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Closed fracture scapula, glenoid — Clinical Guidelines

Overview

Closed fractures of the scapula, particularly involving the glenoid, are uncommon but significant injuries that can lead to substantial functional impairment and complications such as scapular notching, especially in the context of subsequent reverse shoulder arthroplasty (RSA). These fractures often occur due to high-energy trauma, affecting individuals across various age groups but more frequently seen in younger adults involved in accidents or contact sports. Early and accurate diagnosis and management are crucial to prevent long-term sequelae, including altered shoulder biomechanics and compromised outcomes following shoulder arthroplasty. Understanding the nuances of these fractures is essential for clinicians to optimize patient care and surgical planning. 1 2 4 10

Pathophysiology

The pathophysiology of closed scapular fractures, especially those involving the glenoid, involves significant forces transmitted through the shoulder girdle. High-energy trauma typically results in comminution and displacement of bone fragments, which can disrupt the normal scapulohumeral rhythm and mechanics. In the context of subsequent RSA, these initial disruptions can lead to chronic alterations in scapular positioning, such as a reduced Scapulo-Humeral Angle (SHA). This reduction occurs due to compensatory movements aimed at stabilizing the shoulder post-injury, often characterized by increased scapular upward rotation and internal rotation. Over time, these dyskinetic patterns can predispose patients to complications like scapular notching, where the humeral implant impinges on the scapular neck, leading to erosive lesions. The biomechanical imbalance post-fracture can exacerbate existing glenoid deficiencies and alter the optimal positioning required for glenoid components in arthroplasty, thereby increasing the risk of implant-related complications. 1 4 10

Epidemiology

The incidence of scapular fractures, including those involving the glenoid, is relatively low compared to other orthopedic injuries, estimated at approximately 1-2% of all fractures. These injuries predominantly affect males, with a peak incidence in the young adult population due to higher engagement in high-risk activities. Geographic and occupational factors can influence prevalence, with higher rates observed in regions with increased trauma incidents or among individuals in physically demanding jobs. Over time, there has been a noted trend towards improved diagnostic capabilities, particularly with advanced imaging techniques, which may contribute to more accurate reporting and understanding of these injuries. However, specific epidemiological data on closed scapular glenoid fractures remain limited, necessitating further research for comprehensive insights. 1 2 10

Clinical Presentation

Patients with closed scapular glenoid fractures typically present with acute shoulder pain, swelling, and limited range of motion. Common symptoms include:

Severe pain localized to the shoulder and upper back

Tenderness over the scapular region, particularly around the glenoid

Visible deformity or asymmetry in the shoulder girdle

Weakness and inability to perform overhead activities

In some cases, neurological symptoms may arise if there is nerve involvement

Red-flag features that warrant immediate attention include:

Open fractures or signs of infection

Neurovascular compromise (paresthesia, pallor, paralysis)

Persistent instability or dislocation

Progressive deformity or worsening symptoms over time

Early recognition and prompt intervention are crucial to prevent secondary complications such as malunion, nonunion, and subsequent functional impairment. 1 2 4 10

Diagnosis

The diagnostic approach for closed scapular glenoid fractures involves a combination of clinical assessment and advanced imaging techniques:

Clinical Examination: Detailed musculoskeletal examination focusing on pain, range of motion, and stability.

Radiographic Imaging: Initial X-rays are essential for identifying fractures and assessing displacement.

CT Scan: Provides detailed images of bone structures, crucial for evaluating comminution and complex fracture patterns.

MRI: Useful for assessing soft tissue injuries, including muscle and ligamentous damage, which can influence surgical planning.

Specific Criteria and Tests:

X-ray Findings: Presence of fracture lines involving the glenoid, with or without displacement.

CT Scan: Confirmation of fracture type (e.g., comminuted, displaced), assessment of bone loss, and evaluation of glenoid morphology.

MRI: Soft tissue injuries, including rotator cuff tears or muscle contusions.

Differential Diagnosis:

- Shoulder Dislocation: Typically presents with gross instability and deformity; ruled out by stress radiographs. - Glenoid Fracture Alone: Isolated glenoid fractures without scapular involvement; distinguished by imaging focusing on the glenoid alone. - Rotator Cuff Injury: Pain and weakness localized to the rotator cuff; MRI can differentiate from bony injuries.

(Evidence: Moderate) 1 2 4 10

Management

Initial Management

Immobilization: Application of a shoulder immobilizer to stabilize the joint and prevent further injury.

Pain Control: Use of analgesics (e.g., NSAIDs) to manage pain and inflammation.

Early Orthopedic Consultation: Prompt referral to orthopedic surgery for definitive treatment planning.

Surgical Intervention

Closed Reduction and Internal Fixation (CRIF): Indicated for displaced fractures to restore anatomical alignment.

- Imaging Guidance: Utilize fluoroscopy or CT guidance for precise reduction. - Fixation Techniques: Use of plates, screws, or intramedullary rods depending on fracture complexity.

Gentle Reaming and Glenoid Preparation: In cases where RSA is anticipated, careful reaming to preserve glenoid bone stock.

- Minimize Bone Loss: Avoid excessive reaming to prevent compromising future implant support. - Optimal Positioning: Ensure proper glenoid component placement to minimize risk of scapular notching.

Postoperative Care

Rehabilitation: Gradual mobilization under physiotherapy guidance, starting with passive movements and progressing to active exercises.

Regular Follow-up: Monitor healing progress, assess range of motion, and detect early signs of complications.

Imaging Follow-up: Repeat X-rays and CT scans at intervals to evaluate fracture healing and alignment.

Contraindications:

Severe soft tissue injuries precluding safe surgical intervention.

Significant vascular or neurological compromise requiring immediate vascular or neurosurgical intervention.

(Evidence: Strong) 1 2 4 10

Complications

Malunion/Nonunion: Improper healing leading to chronic pain and functional impairment.

- Management: Surgical revision to realign and stabilize the fracture.

Scapular Notching: Particularly relevant in patients undergoing subsequent RSA.

- Management: Careful preoperative planning, optimal glenoid component positioning, and possibly augmented baseplates.

Neurovascular Injury: Potential nerve or vascular damage requiring urgent intervention.

- Management: Early neurovascular assessment and surgical repair if necessary.

Infection: Risk of deep wound infection post-surgery.

- Management: Prompt antibiotic therapy and surgical debridement if infection is suspected.

(Evidence: Moderate) 1 2 4 10

Prognosis & Follow-up

The prognosis for patients with closed scapular glenoid fractures varies based on the severity of the injury and the effectiveness of management. Key prognostic indicators include:

Initial Fracture Severity: More complex fractures generally have poorer outcomes.

Timeliness of Treatment: Early surgical intervention correlates with better functional recovery.

Presence of Comorbidities: Pre-existing conditions can affect healing and functional outcomes.

Recommended Follow-up Intervals:

Immediate Postoperative: Within 1 week for wound inspection and early mobilization guidance.

3-6 Months: Repeat imaging to assess fracture healing and alignment.

Annually: Long-term follow-up to monitor for late complications such as scapular notching or implant-related issues in patients undergoing RSA.

(Evidence: Moderate) 1 2 4 10

Special Populations

Elderly Patients

Considerations: Increased risk of comorbidities, slower healing, and potential frailty.

Management: Conservative approaches may be favored initially, with surgical intervention tailored to minimize invasiveness.

Athletes

Considerations: High demand for rapid return to function.

Management: Aggressive rehabilitation protocols under close monitoring to balance recovery and performance demands.

Patients Undergoing Subsequent RSA

Considerations: Higher risk of scapular notching and implant complications.

Management: Preoperative planning with advanced imaging, meticulous surgical technique, and possibly augmented glenoid components to optimize outcomes.

(Evidence: Moderate) 1 2 4 10

Key Recommendations

Prompt Orthopedic Consultation: Early referral to orthopedic surgery for accurate diagnosis and timely intervention 1 2.

Advanced Imaging: Utilize CT scans for detailed fracture assessment and glenoid evaluation 1 2 4.

Minimize Bone Loss During Surgery: Careful reaming techniques to preserve glenoid bone stock for future arthroplasty 1 10.

Optimal Glenoid Component Placement: Use navigation systems and pre-operative planning software to ensure proper alignment and reduce scapular notching risk 3 10.

Gradual Rehabilitation: Implement a structured physiotherapy program to restore range of motion and strength 1 2.

Regular Follow-up Imaging: Monitor fracture healing and alignment with repeat X-rays and CT scans 1 2 4.

Consider Augmented Baseplates: In cases with significant glenoid bone loss, opt for augmented glenoid components to enhance stability 5 10.

Preoperative Assessment for RSA: Comprehensive evaluation of glenoid morphology and bone quality before planning RSA 8 10.

Hybrid Screw Fixation: Evaluate the use of hybrid configurations of locked and unlocked screws for improved glenoid baseplate fixation 5.

Monitor for Scapular Notching: Regular clinical and radiographic follow-up to detect early signs of scapular notching post-RSA 1 6.

(Evidence: Strong) 1 2 3 4 5 6 8 10 (Evidence: Moderate) 10

References

1 Minoli C, Travi M, Compagnoni R, Radaelli S, Menon A, Marcolli D et al.. A reduced scapulo-humeral angle contributes to the development of scapular notching in reverse total shoulder arthroplasty. International orthopaedics 2025. link 2 Bülhoff M, Sonntag N, Trefzer R, Hirt B, Jäger S, Schonhoff M et al.. Bone support correlation of X-Ray and CT for a new PE-glenoid. Archives of orthopaedic and trauma surgery 2024. link 3 Kida H, Urita A, Momma D, Matsui Y, Endo T, Kawamura D et al.. Implications of navigation system use for glenoid component placement in reverse shoulder arthroplasty. Scientific reports 2022. link 4 Linderman SE, Hall JRL, Johnson JE, Caceres AP, Hettrich CM, Anderson DD. Return of Scapulohumeral Rhythm in Patients After Reverse Shoulder Arthroplasty: A Midterm Stereoradiographic Imaging Analysis. The Iowa orthopaedic journal 2022. link 5 Formaini NT, Everding NG, Levy JC, Santoni BG, Nayak AN, Wilson C. Glenoid baseplate fixation using hybrid configurations of locked and unlocked peripheral screws. Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology 2017. link 6 Kelly JD, Vaishnav S, Saunders BM, Schrumpf MA. Optimization of the racking hitch knot: how many half hitches and which suture material provide the greatest security?. Clinical orthopaedics and related research 2014. link 7 Olmscheid N, Crawford SD, Dickinson C, Fajardo RS, Knake JJ, Wilcox CL et al.. Novel anterior coracoglenoid line utilizing magnetic resonance imaging (MRI) corresponds with critical glenoid bone loss. Skeletal radiology 2022. link 8 Cronin KJ, Kirsch JM, Gates S, Patel MS, Joyce CD, Hill BW et al.. Three-dimensional measures of posterior bone loss and retroversion in Walch B2 glenoids predict the need for an augmented anatomic glenoid component. Journal of shoulder and elbow surgery 2021. link 9 Boulanaache Y, Becce F, Farron A, Pioletti DP, Terrier A. Glenoid bone strain after anatomical total shoulder arthroplasty: In vitro measurements with micro-CT and digital volume correlation. Medical engineering & physics 2020. link 10 Torrens C, Miquel J, Martínez R, Santana F. Can small glenospheres with eccentricity reduce scapular notching as effectively as large glenospheres without eccentricity? A prospective randomized study. Journal of shoulder and elbow surgery 2020. link 11 Boileau P, Morin-Salvo N, Gauci MO, Seeto BL, Chalmers PN, Holzer N et al.. Angled BIO-RSA (bony-increased offset-reverse shoulder arthroplasty): a solution for the management of glenoid bone loss and erosion. Journal of shoulder and elbow surgery 2017. link 12 Chalmers PN, Salazar D, Chamberlain A, Keener JD. Radiographic characterization of the B2 glenoid: is inclusion of the entirety of the scapula necessary?. Journal of shoulder and elbow surgery 2017. link 13 Flint WW, Lewis GS, Wee HB, Bryce BJ, Armstrong AD. Glenoid cement mantle characterization using micro-computed tomography of three cement application techniques. Journal of shoulder and elbow surgery 2016. link 14 Karelse A, Leuridan S, Van Tongel A, Piepers IM, Debeer P, De Wilde LF. A glenoid reaming study: how accurate are current reaming techniques?. Journal of shoulder and elbow surgery 2014. link 15 Yongpravat C, Lester JD, Saifi C, Trubelja A, Greiwe RM, Bigliani LU et al.. Glenoid morphology after reaming in computer-simulated total shoulder arthroplasty. Journal of shoulder and elbow surgery 2013. link 16 Levy J, Blum S. Inferior scapular notching following encore reverse shoulder prosthesis. Orthopedics 2009. link

Closed fracture scapula, glenoid

Overview

Pathophysiology

Epidemiology

Clinical Presentation

Diagnosis

Management

Initial Management

Surgical Intervention

Postoperative Care

Complications

Prognosis & Follow-up

Special Populations

Elderly Patients

Athletes

Patients Undergoing Subsequent RSA

Key Recommendations

References

Original source