Can displaced extra-articular fractures of the scapula be stabilized through a direct lateral-column approach

Abstract

Background: Displaced extraarticular fractures of the scapula are uncommon, and rarely require operative fixation. When managed operatively, a posterior Judet approach with detachment of the deltoid muscle from the scapular spine and elevation of the infraspinatus from its fossa, is often performed. This approach is invasive and involves extensive soft tissue dissection. This paper describes the utility of single-column fixation with a direct lateral column approach, with mobilisation of the deltoid, and elevation of the interval between the infraspinatus and teres minor. Our aim is to assess the functional and radiological outcomes of this alternative approach.

Methods: We performed a retrospective cohort study of all patients who underwent operative fixation of their extra-articular scapula fracture (with at least 12 months follow up), using the direct lateral-column approach. Operative indications included patients with an extra articular scapular neck or body fracture, with medial/lateral displacement of ≥20 mm, angulation ≥45°, double disruption of the shoulder suspensory complex, and glenopolar angle (GPA) ≤ 22°. Functional outcomes were assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Subjective Shoulder Value (SSV), pain score & return to work. Radiological assessment was done by 2 independent assessors.

Results: Between January 2014 and December 2016, 12 patients (11 males and 1 female) underwent fixation of their scapula fracture using this approach. Eleven patients (91.7%) returned their questionnaire at an average of 15.6 months (12-28 months). All fractures had healed at the time of the final follow-up. The scapular neck angulation was corrected from 38.7° pre-operatively (0-74°) to 3.6° post-operatively (0-20°). The mean post-operative GPA was 35.4° (30.2°-42.0°). None of the patients had superficial or deep infections, or post-operative neurovascular injuries. Two patients underwent elective removal of their clavicle hook plates. The mean SSV was 88.9 (70-100) and mean pain score was 1.5 (0-8). The mean DASH score was 11.4 (0-51.6). Ten patients returned back to their pre-injury work, with an average return to work of 3.3 months (2 weeks-8 months). Only one patient had a poor DASH score. He had associated ipsilateral segmental fracture of the humerus, fracture of the lateral clavicle and brachial plexus injury.

Conclusions: The direct lateral-column approach is an alternative technique for fixation of the extra-articular neck and body scapular fracture. Plating of the lateral column of the scapula through this single approach is associated with correction of scapular angular deformity, no complications and good clinical results at more than 12 months' follow-up.

Keywords: Direct lateral approach; Extra-articular; Functional outcomes; Scapular fractures; Single-column fixation.

Fig. 1

Single lateral incision over scapula.

Fig. 2

Deltoid is preserved and retracted to expose the glenoid.

Fig. 3

Plane between infraspinatus and teres minor.

Fig. 4

XR demonstrating pre-op 3-D CT of scapular fracture and post-op XR showing single-column lateral plating.