ORIF - Lag screw fixation

Coracoid fractures are typically associated with more complex fractures of the scapula, and/or clavicle, and may also involve the suspensory ligament complex.

Coracoid base fractures should be differentiated from tip fractures as the surgeon needs to establish the exact location of the fracture line in relation to the coracoclavicular ligaments (coracoclavicular: trapezoideum, conoideum) and the inserted tendons (short caput of the biceps/coracobrachialis).

Any disrupted ligaments are treated as described in the section of LSSS.

The coracoid projects anteriorly and inferiorly with a curved undersurface. The coracoid is divided into three parts, the middle part is flat, the anterior part bends forwards and downwards, and the posterior part runs to the base. This particular anatomical configuration must be kept in mind when screw fixation is used.

This procedure is normally performed with the patient in a beach chair position.

A superiorly extended deltopectoral approach may be used.

If the fracture line is lateral/distal to the coracoacromial ligaments, reduction may be made difficult by the pull of the short head of biceps tendon.

In this case the approach is extended superiorly to allow for the placement of a reduction clamp.

Pearl: If the medial tip of the reduction clamp keeps slipping on the bone, drill a small 2.5 mm hole. This will give a grip for the medial tip of the reduction clamp

Once reduced a K-wire is inserted for temporary fixation.

Care must be taken that the K-wire (and screw) do not enter the scapular notch as this may compromise the suprascapular nerve (controlling the supra- and infraspinatus muscle).

Check the reduction and temporary fixation with an image intensifier.

Insert your lag screw over the K-wire and then remove the K-wire and clamp.

Base fractures are fixed in a similar fashion as a tip fracture, however the screw is more posterior and almost vertical.

For postoperative treatment of surgically operated scapular fractures and nonoperative treatment of fractures of the scapula which are treated conservatively is basically the same.

The decision to operate or not to operate is made on the basis on the fracture type, the degree of fragment displacement and the intrinsic fracture stability. The stability of a fracture can be further determined with the aid of an image intensifier.

It is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended.

• Straightening and flexion of the elbow

• Open and closure of the hand
• Squeezing of a soft ball

• Bending of the wrist forward, backwards and in a circular motion.
• Movement of an open hand from side to side.

• Squeezing the shoulder blades together, while shoulders remain relaxed

Pendular exercises can be started when pain starts to subside after the first few days.

One progresses gradually from passive to assisted active range of motion exercises making sure that assisted active abduction is done without elevation of the shoulder.

Active assisted range of motion exercises are started with:

• External rotation
• Internal rotation
• Forward flexion with the arms on the table
• Forward flexion and elevation of the arm with a ball on the wall

Sub-maximal isometric exercises with:

• Internal rotation
• External rotation
• Abduction
• Extension

Note: Timing and progression of exercises is ultimately directed and determined by the operating surgeon since such factors as bone quality, type of fracture and fixation may vary from case to case.

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest. Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the weight of the arm. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath which wraps around the humerus and the chest to restrict further shoulder motion, and keep the arm securely in the sling.
Commercially available devices provide similar immobilization, with or without the circumferential support of a swath.

Sling and swath (A), shoulder immobilizer (B), Gilchrist bandage (C), and other such devices all provide essentially similar support for the shoulder joint.

Sleeping
The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and shoulder.

Some patients may find it more comfortable to sleep in a sitting or semi reclined position.

When sleeping on the side, a pillow can be placed across the chest to support the injured side.

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.

Loose fitting clothing and button-up shirts are ideal. The unaffected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm. When undressing, start with the non-affected arm, then the affected arm.

In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or an abduction cushion as shown in this diagram.

Nonoperative management of scapular fractures usually begins with maximal support - a sling and swath equivalent worn continuously. If the patient finds lying down uncomfortable, then a sitting position may be preferred for sleeping.

A patient who is very comfortable, at the beginning of treatment or after some recovery, may need less immobilization, and even begin gentle use of the injured arm.

The degree of required immobilization and the rate progression may be speeded up as comfort permits.

When pain permits, begin with pendulum exercises (as illustrated).

At the same time active hand and forearm use should also be encouraged.

Isometric exercises can begin as soon as tolerated for the shoulder girdle including scapular stabilizers, and the upper extremity.
X-rays should be checked to rule out secondary fracture displacement.

As comfort and mobility permit, and fracture consolidation is likely, the patient should begin active assisted motion. Physical therapy instructions and/or supervision are provided as desired and available.

If passive range of motion exercises are progressing satisfactory, one can then cautiously progress to active assisted.

A “shoulder therapy set” might be helpful. Typically included devices are:

• An exercise bar, which lets the patient use the uninjured left shoulder to passively move the affected right side.
  

• A rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to provide full passive forward flexion of the injured right shoulder.

As passive motion improves, and active assisted exercises progress satisfactory, and the fracture becomes fully consolidated one can begin strengthening. First one strengthens by active motion against gravity. To increase muscle strength, one must increase the resistance against which the muscles are working. Endurance training follows.

Beware of premature forward flexion which is done passively but puts a significant strain on the supraspinatus and its repaired tendon.

Elastic devices are useful in providing varying degrees of resistance. Ultimately the athletic patient can progress to resistance machines and free weights.

Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not progressing satisfactorily.
Remember to monitor rotator cuff strength. Significant weakness may indicate an unidentified rotator tendon cuff rupture which is in need of surgical repair.

To reduce the risk of stiffness, immobilization should be discarded as soon as possible. This can be done progressively, beginning with elimination of the swath (circumferential bandage) during the daytime and encouraging pendulum exercises.
The sling may be used on a part-time basis as soon as appropriate.
If formal physical therapy has not been prescribed, it should be considered for any patient whose range of motion is not improving as expected.