Indications and Outcomes
Recommendations for management of scapular fractures have been based upon level 5 evidence and expert opinion. Until recently, explicitly defined and validated measures for fracture characteristics have not been consistently reported. Contemporary recommendations are based on displacement, angulation, articular involvement, and the integrity of the SSSC.
"Floating shoulder" is a term originally described by Ganz and Noesberger[9,29] and modified by Goss, describing a specific injury to the SSSC. The term floating shoulder specifically describes concomitant fractures of the clavicle and the neck of the scapula, a relatively rare type of double disruption occurring from high-energy trauma. In 2013, Pailhes et al. retrospectively reviewed 40 "floating shoulder" injuries (24 nonoperative, 16 operative) and did not find a statistically significant difference between the two treatment groups regarding measurable clinical outcomes, supporting the notion that floating shoulder injuries can be treated based on the displacement and instability of each fracture individually. Yadav et al. compared the clinical outcomes and glenopolar angle (GPA) in two cohorts of patients with floating shoulder, those treated conservatively and those who received surgery for floating shoulder. Twelve patients' clavicle fractures were fixed while 12 were treated nonsurgically. While the operative groups had improvement in the GPA, there were no significant differences in functional outcome.
The glenopolar angle (GPA), originally described by Bestard et al. is considered a good measure of shoulder deformity, comparing the rotational misalignment of the scapular body to the glenoid articular surface,[6,34] The GPA is the angle between a line connecting the most cranial and caudal points of the glenoid cavity and a line connecting the most cranial point of the glenoid cavity with the apex of the inferior angle of the scapula. Normal GPA ranges between 20–45°. Wijdicks et al. found the angle of radiographic beam relative to the scapula at the time of image acquisition effects the GPA. When the beam was angled between 0–20° from the anteroposterior view, there was a significant difference in GPA compared with a beam angle >20° degrees (P<0.001). They suggested that the lack of a true anteroposterior view and variations in radiographic beam angle may compromise the utility of this radiographic measurement.
Management of scapular neck and body fractures remains controversial due, in large part, to the high union rate with nonoperative management and unpredictable functional consequences of scapular malunion. Bozkurt et al. found a strong correlation between GPA and Constant score in nonoperatively managed extraarticular scapular fractures. Smaller studies have supported the correlation between GPA and functional outcome.[34,36] Herera et al. treated extraarticular scapular fractures surgically and reported Disability of the Arm, Shoulder and Hand (DASH) scores of 14 at 26 mo with near complete recovery of strength and excellent range of motion. Dienstknecht et al. performed a meta-analysis of 22 studies that included 463 scapular neck fractures and found less pain and improved radiographic measures in the operative group (234/463), but range of motion was significantly better in the nonoperative group. The complication rate from surgery was about 10%.
Because of the lack of high quality evidence regarding management, absolute surgical indications are unclear. The least controversial surgical indications are open fractures, those associated with vascular injury requiring surgical repair, lateral displacement of the lateral border of the scapula greater than 25 mm, angular deformity in the plane of the scapular body of greater than 45°, and intraarticular step-off of the glenoid surface greater than 3 mm.[4,10] This creates two categories of surgical indications for scapular fractures: body fractures with displacement or angulation, and glenoid articular fractures.
Nonoperative management of a fracture that fails to meet the above surgical criteria should include a sling for 2–3 wk to allow pain improvement followed by progressive passive range of motion once pain subsides. Physiotherapy can be helpful. After 4 wk, active range of motion can begin, followed at 8 wk by institution of progressive strengthening. The goal is for full passive and active range of motion with improvements in strength and no further restrictions by 3 mo after injury. Failure to progress with therapy or continued, worsening deformity of the scapula may be a surgical indication but specific criteria are yet to be defined.[4,10]
Curr Orthop Pract. 2015;26(2):99-104. © 2015 Lippincott Williams & Wilkins