part fractures and 47 for four-part fractures. Only 4 of the 15 patients reported pain, and it was graded as mild. Osteonecrosis occurred in two shoulders and osteoarthritis in one. The same group of authors from Sweden reported on outcomes of three-part and four-part fractures in 38 patients with 3-year follow-up. [56] Of those patients, 28 were treated nonoperatively, 7 underwent open reduction and internal fixation, and 3 underwent hemiarthroplasty. They found a strong agreement between the Constant score and patient opinion.
A report from Switzerland showed that three-part fractures treated operatively had a higher Constant score than those treated conservatively and that four-part fractures did worse than three-part fractures. [47] Nonoperative treatment of four-part fractures had the worst Constant score. [54] A report on 26 hemiarthroplasties done for acute three-part and four-part fractures showed that 73% of patients had slight or no pain. Most patients had trouble with lifting, carrying a weight, and using the hand at or above shoulder level.
Another report from Sweden reported poor functional results after hemiarthroplasty in 29 patients with 2- to 12-year follow-up. [31] Average Constant score was 38 (range, 16 to 69). Bone and soft tissue abnormalities not corrected at the time of surgery were implicated in poor results.
Skutek et al [48] reported on 13 active older patients treated with hemiarthroplasty and found 85% of patients rated the result as good or excellent on a visual analogue scale. Norris et al [40] reported on delayed prosthetic shoulder arthroplasty for displaced fractures and found improvement in function, but the surgery was technically difficult and inferior to acute replacement. Zyto et al [55] found in a review of patients with three-part and four-part fractures that there was no difference in outcome for surgically or nonsurgically treated fractures, but that three-part fractures did better than four-part fractures and the Constant score was more closely aligned with patient opinion than the Neer score.
In a report by Goldman et al [14] from the Hospital for Joint Diseases in New York, the age, fracture type, and sex of the patient were important influences on outcome. Age greater than 70, female sex, and four-part fractures were correlated with poor range of motion. Pain was reliably relieved by hemiarthroplasty, but motion and function were unpredictably restored.
Complications
There are no postsurgical complications of nonoperative treatment. The problems after proximal humeral fracture are motion loss, weakness, and pain. Occasionally, impingement can result from displaced greater tuberosity fractures.
SCAPULA FRACTURES
Fractures of the scapula are uncommon, accounting for only 3% to 5% of shoulder girdle injuries [7] [44] and less than 1% of all fractures. [37] [52] The rarity of this injury is likely due to the great mobility of the scapula coupled with the fact that it is well protected by layers of muscle. Scapula fractures commonly occur from direct trauma involving considerable violence. Most studies report a male predominance of scapular fractures with an average age of 35 to 45. [45] The significant trauma required to fracture the scapula results in associated injuries in 98% of these patients. Many of these injuries may be life-threatening.
Traditionally, most scapula fractures have been treated conservatively. Early studies revealed that nonoperative treatment of most of these injuries resulted in predominately good functional outcomes with patients having minimal symptoms. More recent studies have broadened the indications for open reduction and internal fixation. [6] [17] [38] Conservative management, however, remains the treatment of choice for the most scapula fractures today.
Anatomy
The scapula is well protected by several layers of muscles. The subscapularis covers the anterior scapula, and the serratus anterior attaches to its anterior medial border. The posterior surface of the scapula is covered by the supraspinatus, infraspinatus, and trapezius muscles. The deltoid covers a portion of the infraspinatus and the lateral subscapularis. The levator scapulae and the rhomboids attach to the medial border of this bone with the teres minor and major attaching to the lateral border. The pectoralis minor, short head of the biceps, and coracobrachialis attach to the coracoid process. The long head of the biceps originates from the superior glenoid with the triceps originating from the inferior glenoid.
The coracoid process extends upward and lateral from the superior border of the scapula. The pectoralis minor tendon attaching to this bony process provides some protection for the brachial plexus and axillary artery, which run posterior to this tendon. The scapula notch is located medial to the coracoid process. The transverse scapula ligament crosses this notch with the suprascapular artery passing over this structure and the suprascapular nerve passing beneath it. The acromion is the lateral continuation of the scapula spine.
The mobility of the shoulder depends, in part, on the smooth simultaneous movement of the humerus and the scapula. The scapula contributes to about one third of shoulder motion.
Evaluation
Scapula fractures are most often seen as an incidental finding on chest radiographs of polytrauma patients. Patients with scapula fractures usually hold their affected arm in adduction and protected from any motion. Tenderness often is pronounced over the scapula. The amount of ecchymosis may be minimal. In addition, patients with a displaced glenoid neck or an acromial fracture may have a flattened shoulder.[18] Coracoid and scapular body fractures may lead to pain with deep inspiration because of respiratory muscular attachments to these bones. Weak rotator cuff function and an inability to elevate the arm actively may be present, representing the pseudorupture of the rotator cuff as described by Neviaser. [36] The usual patient with a scapular fracture, however, has many severe associated injuries requiring urgent care, and the scapula fracture is often overlooked on initial evaluation.
Radiographs
The position of the scapula and surrounding thoracic structures make detailed views of this bone difficult. A true lateral scapula view along with an axillary view of the shoulder reveal most glenoid neck, body, and acromion fractures. CT scans may help define fracture segments in the transverse plane, especially of the glenoid.
An os acrominale can be confused with an acute fracture. This is a condition of the acromion in which adjacent ossification centers fail to fuse. The open epiphyseal line is at the level of the acromioclavicular joint. An axillary lateral aids in the evaluation. Sixty percent of patients with an os acrominale are affected bilaterally, so that a radiograph of the uninvolved side may be beneficial. [7] In addition, rounded borders with a uniform space are often seen in this condition as opposed to a true fracture.
Classification
Scapula fractures are often described by anatomic location. The scapula may be divided into five areas: glenoid neck, intra-articular glenoid, scapula body and spine, coracoid, and acromion. Fracture lines involving several areas may be seen. Most studies show the neck (10% to 55%) and the body (50% to 80%) to be the most commonly involved sites. [3] [20] [25]
Miller and Ada [30] described the following classification system based on their series of 146 fractures: Type I fractures involve the acromion or coracoid, type II involve neck fractures, type III involve intraarticular glenoid, and type IV are body fractures (Fig. 3) (Figure Not Available) . Zdravkovic and Damholt [53] classified scapula fractures into three types: type I, fractures of the body; type II, fractures of the coracoid or acromion; and type III, fractures of the neck or glenoid (see Fig. 1 (Figure Not Available) ). Thompson et al [49] described a slight variation, with class I representing coracoid and acromion fractures, class II representing glenoid and neck fractures, and class III representing major body fractures.
Figure 3. (Figure Not Available) Miller's classification of scapula fractures. Types I-A, I-B, II-A, II-B, II-C, and III most often require operative treatment. I-A, Acromion; I-B, base of acromion, spine; I-C, coracoid; II-A, neck lateral to base of acromion-spine; II-B, neck, extending to base of acromion or spine; II-C, neck, transverse type; III, glenoid, intraarticular; IV, body. ( From Miller ME, Ada JR: Injuries to the shoulder girdle: In Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma. Philadelphia WB Saunders, 1998, p 1658.)
Goss [16] included scapula fractures in his description of shoulder injuries. He described a shoulder ring, called the superior shoulder suspensory complex, which included the glenoid, coracoid, acromion, distal clavicle, and connecting ligaments (Fig. 4) (Figure Not Available) . A single disruption of this ring is a stable injury. Two or more disruptions of the complex creates an unstable injury, which often needs open reduction and internal fixation. For example, a neck fracture associated with a distal clavicle fracture represents an unstable injury.
Figure 4. (Figure Not Available) Superior shoulder supensory complex. Anteroposterior ( A) and lateral ( B) views of the bone-soft-tissue ring and superior and inferior bone struts. (© 1995 American Academy of Orthopaedic Surgeons. Reprinted from the Journal of the American Academy of Orthopaedic Surgeons, Volume 3(1): pp. 22-33; with permission).
Associated Injuries
Of patients with scapula fractures, 98% have severe associated injuries that can be life-threatening. Numerous studies have been published describing the incidence and types of these injuries. [3] [13] [20] Often the diagnosis of a scapula fracture is delayed because of these injuries. Thompson et al [49] found that patients with scapula fractures have an average of 3.9 associated injuries.
Pneumothorax, either immediate or delayed, has been shown to be consistently associated with scapula fractures. McLennen and Ungersma [27] found 53% of their study group to have a pneumothorax. The pneumothorax may be delayed 3 days, so that follow-up examinations and radiographs are essential. Other investigators have found the incidence of pneumothorax to be considerable but with slightly lower percentages. [3] [13]
Many other associated injuries are common. High incidences of ipsilateral upper torso injuries have been described by several authors. [13] [53] Ipsilateral rib fractures occur in 50% of scapula fractures. [53] Pulmonary contusion can be seen in association with scapula fractures. In addition, associated fractures of the clavicle (23% to 39%), brachial plexus injuries (5% to 13%), and skull fractures (24%) are commonly seen. [3] [13] [53] Fisher et al [13] found that associated injuries caused approximately 15% mortality. Scapula fractures should raise the suspicion of the clinician to search for associated injuries if not already evident.
Nonoperative Treatment
Even though studies have broadened the indications for open reduction and internal fixation of scapula fractures, most still are treated nonoperatively. Treatment is primarily symptomatic. Ice is applied initially to help decrease the swelling. The shoulder is immobilized for a short period of time, usually 3 to 4 weeks, or until the pain subsides. [15] Immobilization is accomplished with either a sling or a sling and swathe bandage. Bateman [5] described cross-strapping with adhesive moleskin to immobilize the scapula in nonambulatory patients. This type of immobilization may produce a stiff shoulder. Many authors point to the importance of early progressive range-of-motion exercises. [7] [15] [30] As the pain decreases, typically within 1 week, the shoulder is taken through range-of-motion exercises out of the sling with clearly defined limits. Pendulum exercises and overhead pulleys are often used. By 6 weeks, most scapula fractures are healed, and external support may be discontinued. Range-of-motion exercises and use of the upper extremity are encouraged. With increased motion of the shoulder, the patient may begin strengthening exercises. Isometric and progressive resistance exercises of the rotator cuff and the deltoid are essential after fracture healing. Patients should be instructed that it takes several months of rehabilitation before full function is again obtained.
Outcomes
Greater than 90% of scapula fractures are displaced only minimally and require only conservative treatment. [15] Many fractures that meet the indications for open reduction and internal fixation are treated conservatively because they are diagnosed late or the patients have severe injuries that prevent an operative procedure. Few large-scale studies based on treatment and outcomes have been published because of the rarity of this injury.
The preponderance of the literature reports satisfactory results with conservative treatment of most scapula fractures. [3] [20] [24] [26] [44] [50] [53] Most of the fractures in these series involved the scapula body, spine, and undisplaced neck fractures. McGahan et al [25] reviewed 137 fractures of the scapula. Treatment in this series was almost always conservative. Because of associated injures in a large percentage of their patients, open reduction could not be carried out, and conservative treatment was instituted. Conservative treatment gave satisfactory end results in terms of motion, union, and disability of the shoulder.
Several studies have reported slightly worse outcomes after conservative treatment. [17] [38] Most fractures in these studies involved fracture dislocations of the glenoid, unstable fractures of the neck, and significantly displaced apophyseal fractures. Ada and Miller [1] retrospectively reviewed 148 scapula fractures and had follow-up in 24 patients with worse results than in previous studies. They found decreased range of motion in 20% to 45%, weakness with exertion in 40% to 60%, and pain at rest in 50% to 100% of patients. Based on their findings, this group believed that the indications for operative management should be expanded to include displaced scapula neck and spine fractures.
Miller and Ada, [30] in reviewing the literature and based on their own patient group, found surgical management appropriate treatment of some displaced fractures of the scapula. They concluded that any displaced or deranged glenoid fractures unquestionably functioned better with surgery. [6] Neck fractures with more than 40° of angulation in the transverse or the coronal plane or with 1 cm or more of displacement are included as surgical indications. Scapula spine fractures at the base of the acromion or with more than 5 mm of displacement may need open reduction and internal fixation. [30]
Complications
Numerous associated injuries are possible with scapula fractures; however, complications of nonoperative treatment are uncommon. The occurrence of these complications depends on the location of the fracture, amount of comminution, and degree of displacement. Union and malunion are rarely a problem. In Miller and Ada's series, [30] only one fracture failed to unite. Most problems of nonoperative treatment of these fractures are related to pain and loss of function. Displaced glenoid and glenoid neck fractures, as well as comminuted fractures, may lead to abduction weakness, subacromial pain, decreased range of motion, and posttraumatic arthritis. These complications are uncommon, and the prognosis for most scapula fractures treated nonoperatively is excellent.
SUMMARY
Fractures about the shoulder may occur in patients of all ages from high-energy and low-energy trauma. Orthopedic surgeons must know the anatomy of these bones, their muscular attachments, and proximity of neurovascular structures to provide appropriate treatment. A thorough history and physical examination identify most of these fractures. Selective radiographs of each bone assist the surgeon in classifying the fracture and developing a treatment plan. One must always bear in mind the possibility of associated injuries, which may be limb-threatening or life-threatening, especially with scapula fractures. Conservative management is the treatment of choice for most fractures about the shoulder.
References
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