Scapular Fractures: Classification, Diagnosis, and Management скачать в хорошем качестве

Scapular Fractures: Classification, Diagnosis, and Management

Join and support the channel    / @nabilebraheim   Scapular Fractures: Classification, Diagnosis, and Management Scapular fractures are typically high-energy injuries and are associated with an increase in the Injury Severity Score. 50% of scapular fractures involve the body and spine of the scapula. 10% of scapular fractures involve the glenoid fossa. Associated Conditions 70–80% of scapular fractures occur with associated injuries. There is a high association with rib fractures. Other associated injuries include: Head injury Ipsilateral upper extremity injury Pulmonary contusion and pneumothorax Hemopneumothorax Isolated scapular injury is a marker for significant chest trauma. These patients should be admitted for pulmonary consultation. Neurovascular deficits occur in approximately 10% of cases. Diagnosis and Incidence 90% of scapular fractures are nondisplaced or minimally displaced. These fractures are often missed or diagnosed late in up to 15% of polytrauma patients. Management Most scapular fractures are treated conservatively. Even if moderately displaced, they can often be managed nonoperatively. Treatment approach: Sling immobilization Codman pendulum exercises for 2 weeks Active and passive range of motion thereafter Classification of Scapular Fractures Scapular fractures are classified based on their location: Extra-articular fractures: Acromial fracture: May require surgery if significantly displaced. Coracoid fracture: Occurs proximal to the coracoclavicular (CC) ligament. Often associated with superior shoulder suspensory complex (SSSC) injuries. May require surgery. Scapular neck fracture/Clavicle fracture: Management is controversial. Most are treated conservatively, even if moderately displaced. Treatment Most cases are treated with sling immobilization and early range of motion. Rehabilitation protocol: Sling for comfort Early therapy referral Progressive range of motion exercises Fracture union typically occurs within 6 weeks with minimal functional deficit. Surgical Indications The goal of surgery is to restore shoulder joint stability and rotator cuff function. Surgery is indicated in the following cases: Glenoid cavity involvement more than 25% with humeral head subluxation. Intra-articular fracture with more than 5 mm step-off or gap within the joint. Scapular neck fractures with: more than 40° angulation more than 1 cm translation Excessive medialization of the glenoid Surgical Approaches The approach depends on the major fracture fragment displacement. Anterior Approach Used for anterior rim fractures, such as bony Bankart fractures (anterior-inferior glenoid fractures). Care must be taken to avoid axillary nerve injury. Posterior Approach Typically performed through a straight posterior or modified Judet approach. Straight posterior approach: Transverse incision over the spine of the scapula. Detach posterior deltoid. Enter through the interval between the teres minor and infraspinatus muscles. Used for posterior glenoid rim fractures or fractures along the lateral border of the scapula. Injury to the Posterior Shoulder Suspensory Complex Some refer to this injury as a "floating shoulder" because the glenohumeral joint is detached from the rest of the skeleton. The key question is whether the injury is stable or unstable. Unstable injuries often require surgery. Typical floating shoulder injuries involve: Scapular neck fractures Clavicle fractures Past treatment involved ORIF (Open Reduction Internal Fixation) of the clavicle. Recent studies show that nonoperative treatment with a sling can yield equivalent or superior outcomes to surgery. Surgical stabilization should be reserved for fractures meeting specific criteria. Scapulothoracic Dissociation Scapulothoracic dissociation is a severe injury involving lateral displacement of the scapula with soft tissue and neurovascular injury. Considered a closed forequarter amputation. The scapula is displaced laterally, often associated with: Clavicle fracture (distracted) Acromioclavicular joint injury Sternoclavicular injury X-ray findings: Lateral displacement of the scapula Important considerations: Check for subclavian artery and brachial plexus injury. The brachial plexus is torn first, before the artery. Brachial plexus injury is more common than arterial injury. Patient outcome depends on neurological status. Quizzes 1) What is the most common associated injury with scapular fractures? A. Abdominal injury B. Lower extremity fracture C. Rib fractures and thoracic trauma D. Pelvic fracture Correct Answer: C Scapular fractures frequently occur with rib fractures, pneumothorax, or hemothorax. 2) What is a key surgical indication for glenoid fractures? A. 10% involvement of the joint B. 2 mm step-off C. humeral head subluxation D. Medialization of 5 mm Correct Answer: C Surgery is recommended if glenoid fracure is involved with humeral head subluxation