In a complete articular fracture with an anterior fragment a posterior arthrotomy is necessary to reduce the fragment. Its fixation is achieved with a lag screw inserted posteriorly.
4. Restoration of articular surface
Reduction of the joint surface using K-wires
Reduction of the articular surface may be facilitated by the insertion of a K-wire to be used as joystick. The use of a cannulated system is preferred. Therefore, insert the K-wire for the potential cannulated screw in the planned lag screw trajectory.
When reduction of the articular surface is completed, insert the K-wire further to temporarily fix the articular fracture.
Alternatively, a repositioning clamp can be used to reduce the fragments of the glenoid fossa.
If possible, the fracture of the glenoid fossa should be fixed with a lag screw(s).
Once the articular fracture is fixed, proceed with the fixation of the neck as for simple extra articular fractures.
5. Reduction and fixation of the glenoid neck using reconstruction plate
The articular segment is now fixed. Once the neck fracture is reduced, it is best to use cortical screws for fixation of the plate into the articular segment to bypass the inserted lag screw.
One or two K-wires are partially inserted in the articular block and used as a joystick for reduction.
The joint block is reduced to restore the anatomical angle of the glenoid fossa. Large deviations of the angle (>20 °) will reduce the functional outcome.
If the reduction is not successful, an alternative procedure where the plate is used as a reduction aid can be employed (see below)
K-wires are inserted for temporary fixation. Care should be taken that the position of the K-wires does not interfere with the planned position of plate and screws.
The reconstruction plate is shaped to a near perfect anatomical fit.
At least two screws are necessary for sufficient fixation of the glenoid joint block.
Ideally, three bicortical screws are inserted in the lateral scapular border. If the bone stock is poor, locking screws are indicated.
6. Alternative reduction and fixation using an angle stable plate
It is best to use a reconstruction plate designed to take angularly stable screws.
The plate is bent at the right spot to subtend the usual angle between the glenoid and the lateral border of the scapula (130 - 135 degrees).
Up to 10 degrees deviation from the anatomically correct angle can be tolerated.
When angularly stable fixation is used the plate does not have to fit the bone, but must fit the overall contour.
The plate is fixed to the glenoid segment with two bicortical screws.
If locking screws are used, care must be taken regarding their direction so that they do not enter the joint.
In a transverse fracture of the glenoid where lag screw fixation is physically not possible, maintain reduction and compression of the fracture with a clamp, then reduce the neck fracture.
The reduction and compression of the articular fracture is then maintained by the fixation of the plate to the articular segment.
The plate is then used as a reduction aid.
A trasglenoid X-ray is recorded to verify whether the anatomical angle is achieved.
Large deviations of the angle (>20°) will reduce the functional outcome.
When the correct reduction and the correct angle between the glenoid fossa and the lateral border of the scapula have been achieved, screws are inserted along the lateral border of the scapula.
Correct reduction and fixation is verified by image intensification.
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.
Phase I: Day one
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
Phase II: Two to six weeks
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:
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:
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.
Sling and swath
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.
Activities of daily living
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.
Shoulder abduction cushion
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.
Mobilization: 2-3 weeks posttrauma
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.
Active assisted exercises: 3-6 weeks postoperative
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.
Shoulder therapy set: 3-6 weeks postoperative
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.
Strengthening: from week 6 on
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.
Pitfall: shoulder stiffness
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.