Rockwood Children CH19

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

Authors’ Preferred Treatment for Scapula Fractures (Algorithm 19-2)

Scapula Fractures

Glenoid neck Fractures

Glenoid cavity Fractures

Scapula body fxs

Acromion fxs

Coracoid fxs

Nonoperative management

ORIF if displaced

< 5 mm intra- articular displacement

> 5 mm intra- articular displacement

Non-operative management

ORIF

> 1 cm displacement

Non-/minimally displaced

Nonoperative management

< 1 cm displacement and < 40° angulation

> 1 cm displacement and > 40° angulation

ORIF

Nonoperative management

ORIF

Algorithm 19-2.  Authors’ preferred treatment for scapula fractures.

Postoperative Care Postoperatively, patients are placed in a sling or shoulder immobi- lizer for 3 to 6 weeks. Subsequently, pendulum exercises are per- formed followed by advancement to active range of motion based on radiographic union and pain. Strengthening and contact sports are not permitted for a minimum of 3 months postoperatively. Most pediatric and adolescent scapula fractures are treated nonoperatively with immobilization for 3 to 4 weeks fol- lowed by pendulum exercises and progressed to active range of motion as tolerated. This includes scapula body fractures, acromion fractures, coracoid process fractures, and glenoid neck and cavity fractures without significant displacement. Operative treatment is reserved for open fractures and gle- noid cavity fractures with significant size and/or displace- ment leading to glenohumeral subluxation/dislocation.

Coracoid process fractures displaced greater than 2 cm are also treated with ORIF. Our preference is to perform arthroscopic reduction of type Ia glenoid cavity fractures and ORIF for the remain- der of glenoid cavity fractures and glenoid neck fractures requiring operative fixation. We routinely obtain three-dimensional CT scans to aid in preoperative planning and

determination of the best surgical approach to utilize based on the fracture pattern.

Care must be taken during ORIF when retracting structures about the shoulder region, as vigorous retraction can damage neurovascular structures. For example, the musculocutaneous nerve is at risk during excessive medial retraction about the gle- nohumeral joint/coracoid. It is necessary to obtain a near-anatomic reduction of the artic- ular surface during ORIF of glenoid cavity fractures as residual displacement greater than 2 mm leads to poorer outcomes. 76,96 Furthermore, failure to reduce large glenoid cavity fragments may lead to persistent glenohumeral subluxation/dislocation. Outcomes No data exist regarding the outcomes of pediatric and adoles- cent patients treated with ORIF for scapula fractures. The adult literature has demonstrated that the results of operative fixa- tion of glenoid cavity fractures depend on near-anatomic res- toration of joint alignment. If residual incongruity is less than 2 mm, good-to-excellent results can be expected for 80% to

Potential Pitfalls and Preventive Measures

Scapula Fractures: SURGICAL PITFALLS AND PREVENTIONS Pitfall Prevention • Neurovascular injury

• Avoid overly vigorous retraction

• Obtain near-anatomic ( < 2 mm incongruity) of glenoid cavity fragments

• Persistent glenohumeral subluxation/dislocation