Surgical approaches for scapular fractures are either anterior or posterior. The anterior deltopectoral approach is useful for anterior glenoid rim fractures or as part of a combined approach when the coracoid fragment is a dominant component of the fracture pattern. There is extremely limited access to the scapular neck, body, and posterior glenoid through an anterior approach, so the vast majority of scapular fractures are treated through a posterior approach.
One of the original posterior approaches used for scapular fractures was the Judet approach. This involves elevating the entire infraspinatus muscle belly on its neurovascular pedicle and exposing the posterior surface of the scapular body. More recently, the modified Judet approach has become the preferred approach when extensile exposure is needed (Figure 2). Alternatively, a vertical incision posteriorly along the lateral scapular border can be used to access the same lateral interval (the infraspinatus and the teres minor). This precludes exposure to the medial scapular border and can also make it slightly more difficult to work in the window for lateral border fracture reduction.
(A) Superficial and (B) deep modified Judet posterior approach to the scapula as described by Obremeskey et al. (Reproduced with permission from Obremskey WT, Lyman JR. J Orthop Trauma. 2004; 18:696–699).
For complex glenoid fractures that have body involvement, we typically prefer a modified Judet approach. Commonly this fracture pattern involves two dominant components that must be treated separately: the body and the glenoid. Most often, the body component is displaced in multiple planes and involves a fracture line that exits the medial or superomedial body. Typically, the main body fragment lies lateral to the glenoid, so in order to reduce the glenoid fracture accurately, the inferior body fragment must first be medialized. This can be performed and stabilized along the medial fracture exit. Typical minifragment implants work well along the medial scapular spine for this function (Figure 3). With the glenoid "decompressed," the posterior and inferior glenoid as well as the lateral border can be reduced under direct vision. We prefer 2.7-mm or 3.5-mm plates along the lateral border, as the bone stock is very stout in this region (Figure 3). Screws may be directed into the coracoid using a scapular Y view to maximize the fixation (Figure 4). The posterior deltoid origin that was tenotomized during the surgical approach is repaired meticulously through drill holes using nonabsorbable suture to prevent dehiscence.
Postoperative radiographic image demonstrating medial scapular spine plate and lateral scapular border plate applications.
Postoperative radiographic images showing lateral scapular border plate application and placement of a screw into the coracoid process. (A) Anteroposterior view. (B) Scapular Y view.
Postoperatively, passive motion exercises are initiated immediately under the supervision of a physiotherapist. Progression proceeds as with nonoperatively treated fractures.
Curr Orthop Pract. 2015;26(2):99-104. © 2015 Lippincott Williams & Wilkins