Rockwood Children CH19

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

Techniques A sling or shoulder immobilizer is used for 3 to 6 weeks depend- ing on patient, injury severity, and healing. When there is suf- ficient healing and reduction in pain, rehabilitation progresses from pendulum exercises to full range of motion and strength- ening. Return to sports is usually 8 to 12 weeks after injury. Outcomes No large studies exist regarding the outcomes of children treated for scapula fractures. In the adult literature, the vast majority of patients obtain fracture union and have minimal to no pain with good functional outcomes expected. 53,113 Similarly, most reports indicate children do well with this rare injury. Operative indications for scapula fractures are limited in the pediatric and adolescent populations but include open fractures, fractures with associated neurovascular injuries requiring oper- ative intervention, scapulothoracic dissociation, large glenoid rim fractures with associated proximal humerus subluxation/ dislocation, type II glenoid neck fractures, coracoid process frac- tures with greater than 2 cm of displacement, and glenoid cavity fractures with displacement greater than 5 mm. 2,4,76,112 Floating shoulder injuries involving the midshaft of the clavicle and the glenoid neck can be treated by ORIF of the clavicle as the gle- noid neck will reduce via ligamentotaxis provided by the intact CC ligament. 9 Similarly, floating shoulder injuries involving frac- tures of the glenoid neck, midshaft of the clavicle, and scapula spine will heal by ORIF of the clavicle and scapula spine due to ligamentotaxis provided by the intact CC and/or coracoacromial ligaments. 9 Nonoperative management with immobilization should be used for the remainder of injuries. OPERATIVE TREATMENT OF SCAPULA FRACTURES Indications/Contraindications

PATHOANATOMY AND APPLIED ANATOMY RELATED TO SCAPULA FRACTURES

The scapula is a flat bone on the posterior aspect of the chest wall, covered almost entirely by muscle due to it having 17 mus- cular attachments on it. Only the dorsal aspect of the scapular spine and acromion are subcutaneous, and thus the remainder of the bone is deep and well protected from low-energy mecha- nisms of injury. Three articulations occur with the scapula; the acromion articulates with the clavicle at the AC joint; the prox- imal humerus articulates with the glenoid at the glenohumeral joint; and the posterior chest wall articulates with the anterior scapula to make up the scapulothoracic articulation.

TREATMENT OPTIONS FOR SCAPULA FRACTURES

NONOPERATIVE TREATMENT OF SCAPULA FRACTURES Indications/Contraindications

Nonoperative Treatment of Scapula Fractures: INDICATIONS AND CONTRAINDICATIONS Indications Relative Contraindications

• Nondisplaced or

• Open fractures

minimally displaced scapula body fractures

• Acromion fractures

• Fractures with associated

neurovascular injuries requiring surgical intervention

• Coracoid fractures with < 2 cm of displacement

• Glenoid cavity fractures with > 5 mm of intra-articular displacement • Large glenoid rim fractures with associated proximal humerus subluxation/dislocation

Open Reduction and Internal Fixation Preoperative Planning ✔ ✔ ORIF of Scapula Fractures:

• Glenoid fractures with

< 1 cm of displacement and 40 degrees of angulation

PREOPERATIVE PLANNING CHECKLIST

• Glenoid cavity fractures with < 5 mm of intra- articular displacement

• Type II glenoid neck fractures

❑❑ Flattop Jackson table or standard OR table with the ability to go into beach chair position depending on the approach being utilized ❑❑ Lateral decubitus in bean bag or beach chair

OR table

• Severely comminuted

glenoid fractures unable to support stable fixation

Position/positioning aids

Most scapula fractures can be treated nonoperatively with immobilization alone, no matter what part of the scapula the fracture involves. Exceptions include open fractures, fractures with associated neurovascular injuries requiring operative intervention, scapulothoracic dissociation, large glenoid rim fractures with associated proximal humerus subluxation/dislo- cation, type II glenoid neck fractures, and glenoid cavity frac- tures with displacement greater than 5 mm. 2,4,76,112 All of these are very rare in children but need not be missed.

❑❑ Contralateral side of fracture

Fluoroscopy location

❑❑ 2.7-mm or 3.5-mm plate/screw constructs; heavy nonabsorbable suture

Equipment

❑❑ U-drapes

Draping

The position of the patient and necessary implants will depend on which part of the scapula is fractured. Typically, it is neces- sary to utilize plates that can be bent and twisted to match the