Orthopedics

Feature Article 

Long-term Functional Outcomes of Nonoperatively Treated Highly Displaced Scapular Body and Neck Fractures

Rebecca A. Rajfer, MD; Traci Salopek, MSW, CCRC; Brian A. Mosier, MD; Mark Carl Miller, PhD; Gregory T. Altman, MD

Abstract

Historically, extra-articular scapular body fractures were treated nonsurgically, but displaced fractures of the glenoid neck can lead to dysfunction. Controversy exists regarding which extra-articular scapular fractures should be treated surgically; however, nonsurgical management of severely displaced scapular body fractures can result in satisfactory outcomes. Inclusion criteria for this study were medial or lateral displacement greater than 2 cm, angular deformity between fracture fragments greater than 45°, or glenopolar angle less than 22°. Functional outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) score, Short Form-36 (SF-36) score, and American Shoulder and Elbow Surgeons (ASES) shoulder score. Radiographs and computed tomography scans were available for all patients. Range of motion (ROM), strength, other injuries, and complications also were recorded. Twelve patients (10 males, 2 females) with a mean age of 45.6 years (range, 29–57 years) underwent follow-up for a mean of 54.1 months (range, 28.2–74.4 months). At latest follow-up, mean DASH score was 8.9 (range, 0–35), mean SF-36 score was 72.2 (range, 57.3–96.1), and mean ASES score was 85.9 (range, 46.7–100). Mean ROM and strength expressed as a percentage of the contralateral side ranged from 88% to 99% and 70% to 93%, respectively. At longest follow-up, 10 patients reported excellent satisfaction with their treatment. There were no radiographic non-unions. One patient with concomitant clavicle and acromion fractures treated surgically had a postoperative infection requiring operative irrigation and debridement. None of the patients required or sought additional treatment. Nonoperative treatment of highly displaced scapular body fractures resulted in good patient satisfaction, satisfactory long-term functional outcomes, and only minor loss of motion and strength. [Orthopedics. 2020;43(3):e177–e181.]

Abstract

Historically, extra-articular scapular body fractures were treated nonsurgically, but displaced fractures of the glenoid neck can lead to dysfunction. Controversy exists regarding which extra-articular scapular fractures should be treated surgically; however, nonsurgical management of severely displaced scapular body fractures can result in satisfactory outcomes. Inclusion criteria for this study were medial or lateral displacement greater than 2 cm, angular deformity between fracture fragments greater than 45°, or glenopolar angle less than 22°. Functional outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) score, Short Form-36 (SF-36) score, and American Shoulder and Elbow Surgeons (ASES) shoulder score. Radiographs and computed tomography scans were available for all patients. Range of motion (ROM), strength, other injuries, and complications also were recorded. Twelve patients (10 males, 2 females) with a mean age of 45.6 years (range, 29–57 years) underwent follow-up for a mean of 54.1 months (range, 28.2–74.4 months). At latest follow-up, mean DASH score was 8.9 (range, 0–35), mean SF-36 score was 72.2 (range, 57.3–96.1), and mean ASES score was 85.9 (range, 46.7–100). Mean ROM and strength expressed as a percentage of the contralateral side ranged from 88% to 99% and 70% to 93%, respectively. At longest follow-up, 10 patients reported excellent satisfaction with their treatment. There were no radiographic non-unions. One patient with concomitant clavicle and acromion fractures treated surgically had a postoperative infection requiring operative irrigation and debridement. None of the patients required or sought additional treatment. Nonoperative treatment of highly displaced scapular body fractures resulted in good patient satisfaction, satisfactory long-term functional outcomes, and only minor loss of motion and strength. [Orthopedics. 2020;43(3):e177–e181.]

Scapular fractures comprise approximately 0.4% to 0.9% of all fractures and approximately 3% to 5% of fractures about the shoulder girdle.1 Patients are usually adults in the fourth or fifth decade of life.2–4 The majority of these fractures result from high-energy blunt trauma, and the most common mechanisms are motor vehicle collisions and falls.5 Because of the high-energy mechanisms, the vast majority of scapular fractures are associated with concomitant injuries such as chest injuries, most commonly rib fractures3; however, up to one-third of scapular fractures are believed to occur in isolation.1 Mortality in scapular fractures ranges from 2% to 14%1 and is likely to be associated with multiple rib fractures and flail chest.5

The frequency of scapular neck and body fractures has increased as treatment protocols have improved the survival rate of patients with multi-trauma, but controversy still exists regarding indications for surgery. The first report of scapular fracture treated with open reduction and internal fixation is credited to Lambotte in 1910,6 and more surgical case series emerged soon thereafter. Except for highly displaced glenoid fractures, some surgeons believe nonoperative management should be the mainstay of treatment for reasons of compensatory shoulder motion.5

There are no universally accepted guidelines for surgery, with the majority of extra-articular scapular body fractures treated nonsurgically. However, displaced fractures of the glenoid neck can lead to dysfunction.7 With the advent of 3-dimensional computed tomography (3D CT), radiographic assessment of these fractures has become more reliable in the determination of fracture displacement.8 Although some authors have attempted to define surgical indications such as medial displacement, shortening, angular deformity, intra-articular step-off, and displaced double disruption of the super shoulder suspensory complex,9 other authors have reported satisfactory outcomes with nonoperative treatment of displaced scapular body fractures.2

The goal of this study was to assess whether nonsurgical management of severely displaced extra-articular scapular body fractures results in long-term satisfactory outcomes.

Materials and Methods

Institutional review board approval was obtained for this study. Between 2010 and 2014, a total of 275 patients were treated for scapular body fractures at the authors' level 1 trauma center. Of these patients, 12 met inclusion criteria, and all 12 patients gave informed consent for participation. Inclusion criteria were medial or lateral displacement of the glenoid neck and scapular body greater than 2 cm, angular deformity between fracture fragments greater than 45°, both displacement greater than 1.5 cm and angulation greater than 30°, or glenopolar angle less than 22°.

Patients with combination deformities and displaced double injuries at the superior shoulder suspensory complex also were included. Exclusion criteria were traumatic brain injury preventing participation in rehabilitation protocols, spinal cord injury resulting in paralysis, preexisting shoulder surgeries, age younger than 18 years, and non-English speaking. Standard injury radiographs were obtained (anteroposterior and scapular-Y views) as well as 3D CT scans. After discharge from the hospital, patients underwent follow-up at 6 weeks, 3 months, 6 months, and 12 months.

Functional outcomes measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, Short Form-36 version 1 (SF-36) score, and the American Shoulder and Elbow Surgeons (ASES) shoulder score recorded prospectively. Radiographic data, range of motion (ROM), strength, and complications also were recorded at each follow-up visit. A goniometer was used to assess ROM, and strength measurements were performed using a digital force gauge dynamometer (MicroFET 2; Hoggan Health Industries, Draper, Utah), which measured actual force in pounds.

Patients then were contacted again to participate under a new institutional review board–approved protocol that permitted the addition of one more long-term time point of data. The authors attempted to contact all 12 patients by telephone or by mail. Of the 12 patients, 9 agreed to participate for long-term data collection; the remaining 3 patients could not be contacted. Additional data collected included satisfaction ratings and follow-up on any further treatment received. All 9 patients answered the questionnaires by telephone, and 4 patients returned to the office for physical examination. All reported results reflect the long-term data.

Statistical analysis was performed using Minitab 18 (Minitab Inc, State College, Pennsylvania). A Wilcoxon rank sum test was used to compare SF-36, DASH, and ASES scores as well as ROM and strength testing for patients who completed questionnaires at both the first-year and long-term time points. Results for ROM and strength were reported both as a percentage of the contralateral uninjured extremity as well as absolute numerical difference. Finally, a Wilcoxon rank sum test was used to compare any difference in functional outcome between patients with and without rib fractures at 1 year after treatment; not enough patients were available at the long-term time point to perform this test.

Results

A total of 12 patients (10 males and 2 females) with extra-articular Orthopaedic Trauma Association (OTA) 14B fractures (5 patients with B1 and 7 patients with B2 fractures) with a mean age of 45.6 years (range, 29–57 years) underwent prospective follow-up for a mean of 54.1 months (range, 28.2–74.4 months). All but 1 of the injuries were considered high-energy (Table 1). Mechanisms of injury included 4 motorcycle accidents, 2 motor vehicle accidents, 2 falls, 1 all-terrain vehicle accident, 2 blunt traumas, and 1 electrocution. All of the patients had displaced glenoid neck fractures. Ten patients had medial or lateral displacement greater than 2 cm (mean, 25.4 mm; range, 21–32 mm), 1 patient had a glenopolar angle of 12.9°, and 1 patient had an angular deformity of 56° (Table 2).

Demographic Data

Table 1:

Demographic Data

Fracture Characteristics and Need for Further Surgery

Table 2:

Fracture Characteristics and Need for Further Surgery

Six patients had concomitant rib fractures. Five patients had clavicle fractures; 3 of these patients were treated with open reduction and internal fixation. Two patients had acromion fractures treated with open reduction and internal fixation, with subsequent removal of the hardware. At latest follow-up, mean DASH score was 8.9 (range, 0–35), mean SF-36 score was 72.2 (range, 57.3–96.1), and mean ASES score was 85.9 (range, 46.7–100). Mean ROM expressed as a percentage of contralateral ROM ranged from 88% to 99% (Figure 1). Mean strength expressed as a percentage of contralateral strength ranged from 70% to 93% (Figure 2).

Mean range of motion expressed as a percentage of contralateral range of motion (injured/noninjured). Error bars represent standard error.

Figure 1:

Mean range of motion expressed as a percentage of contralateral range of motion (injured/noninjured). Error bars represent standard error.

Mean strength expressed as a percentage of contralateral strength (injured/noninjured). Error bars represent standard error.

Figure 2:

Mean strength expressed as a percentage of contralateral strength (injured/noninjured). Error bars represent standard error.

All but 2 patients available at longest follow-up reported excellent satisfaction with their treatment, while the others reported good and fair. There were no radiographic nonunions, and all fractures were appraised as united via clinical examination. One patient with concomitant clavicle and acromion fractures treated surgically had a postoperative infection requiring operative irrigation and debridement. None of the other patients required or sought additional treatment for their scapular body fracture.

There were no differences between the first-year outcome measures and the long-term SF-36 (P=.48), DASH (P=.25), and ASES (P=.79) scores. There were no differences when comparing forward flexion (P=.11), abduction (P=.06), and external rotation (P=.88) as a percentage of the contralateral uninjured extremity. There were no differences between the first-year and long-term outcome measures for forward flexion (P>.99), abduction (P=.31), and external rotation (P=.67). At the 1-year time point, there was no difference in SF-36 (P=.58), DASH (P=.87), and ASES (P=.94) scores between patients who had rib fractures and those did who did not have rib fractures.

Discussion

This study found satisfactory long-term outcomes can be achieved with non-operative management of highly displaced scapular neck and body fractures. The findings demonstrate that indications for highly displaced scapular neck and body fractures may still need further refinement. Interestingly, the outcome measures at 1 year did not differ significantly from those obtained at long-term follow-up.

The definition of highly displaced has varied in the literature. Dimitroulias et al2 retrospectively examined 49 patients with substantially displaced scapular body fractures that were treated nonoperatively. Displacement was defined as being 100% and 1 cm, or both. Anavian et al8 outlined a radiographic protocol for evaluation of extra-articular scapular body fractures using radiographs and 3D CT scans; these measurements provided the early groundwork as indications for surgery in later studies. These indications evolved to include medial or lateral displacement greater than 20 mm, angular deformity greater than 45°, combination of angulation greater than 30° and medial or lateral displacement of 15 mm, displacement greater than 10 mm double disruption of the superior shoulder suspensory complex as described by Goss10 in 1993, and glenopolar angle less than 22°.8,11,12

Progression of initially stable fractures also has been a concern. Anavian et al13 suggested certain fracture types have a tendency to progress despite initially being assessed as stable. They found 8 of 49 patients who underwent surgical intervention initially were assessed as stable. All 8 of these patients had type IIC fractures of the Ada and Miller classification.14 The current study included only patients with radiographic parameters that fell under these guidelines (ie, would otherwise be considered for operative management). Ten of the 12 patients in the current study had Ada and Miller type IIC fractures; interestingly, none of these patients later required operative fixation of their scapular body fracture.

Patients with scapular fractures often have other serious injuries. Dimitroulias et al2 demonstrated that the severity of the injury severity score and the presence of rib fractures adversely affected the clinical outcome. In this study, however, no correlation was found between rib fractures and diminished functional outcome. The superior shoulder suspensory complex was injured in 5 patients; of these, 3 patients had clavicle fracture open reduction and internal fixation and 2 patients underwent acromion fracture open reduction and internal fixation.

Inherent weaknesses of the current study include the small number of patients and the lack of a control group. It is also impossible to know whether patients' functional outcomes were directly related to their scapula injury or whether the outcomes were a result of the constellation of injuries. In addition, 5 patients underwent surgery of the acromion or clavicle due to double disruption of the superior shoulder suspensory complex. However, other authors have reported this did not change scapular position.15 The long-term follow-up results of the current study are promising. Further studies, ideally larger randomized studies, are necessary to better identify which candidates meet surgical indications.

Conclusion

The highly displaced scapular body fractures in this series all healed with minimal complications and no nonunions. All but 1 patient reported satisfaction as good or excellent. Nonoperative treatment of highly displaced scapular body fractures resulted in good patient satisfaction, satisfactory long-term functional outcomes, and only minor loss of motion and strength.

References

  1. Bartonicek J. Scapula fractures. In: Court-Brown CM, ed. Rockwood and Green's Fractures in Adults. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:1475–1502.
  2. Dimitroulias A, Molinero KG, Krenk DE, Muffly MT, Altman DT, Altman GT. Outcomes of nonoperatively treated displaced scapular body fractures. Clin Orthop Relat Res. 2011;469(5):1459–1465. doi:10.1007/s11999-010-1670-4 [CrossRef] PMID:21161746
  3. Tadros AM, Lunsjo K, Czechowski J, Abu-Zidan FM. Multiple-region scapular fractures had more severe chest injury than single-region fractures: a prospective study of 107 blunt trauma patients. J Trauma. 2007;63(4):889–893. doi:10.1097/01.ta.0000235876.32569.db [CrossRef] PMID:18090022
  4. Veysi VT, Mittal R, Agarwal S, Dosani A, Giannoudis PV. Multiple trauma and scapula fractures: so what?J Trauma. 2003;55(6):1145–1147. doi:10.1097/01.TA.0000044499.76736.9D [CrossRef] PMID:14676662
  5. Cole PA, Schroder LK, Jacobson AR. Scapula and rib fractures. In: Browner BD, ed. Skeletal Trauma: Basic Science, Management, and Reconstruction. 5th ed. Philadelphia, PA: Elsevier Saunders; 2015:1519–1555.
  6. Lambotte A. Chirurgie Operatoire des Fractures. Paris, France: Masson & Cie; 1913.
  7. Romero J, Schai P, Imhoff AB. Scapular neck fracture: the influence of permanent malalignment of the glenoid neck on clinical outcome. Arch Orthop Trauma Surg. 2001;121(6):313–316. doi:10.1007/s004020000224 [CrossRef] PMID:11482461
  8. Anavian J, Conflitti JM, Khanna G, Guthrie ST, Cole PA. A reliable radiographic measurement technique for extra-articular scapular fractures. Clin Orthop Relat Res. 2011;469(12):3371–3378. doi:10.1007/s11999-011-1820-3 [CrossRef] PMID:21360211
  9. Cole PA, Gauger EM, Schroder LK. Management of scapular fractures. J Am Acad Orthop Surg. 2012;20(3):130–141. doi:10.5435/JAAOS-20-03-130 [CrossRef] PMID:22382285
  10. Goss TP. Double disruptions of the superior shoulder suspensory complex. J Orthop Trauma. 1993;7(2):99–106. doi:10.1097/00005131-199304000-00001 [CrossRef] PMID:8459301
  11. Schroder LK, Gauger EM, Gilbertson JA, Cole PA. Functional outcomes after operative management of extra-articular glenoid neck and scapular body fractures. J Bone Joint Surg Am. 2016;98(19):1623–1630. doi:10.2106/JBJS.15.01224 [CrossRef] PMID:27707848
  12. Cole PA Jr, Gilbertson JA, Cole PA Sr, . Functional outcomes of operative management of scapula fractures in a geriatric cohort. J Orthop Trauma. 2017;31(1):e1–e8. doi:10.1097/BOT.0000000000000710 [CrossRef] PMID:27997467
  13. Anavian J, Khanna G, Plocher EK, Wijdicks CA, Cole PA. Progressive displacement of scapula fractures. J Trauma. 2010;69(1):156–161. doi:10.1097/TA.0b013e3181b40393 [CrossRef] PMID:20016387
  14. Ada JR, Miller ME. Scapular fractures: analysis of 113 cases. Clin Orthop Relat Res. 1991;(269):174–180. PMID:1864036
  15. Gilde AK, Hoffmann MF, Sietsema DL, Jones CB. Functional outcomes of operative fixation of clavicle fractures in patients with floating shoulder girdle injuries. J Orthop Traumatol. 2015;16(3):221–227. doi:10.1007/s10195-015-0349-8 [CrossRef] PMID:25940307

Demographic Data

Patient No.Age, ySexSide of FractureHand DominanceMechanism of InjuryOther Injuries
129MLRFall >6 ft
255MRRMotorcycle accidentClavicle fracture, AC ligament, rib fracture, PTX, pulmonary contusion, hand laceration, tibia fracture
448MRLElectrocution
532MLRMotorcycle accidentAC ligament
650MRRMotorcycle accidentClavicle fracture, rib fracture, pulmonary contusion, SAH
832FRRMotor vehicle accidentClavicle fracture, pelvis fracture, chest, abdomen
939MLRBlunt trauma—200-lb pipeAcromion fracture
1053MLRMotor vehicle accidentRib fracture, distal humerus fracture, ulna fracture, acromion fracture, shoulder soft tissue
1157FRRFall <6 ftRib fracture, distal humerus fracture, ulna fracture, acromion fracture, shoulder soft tissue
1244MRLAll-terrain vehicle accidentClavicle fracture, rib fracture, pulmonary contusion, subarachnoid hemorrhage
1353MLRMotorcycle accident
1555MRRPedestrian struck by motor vehicleRib fracture, SAH, spine fracture, PTX, pulmonary contusion

Fracture Characteristics and Need for Further Surgery

Patient No.SSSC InjuryAda and Miller ClassificationOTA (2018) ClassificationOTA (Prev) ClassificationInclusionFurther Surgery
1NoIIC14B1.LM(2007) 14-A3.1ML displacement 25.1 mm
2YesIIC14B1.LM(2007) 14-A3.2ML displacement 28.5 mm
4NoIIB14B2.LMS(2008) 14-B.2ML displacement 21.1 mmRotator cuff repair
5YesIIB14B2.LMS(2008) 14-B.2Angular deformity 56°AC ORIF (hook plate)
6YesIIC14B1.LM(2008) 14-B.1ML displacement 22 mmClavicle ORIF
8YesIIC14B1.LM(2008) 14-B.2ML displacement 28 mm
9YesIIC, 1A14B2.Y(2008) 14-B.2.P2ML displacement 27.3 mmAcromion ORIF, removal of hardware
10YesIIB, IIC, IA14B2.LMS, 14.A2(2008) 14-B.2.P2ML displacement 22 mmAcromion ORIF, removal of hardware
11NoIIC14B1.LM(2008) 14-B.1ML displacement 32 mm
12YesIIC14B2.LMS(2008) 14-B.2ML displacement 27.3 mmClavicle ORIF
13NoIIC14B1.LM(2008) 14-B.1ML displacement 21 mm
15NoIIC14B2.LMS(2008) 14-B.2Glenopolar angle 12.9°
Authors

The authors are from the Department of Orthopedic Surgery (RAR), Loma Linda University, Loma Linda, California; and the Department of Orthopaedic Surgery (TS, BAM, MCM, GTA), Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Gregory T. Altman, MD, Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 1307 Federal St, 2nd Fl, Pittsburgh, PA 15212 ( Gregory.Altman@ahn.org).

Received: December 12, 2018
Accepted: March 18, 2019
Posted Online: March 20, 2020

10.3928/01477447-20200314-05

Sign up to receive

Journal E-contents