What is the recommended treatment approach for scapula fracture fixation?

Scapula Fracture Fixation

For scapula fractures, isolated body fractures generally heal well with nonsurgical treatment, while surgical fixation is recommended for fractures involving the glenoid neck, those with significant displacement, or intra-articular fractures.

Diagnostic Approach

CT scanning is the optimal imaging modality for scapula fractures due to:

• Complex scapular anatomy and overlying ribs making fractures easily missed on plain radiographs
• Superior ability to assess intra-articular extension, glenopolar angulation, AP angulation, and lateral border offset 1
• 3D-reformatted CT images providing better visualization of displacement and angulation 1

Treatment Algorithm

Nonsurgical Management

Indicated for:

• Isolated scapula body fractures with minimal displacement
• Stable fracture patterns
• Patients with high surgical risk

Benefits:

• Good to excellent outcomes in most cases with early functional treatment 2
• Avoids surgical risks and complications

Surgical Fixation

Indicated for:

• Fractures with significant displacement (>20mm) 3
• Glenoid neck fractures with instability 1
• Intra-articular fractures, especially with displacement 2
• Fractures of the glenoid rim associated with humeral head subluxation 2
• Cases with associated rib fractures or higher injury severity score 1

Surgical approach:

• Posterior approach is commonly used for reduction and fixation 4
• Open reduction and internal fixation (ORIF) with plates and screws

Outcomes and Prognosis

Surgical Outcomes

• Long-term studies show 64-79% good to excellent results after ORIF 5, 2
• Complete functional recovery possible in majority of cases
• Potential complications include hardware issues, infection, and limited mobility

Nonsurgical Outcomes

• Similar healing rates compared to operative treatment 3
• Comparable return to work and pain levels to surgical treatment 3
• May result in malunion if significantly displaced fractures are not surgically addressed

Special Considerations

Timing of Surgery

• For polytraumatized patients, scapula fracture fixation can be delayed until patient is stabilized
• Ideally, surgery should be performed within the first 2 weeks after injury 5

Associated Injuries

• Scapula fractures are often associated with other injuries (80-90% of cases) 4:
  • Clavicle fractures
  • Rib fractures
  • Humeral fractures
  • Pulmonary injuries
  • Brachial plexus injuries

Rehabilitation

• Early functional treatment is important for both surgical and nonsurgical management
• Progressive strengthening exercises should be initiated once healing permits

Common Pitfalls

• Underestimating displacement on plain radiographs - always obtain CT for accurate assessment
• Treating all scapula fractures nonsurgically - certain patterns benefit from surgical fixation
• Delaying treatment beyond 2 weeks may complicate reduction and fixation
• Failing to address associated injuries which may impact overall outcome

Follow-up

• Regular radiographic assessment to monitor healing
• Functional assessment of shoulder range of motion and strength
• Evaluation for any hardware-related complications if surgical fixation was performed