The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 7

Scientific Articles | April 04, 2012

Surgical and Functional Outcomes After Operative Management of Complex and Displaced Intra-Articular Glenoid Fractures

Jack Anavian, MD¹; Erich M. Gauger, MD²; Lisa K. Schroder, BS, MBA²; Coen A. Wijdicks, MSc³; Peter A. Cole, MD²

¹ Department of Orthopaedics, Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903
² Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, 640 Jackson Street, St. Paul, MN 55101. E-mail address for P.A. Cole: Peter.A.Cole@HealthPartners.com
³ Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO 81657

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Investigation performed at the Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, Saint Paul, Minnesota

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Apr 04;94(7):645-653. doi: 10.2106/JBJS.J.00896

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Abstract

Background:

Operative treatment is indicated for displaced fractures of the glenoid fossa. However, little is known regarding functional outcomes in these patients. This study assesses surgical and functional results after treatment of displaced, high-energy, complex, intra-articular glenoid fractures.

Methods:

Thirty-three patients with displaced intra-articular fractures of the glenoid were treated surgically between 2002 and 2009. The indications for operative treatment included articular fracture gap or step-off of ≥4 mm. Twenty-five patients also had extra-articular scapular involvement. A posterior approach was utilized in twenty-one patients, an anterior approach in seven, and a combined approach in five. Functional outcomes, including Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores, shoulder motion and strength, and return to work and/or activities, were obtained for thirty patients (91%).

Results:

At a mean follow-up of twenty-seven months (range, twelve to seventy-three months), all patients had radiographic union of the fracture. The mean DASH score was 10.8 (range, 0 to 42). All mean SF-36 subscores were comparable with those of the normal population. Twenty-six patients (87%) were pain-free at the time of follow-up, and four had mild pain with prolonged activity. Twenty-seven (90%) of thirty patients returned to their preinjury level of work and/or activities.

Conclusions:

Our data suggest that surgical treatment for complex, displaced intra-articular glenoid fractures with or without involvement of the scapular neck and body can be associated with good functional outcomes and a low complication rate.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | Appendix

Fractures through the glenoid fossa generally occur as the result of a high-energy force driving the humeral head into the glenoid fossa^1-3. These forces can further propagate into the scapular neck and body. Several authors have attempted to characterize and classify these fractures for prognostic and treatment purposes^1,2,4. Untreated, displaced intra-articular fractures of the glenoid fossa can lead to poor outcomes, reportedly including glenohumeral joint arthritis and instability^1,2,4-10.

Open reduction and internal fixation is typically the treatment of choice for displaced intra-articular fractures, including those of the glenoid fossa. Several authors have shown good surgical and functional results with operative management of these fractures^5,6,9,11-14. However, there are few studies describing patient-based functional outcomes for surgical treatment of extra-articular scapular fractures^15,16, and we know of no patient-based outcome studies critically examining the operative treatment of intra-articular fractures of the glenoid fossa.

The purpose of this study was to report patient-based functional outcomes after open reduction and internal fixation in patients with intra-articular fractures of the glenoid fossa, with use of detailed and contemporary assessment tools.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | Appendix

This study was approved by the institutional review board. Between March 2002 and February 2009, 511 patients presented to our Level-I trauma center or to the private clinic of the senior author (P.A.C.) either with an acute scapular fracture or malunion of a scapular fracture. One hundred and eighteen of these patients underwent open reduction and internal fixation of the fracture or malunion, and sixty-two of them had been referred from other institutions. Therefore, fifty-six (12%) of 449 patients with scapular fractures presenting primarily to the trauma unit had surgical treatment. Of the total of 118 patients who had open reduction and internal fixation, thirty-three (28%) had displaced intra-articular fractures of the glenoid fossa, with or without extra-articular involvement of the scapula.

All of the patients in this cohort met the prospectively defined indications for operative treatment according to articular involvement (a gap or step-off of ≥4 mm)^4,12,14, and some patients had additional operative indications such as a scapular neck that was angulated >40° or a displaced double disruption of the superior shoulder suspensory complex as described by Goss¹⁷. This complex is made up of a theoretical ring consisting of the glenoid, coracoid, clavicle, and acromion process, as well as the respective connecting soft tissues between these structures, the coracoclavicular ligament, and acromioclavicular joint capsule¹⁷. We use the term triple disruption of the superior shoulder suspensory complex to indicate that three structures in this osseoligamentous chain were broken. These operatively treated glenoid fractures form the basis of this study.

Preoperative evaluation included anteroposterior (Grashey), transcapular Y (lateral), and axillary radiographs of the shoulder. Two and three-dimensional computed tomography (CT) scans were made for all patients for the purposes of preoperative planning. Two-dimensional CT scans were more helpful in defining articular fragments and measuring articular fracture gap and step-off (Fig. 1-A). Due to the ability to rotate the three-dimensional CT image 360° in all planes, three-dimensional CT reconstructions (Figs. 1-B and 1-C) were more helpful to define neck, body, and process displacement and to determine the fracture patterns. Fractures were classified according to the modified Ideberg classification proposed by Mayo et al.⁴ and the revised Arbeits Gemeinshaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification system¹⁸.

Fig. 1-A Fig. 1-B Fig. 1-C

Two-dimensional axial CT view showing 12 mm of articular fracture gap in a patient with complete articular fracture of the glenoid and scapular neck and body (Fig. 1-A). Coronal (Fig. 1-B) and sagittal (Fig. 1-C) views of a three-dimensional CT scan showing the overall fracture pattern and degree of articular involvement.

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Neurologic injuries were diagnosed preoperatively with electromyography and neuroconductive studies when the patients presented more than two weeks after their injuries.

Surgical Technique

Approach

The choice of surgical approach was dependent on the fracture pattern and degree of comminution of the glenoid. Whenever there was involvement of the scapular body, a posterior Judet incision was made. The approach involved either elevating the infraspinatus and teres minor muscles off the posterior aspect of the scapula with the deltoid, after detachment from the vertebral border and spine of the scapula, or elevating a subcutaneous flap first through the Judet incision and utilizing the muscular intervals between the teres minor and infraspinatus for the lateral border and access to the vertebral border as necessary on the basis of the fracture pattern. This latter intermuscular approach allowed the surgeon the option of seeing and manipulating inside the glenohumeral joint when necessary through an arthrotomy. Both approaches yielded access to the lateral border and neck for fixation, as well as to posterior glenoid fragments. The more comminuted the scapular body and neck, and the greater the time from injury to surgery, the more likely access to the whole infraspinatus fossa was desired. Greater fragmentation of the articular surface generally required use of the intermuscular interval. A standard deltopectoral approach was used in patients who had separate anterior glenoid fragments that could not be reduced from the posterior approach or who had isolated superior glenoid fractures, which commonly involved the coracoid.

Surgical Tactic

The patient was positioned in a floppy (forward) lateral decubitus position for posterior approaches, allowing the surgeon to work perpendicular to the plane of the scapula, or in a beach-chair position when a deltopectoral approach was used for anterior articular fragments. The anterior glenoid fractures were typically reduced and fixed with a 2-mm buttress plate and screws, although larger fragments were fixed with 2.7-mm screws. An arthrotomy was used to visualize the reduction, and the capsule was closed with number-2 braided nonabsorbable suture. Three patients had glenoid fragments attached to a torn labrum that warranted repair, and suture anchors were chosen to augment fixation.

Intraoperative inspection of the suprascapular neurovascular bundle was always conducted when a posterior approach was used.

The fixation of coracoid and acromion fractures (as previously described¹⁶) from the posterior approach generally followed reduction of the lateral border of the scapula first. Typically, a 4-mm Schanz pin (with T handle) in the glenoid neck and another in the distal lateral border were necessary to manipulate this reduction and overcome the displacement and deforming forces, particularly for fractures treated several days after the time of injury. Most often, the glenoid and neck were anteverted and medialized with respect to the lateral border and associated body fragments. Rarely, in late-presenting injuries, an articulating distractor was used to help to obtain and maintain reduction during fixation. After the lateral border was reduced, the scapular neck fracture was provisionally fixed, followed by reduction of the vertebral border displacement, as needed, with a small pointed bone tenaculum. In this sequential fashion, the perimeter of the scapula was completely reduced with clamps and/or provisional plates or screws followed by definitive fixation. After fixation, detached fascia was sutured with heavy braided nonabsorbable suture back to the scapular spine and vertebral border through drill-holes and was closed over a suction drain.

Techniques for Fixation

For adequate strength, 2.7-mm dynamic compression plates were used for fixation along the lateral border of the scapula. The longest plate possible to achieve balanced fixation was selected and applied to the lateral border, extending up to the base of the glenoid rim. Because only a few points of fixation are generally possible in the juxta-articular portion of the lateral border at the glenoid neck, locking plates were preferentially used. For glenoid neck fractures extending into the spinoglenoid notch, 2.7-mm reconstruction plates were used because they are more easily contoured and can be placed in parallel to achieve more secure fixation when the neck is comminuted or unstable. The spine of the scapula and the vertebral border were also fixed with 2.7-mm reconstruction plates because of their malleability for contouring. As they have very thin borders, locking plates were also preferred in these locations (Fig. 2). For severely displaced comminution of the scapular body that does not reduce after fixation of the perimeter, spring plates can be used to supplement and “push down” such displaced fragments.

Fig. 2

Postoperative anteroposterior scapular view (unrelated to Figure 1) showing fixation strategies for a complex scapular fracture with intra-articular and extra-articular involvement.

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Rehabilitation

Postoperatively, patients received antibiotics for twenty-four hours, were given a sling for comfort, and began full passive and active-assisted shoulder motion, which continued for the first month. The only exceptions were patients who underwent anterior approaches in which the subscapularis was released from its insertion on the lesser tuberosity. In such patients, external rotation was limited to 30° for the first six weeks postoperatively. The goal during the second month was to achieve full active shoulder motion. Strengthening was initiated in the third month, with 3 to 5-lb (1.35 to 2.25-kg) weights, with no restrictions after three months. It was not unusual for patients to outpace this regimen because of their lack of symptoms. Generally, they must work on endurance for months; however, they are near maximum function by six months postoperatively.

Postoperative Evaluation

Postoperative and follow-up radiographs included anteroposterior (Grashey), transcapular Y (lateral), and axillary projections at the two-week and six-week follow-up appointments, and only anteroposterior radiographs at subsequent office visits. In all patients, the success of reduction and restoration of the articular surface was judged from comparisons of preoperative and postoperative radiographs and by comparison with the anteroposterior radiographs of the contralateral side made for every patient prior to surgery. Union was defined as filling in of fracture lines with osseous consolidation in the context of painless motion. All of the patients were followed until they had pain-free shoulder motion, no tenderness with palpation of the posterior scapular borders, and fracture union on radiographs.

Shoulder strength was assessed during each follow-up visit with use of a handheld dynamometer (microFET 2; Hoggan Health Industries, Draper, Utah)^19,20, which was used to measure resistance in pounds of force in forward flexion (forearm pronated and elbow extended), in abduction (forearm pronated and elbow extended), and in external rotation (arm at side and elbow flexed 90°). These strength measurements for the injured limb were recorded and expressed as a percentage of the strength of the contralateral, uninjured limb.

Range of motion was measured on both sides with a 14-in (36-cm) goniometer by a single examiner (P.A.C.). The goniometer was placed parallel to the midaxial line of the thorax and the midaxial line of the brachium.

Functional outcome was assessed with use of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire²¹ and Short Form-36 (SF-36) (version 2)²² at the six-month follow-up interval. In addition, at each follow-up visit, the patients were questioned regarding the presence of pain, numbness, and other symptoms such as popping or crepitance. All major and minor complications were documented.

Statistical Analysis

Statistical analysis was done to compare the range of motion and strength measurements of the injured arm with those of the uninjured arm, with use of a one-sample t test.

Source of Funding

Research grant funding for this study was provided by Synthes and Zimmer, Inc., but did not play a role in this investigation with regard to treatment choices.

Results

Introduction | Materials and Methods | Results | Discussion | Appendix

Patient Cohort

Detailed patient demographics, including injury mechanism, fracture classification, degree of articular comminution and displacement, as well as surgical approach, are provided in the AppendixAppendix. There were thirty-one male and two female patients, with a mean age of forty-four years (range, eighteen to seventy-five years). Only five patients were over sixty years old. Median time from injury to surgery was sixteen days (range, three to fifty-seven days), with eleven patients undergoing surgery after more than three weeks.

Sixteen patients had fractures with three articular fragments, fifteen patients had two-part articular fractures, and two patients had a fracture with four distinct articular fragments. Associated complex fracture patterns accounted for the majority of this high-energy patient cohort, as there were no AO/OTA type-B1.1 fractures. Only seven (21%) of thirty-three fractures were type B1.2 or 2.2, and even these represented major glenoid involvement with three or four fragments in every case. Only three patients had an isolated articular glenoid fracture. Mean preoperative fracture gap and step-off were 8 mm (range, 2 to 25 mm) and 5 mm (range, 2 to 13 mm), respectively. Of the thirty-one patients who had fracture gap as the surgical indication, the mean fracture gap was 8 mm (range, 4 to 25 mm). Of the twenty-five patients who had articular step-off as the indication, the mean step-off was 6 mm (range, 4 to 13 mm). Twenty-three patients had both articular fracture gap and step-off as surgical indications. Twenty-five patients also had extra-articular scapular involvement.

A posterior approach was utilized in twenty-one patients; an anterior approach, in seven; and a combined approach, in five. The mean, median, and mode estimated blood loss were 661, 475, and 200 mL, respectively. Twenty-eight patients had estimated blood loss of ≤1000 mL. The degree of blood loss generally was proportional to the time from injury and the complexity of the fracture pattern. Associated ipsilateral upper-extremity injuries and nerve injuries are listed in the AppendixAppendix. A profound brachial plexus injury occurred in two patients, leading to complete dysfunction of the injured upper extremity in one patient. Suprascapular nerve injuries were detected during the approach at the level of the spinoglenoid notch in eight patients. The injured nerves were mobilized from the surrounding tissues and repaired, after fracture fixation was completed, with a 4-0 or 6-0 monofilament suture at the undersurface of the infraspinatus muscle. No interposition cable grafts were used.

Radiographic Outcomes

On follow-up radiographic evaluation, all thirty-three fractures had complete fracture union. Thirty (91%) of thirty-three patients showed anatomic restoration of the articular surface after surgery, and there were no losses of reduction or failed fixation. The mean postoperative fracture gap and step-off were 0.5 mm (range, 0 to 4 mm) and 0.5 mm (range, 0 to 3 mm), respectively.

Functional Outcomes

Table I provides the individual functional outcomes that were obtained for thirty (91%) of the thirty-three patients at a mean follow-up of twenty-seven months (range, twelve to seventy-three months). The remaining three patients were lost to follow-up after healing. The mean and median DASH scores were 10.8, and 8.5, respectively (range, 0 to 42; normative mean = 10.1)²³. The mean subscores of all SF-36 subscores of the study patients were comparable with those of the normal population (study mean scores across all parameters were 68 to 90 compared with mean scores of 61 to 84 for control subjects).Twenty-six patients (87%) were pain-free at the time of the final follow-up, and four of thirty patients reported mild pain with prolonged activity. Twenty-seven (90%) of thirty patients had returned to their preinjury occupation and activities.

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TABLE I Patient Outcomes

			Range of Motion*				Strength†
Case	Duration of Follow-up (mo)	DASH Score‡	Forward Flexion	Abduction	External Rotation	Internal Rotation§	Forward Flexion	Abduction	External Rotation	Return to Work and/or Activities	Nerve Injury#
1	72	0	153/160 (96)	104/106 (98)	40/37 (108)	T4/T4	28/32 (88)	29/28 (104)	22/30 (73)	Yes	None
2	73	2	180/183 (98)	135/132 (102)	79/84 (94)	T2/T2	30/33 (91)	20/21 (95)	28/28 (100)	Yes	None
3**											None
4	39	4	158/165 (96)	90/91 (99)	35/38 (92)	T7/T4	21/22 (95)	13/11 (118)	18/22 (82)	Yes	None
5	24	5	156/151 (103)	122/120 (102)	20/41 (49)	T1/T2	25/40 (63)	20/29 (69)	15/35 (43)	Yes	SSN
6	23	22	157/164 (96)	114/116 (98)	66/79 (84)	T6/T5	17/22 (77)	12/9 (133)	13/20 (65)	Yes	None
7	28	6	90/166 (54)	70/153 (46)	5/69 (7)	T5 /T4	11/30 (37)	12/12 (100)	29/33 (88)	Yes	Axillary, SSN, and BP
8	25	18	151/161 (94)	80/120 (67)	66/76 (87)	T3 /T2	5/23 (22)	5/13 (38)	4/22 (18)	Yes	Axillary, SSN, and Radial
9	12	42	170/120 (142)	150/99 (152)	52/100 (52)	T3/T3	8/25 (32)	10/22 (45)	14/27 (52)	No	None
10	36	29	125/170 (74)	96/145 (66)	40/82 (49)	T4/L5	5/13 (38)	4/10 (40)	10/18 (56)	Yes	None
11	28	6	171/165 (104)	84/92 (91)	27/31 (87)	T4/T4	13/11 (118)	11/9 (122)	7/7 (100)	Yes	SSN
12**											None
13	54	11	151/141 (107)	103/99 (104)	61/80 (76)	T3/T4	24/36 (67)	17/24 (71)	24/36 (67)	Yes	None
14	24	5	159/160 (99)	96/98 (98)	79/82 (96)	T4/T3	24/29 (83)	18/20 (90)	29/34 (85)	Yes	None
15	12	12	159/163 (98)	109/105 (104)	54/63 (86)	T4/T2	19/24 (79)	9/15 (60)	16/18 (89)	Yes	None
16	24	3	142/142 (100)	105/109 (96)	45/62 (73)	L4/T4	9/15 (60)	11/10 (110)	8/14 (57)	Yes	None
17	14	0	174/170 (102)	147/150 (98)	75/85 (88)	T2/T3	12/22 (55)	9/15 (60)	7/17 (41)	Yes	SSN
18	24	3	149/125 (119)	100/94 (106)	42/59 (71)	L3/T5	14/14 (100)	12/11 (109)	14/18 (78)	Yes	None
19	54	8	162/162 (100)	98/90 (109)	68/90 (76)	T6/T6	19/29 (66)	16/16 (100)	22/35 (63)	Yes	SSN
20	16	16	††				††			No	BP
21	12	4	165/166 (99)	110/107 (103)	77/81 (95)	T4/T4	21/21 (100)	17/17 (100)	21/24 (88)	Yes	None
22	13	33	130/140 (93)	93/110 (85)	52/78 (67)	T7/T5	15/27 (56)	10/15 (67)	13/23 (57)	No‡‡	Axillary
23	40	9	155/160 (97)	91/94 (97)	28/48 (58)	T4/T4	28/31 (90)	23/24 (96)	31/33 (94)	Yes	None
24	22	4	157/157 (100)	97/97 (100)	64/78 (82)	T3/T2	19/27 (70)	14/13 (108)	28/25 (112)	Yes	None
25	41	0	180/180 (100)	160/170 (94)	75/80 (94)	T4/T4	26/24 (108)	9/10 (90)	18/17 (106)	Yes	None
26	18	15	144/153 (94)	98/107 (92)	55/63 (87)	T6/T4	18/26 (69)	13/17 (76)	15/24 (63)	Yes	SSN
27	18	16	140/140 (100)	95/98 (97)	58/65 (89)	T5/T4	31/37 (84)	22/25 (88)	34/41 (83)	Yes	None
28	13	11	163/149 (109)	93/105 (89)	67/77 (87)	T2/T1	15/23 (65)	12/18 (67)	11/26 (42)	Yes	None
29	12§§	16	111/150 (74)	116/122 (95)	34/71 (48)	T3/T2	4/11 (36)	4/6 (67)	2/12 (17)	Yes	SSN
30**											None
31	12	17	130/139 (94)	90/96 (94)	34/40 (85)	T6/T6	21/22 (95)	25/27 (93)	15/20 (75)	Yes	None
32	12	0	133/145 (92)	86/88 (98)	66/74 (89)	T5/T4	15/16 (94)	13/13 (100)	16/17 (94)	Yes	None
33	12	10	170/170 (100)	111/118 (94)	50/66 (76)	T3/T3	10/25 (40)	10/22 (45)	9/24 (38)	Yes	None
Mean	27	10.8	151/156 (97)	105/111 (95)	52/68 (76)	T5/T4	18/25 (72)	14/17 (82)	17/24 (71)	–	–

*The values are given in degrees as the injured/noninjured shoulder, with the percentage in parentheses.
†The values are given in pounds of force as the injured/noninjured shoulder, with the percentage in parentheses.
‡DASH = Disability of the Arm, Shoulder and Hand questionnaire.
§Internal rotation is given as the vertebral level that the patient could reach with the index finger.
#SSN = suprascapular nerve, and BP = brachial plexus.
**Patient was lost to follow-up; therefore, functional outcome could not be assessed.
††Functional outcome could not be assessed in this patient because of brachial plexus injury.
‡‡Inability to return to work was not related to the shoulder injury.
§§Patient had twelve-month DASH follow-up scores and eight-month range-of-motion and strength data.

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TABLE I Patient Outcomes

			Range of Motion*				Strength†
Case	Duration of Follow-up (mo)	DASH Score‡	Forward Flexion	Abduction	External Rotation	Internal Rotation§	Forward Flexion	Abduction	External Rotation	Return to Work and/or Activities	Nerve Injury#
1	72	0	153/160 (96)	104/106 (98)	40/37 (108)	T4/T4	28/32 (88)	29/28 (104)	22/30 (73)	Yes	None
2	73	2	180/183 (98)	135/132 (102)	79/84 (94)	T2/T2	30/33 (91)	20/21 (95)	28/28 (100)	Yes	None
3**											None
4	39	4	158/165 (96)	90/91 (99)	35/38 (92)	T7/T4	21/22 (95)	13/11 (118)	18/22 (82)	Yes	None
5	24	5	156/151 (103)	122/120 (102)	20/41 (49)	T1/T2	25/40 (63)	20/29 (69)	15/35 (43)	Yes	SSN
6	23	22	157/164 (96)	114/116 (98)	66/79 (84)	T6/T5	17/22 (77)	12/9 (133)	13/20 (65)	Yes	None
7	28	6	90/166 (54)	70/153 (46)	5/69 (7)	T5 /T4	11/30 (37)	12/12 (100)	29/33 (88)	Yes	Axillary, SSN, and BP
8	25	18	151/161 (94)	80/120 (67)	66/76 (87)	T3 /T2	5/23 (22)	5/13 (38)	4/22 (18)	Yes	Axillary, SSN, and Radial
9	12	42	170/120 (142)	150/99 (152)	52/100 (52)	T3/T3	8/25 (32)	10/22 (45)	14/27 (52)	No	None
10	36	29	125/170 (74)	96/145 (66)	40/82 (49)	T4/L5	5/13 (38)	4/10 (40)	10/18 (56)	Yes	None
11	28	6	171/165 (104)	84/92 (91)	27/31 (87)	T4/T4	13/11 (118)	11/9 (122)	7/7 (100)	Yes	SSN
12**											None
13	54	11	151/141 (107)	103/99 (104)	61/80 (76)	T3/T4	24/36 (67)	17/24 (71)	24/36 (67)	Yes	None
14	24	5	159/160 (99)	96/98 (98)	79/82 (96)	T4/T3	24/29 (83)	18/20 (90)	29/34 (85)	Yes	None
15	12	12	159/163 (98)	109/105 (104)	54/63 (86)	T4/T2	19/24 (79)	9/15 (60)	16/18 (89)	Yes	None
16	24	3	142/142 (100)	105/109 (96)	45/62 (73)	L4/T4	9/15 (60)	11/10 (110)	8/14 (57)	Yes	None
17	14	0	174/170 (102)	147/150 (98)	75/85 (88)	T2/T3	12/22 (55)	9/15 (60)	7/17 (41)	Yes	SSN
18	24	3	149/125 (119)	100/94 (106)	42/59 (71)	L3/T5	14/14 (100)	12/11 (109)	14/18 (78)	Yes	None
19	54	8	162/162 (100)	98/90 (109)	68/90 (76)	T6/T6	19/29 (66)	16/16 (100)	22/35 (63)	Yes	SSN
20	16	16	††				††			No	BP
21	12	4	165/166 (99)	110/107 (103)	77/81 (95)	T4/T4	21/21 (100)	17/17 (100)	21/24 (88)	Yes	None
22	13	33	130/140 (93)	93/110 (85)	52/78 (67)	T7/T5	15/27 (56)	10/15 (67)	13/23 (57)	No‡‡	Axillary
23	40	9	155/160 (97)	91/94 (97)	28/48 (58)	T4/T4	28/31 (90)	23/24 (96)	31/33 (94)	Yes	None
24	22	4	157/157 (100)	97/97 (100)	64/78 (82)	T3/T2	19/27 (70)	14/13 (108)	28/25 (112)	Yes	None
25	41	0	180/180 (100)	160/170 (94)	75/80 (94)	T4/T4	26/24 (108)	9/10 (90)	18/17 (106)	Yes	None
26	18	15	144/153 (94)	98/107 (92)	55/63 (87)	T6/T4	18/26 (69)	13/17 (76)	15/24 (63)	Yes	SSN
27	18	16	140/140 (100)	95/98 (97)	58/65 (89)	T5/T4	31/37 (84)	22/25 (88)	34/41 (83)	Yes	None
28	13	11	163/149 (109)	93/105 (89)	67/77 (87)	T2/T1	15/23 (65)	12/18 (67)	11/26 (42)	Yes	None
29	12§§	16	111/150 (74)	116/122 (95)	34/71 (48)	T3/T2	4/11 (36)	4/6 (67)	2/12 (17)	Yes	SSN
30**											None
31	12	17	130/139 (94)	90/96 (94)	34/40 (85)	T6/T6	21/22 (95)	25/27 (93)	15/20 (75)	Yes	None
32	12	0	133/145 (92)	86/88 (98)	66/74 (89)	T5/T4	15/16 (94)	13/13 (100)	16/17 (94)	Yes	None
33	12	10	170/170 (100)	111/118 (94)	50/66 (76)	T3/T3	10/25 (40)	10/22 (45)	9/24 (38)	Yes	None
Mean	27	10.8	151/156 (97)	105/111 (95)	52/68 (76)	T5/T4	18/25 (72)	14/17 (82)	17/24 (71)	–	–

Functional outcome was assessed for both shoulder motion and strength in twenty-nine patients and was reported as a percent of that of the contralateral (normal) shoulder (Figs. 3-A and 3-B). One patient (Case 20) was not able to complete functional assessment of the injured limb because of a persistent brachial plexus injury.

Fig. 3-A Fig. 3-B

Assessment of functional recovery of the injured shoulder as a percentage of the contralateral (normal) shoulder for range of motion (Fig. 3-A) and strength (Fig. 3-B), with the shoulder in forward flexion, abduction, and external rotation (ER).

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In addition, subgroup analysis of patients with and without nerve injuries was completed. The mean shoulder motion and strength were determined for all twenty-nine patients, including nine patients with nerve injuries and twenty patients without nerve injuries, and were reported for each shoulder motion tested (flexion, abduction, and external rotation) (Figs. 4-A and 4-B).

Fig. 4-A Fig. 4-B

Mean range of motion (Fig. 4-A) and mean shoulder strength (Fig. 4-B) in forward flexion, abduction, and external rotation (ER) for all twenty-nine patients and subgroups of nine patients with nerve injury and twenty patients without nerve injury.

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There was a significant difference between the injured and uninjured arm in external rotation motion and in all three strength parameters (p < 0.05). A subanalysis was done to evaluate whether a nerve injury contributed to these differences. No change in the motion or strength parameters was found to be significant.

Complications

Surgical complications included intra-articular screw placement in one patient, surgically corrected on postoperative day 2, and postoperative stiffness in one patient, requiring manipulation with the patient under anesthesia at six weeks. There were no infections. One patient underwent surgical resection of symptomatic ectopic bone around the glenoid, and the symptoms resolved. Secondary symptoms related to winging, impingement, and fatigue were not demonstrated in this study group.

Discussion

Introduction | Materials and Methods | Results | Discussion | Appendix

The majority of scapular fractures are treated effectively with nonoperative management. Operative treatment is recommended for displaced intra-articular glenoid fractures to reduce the risk of posttraumatic degenerative joint disease or glenohumeral instability. The reported indications for surgical management include an articular gap or step-off of between 3 and 10 mm, 20% and 30% involvement of the articular surface, and instability of the glenohumeral joint^1,4,13,24-26. While earlier reports on open reduction and internal fixation of glenoid fractures have shown good surgical results and functional outcome, they are limited by smaller numbers with little detail regarding injury and fracture characteristics, choice of surgical approach, and fixation techniques^7,8,11,12,27. In more recent reports, authors have provided recommendations with regard to the most appropriate surgical approach and fixation techniques for a given fracture pattern^4,14,28,29. This is in part due to greater awareness of the extent of scapular neck and body involvement that occurs in the majority of these fractures, and the implications of these associated injuries on the overall outcome.

Hardegger et al.⁸ reported the results after operative treatment of thirty-seven scapular fractures, twelve of which involved the glenoid fossa. However, they did not separately report the results for operatively treated glenoid fossa fractures from the series as a whole. Kavanagh et al.¹² reported on a series of ten patients treated operatively with use of a posterior approach with excellent functional outcome. However, no objective or validated outcome scoring system was used in that study. Leung et al.¹¹ reported excellent results for eleven of fourteen patients treated surgically, with a mean follow-up of 30.5 months, with use of the scoring system proposed by Rowe³⁰. Adam¹³ reported on ten patients who had been treated surgically and had a mean follow-up of eighteen months. Eight of the ten patients had good-to-excellent results; however, again, no validated outcome scoring system was used. The largest previous series in the literature involved twenty-seven patients, with a mean follow-up of forty-three months, in a report by Mayo et al.⁴. Anatomic reduction was achieved in 89% of the patients. According to their own scoring system, Mayo et al. noted that 82% had a good-to-excellent outcome and 18% had a poor outcome. They documented that the poor outcomes resulted from associated nerve injuries and/or a poor rehabilitation effort. The series with the longest follow-up is that by Schandelmaier et al.⁹, who reported on twenty-two patients with Ideberg type-II to type-V fractures, all of whom were followed for a mean duration of ten years (range, five to twenty-three years). The mean Constant score³¹ was 79, with only four patients who had a score of <50 and all four had postoperative or long-term complications. Those authors concluded that surgical treatment yields good-to-excellent results if there is no postoperative complication or permanent brachial plexus injury. None of these previous studies had a detailed assessment of strength or range of motion.

We report our results after operative treatment of displaced intra-articular glenoid fractures in thirty-three patients. At the time of the final follow-up, the mean measurements for forward flexion, abduction, and external rotation of the shoulder were comparable with those of the uninjured, contralateral shoulder. This was somewhat of a surprise, given the severe nature of these injuries. Another clinical observation was that subjects with deficits in muscular strength did not necessarily express dissatisfaction with limb function. The muscular strength differential was not surprising, given the documented 30% nerve injury rate, but the lack of appreciation by the patient of any left-to-right differences in function was unexpected. This finding suggests that, despite encountering significant differences in strength, such differences may not be clinically relevant to a patient's subjective assessment of the outcome.

Definitions for operative indications by millimeter of displacement are neither clearly defined nor validated. Our indication for treatment was an articular fracture gap or step-off of ≥4 mm⁴.

We recommend the use of three-dimensional CT reconstructions to correctly define the injury, to quantify displacement and angulation of neck and body fractures, and to determine the underlying fracture patterns to aid in surgical planning. This recommendation is particularly true when extra-articular fracture of the scapula is present.

We acknowledge that a limitation of the study is the use of radiographs for postoperative fracture reduction assessment, which may be suboptimal relative to CT; however, CT would not have been justified postoperatively, and three shoulder radiographs of each patient were critically evaluated at two and six weeks postoperatively. Another limitation of this study is a relatively short mean duration of follow-up of twenty-seven months (range, twelve to seventy-three months); however, Schandelmaier et al.⁹ did not find deterioration in functional outcome over time in their five to twenty-three-year study of operatively treated glenoid fractures.

In conclusion, we report on a relatively large operative series of intra-articular glenoid fractures from a single center, with detailed documentation of functional outcome, strength, and motion, in a cohort of patients with relatively severe fractures of the glenoid, with or without involvement of the scapular neck and body. While operative treatment of these fractures remains technically challenging, an anatomic reduction with a good functional outcome, satisfactory muscular recovery, and low rate of complications can be attained.

Appendix

Introduction | Materials and Methods | Results | Discussion | Appendix

Tables showing patient demographics and associated upper-extremity injuries are available with the online version of this article as a data supplement at jbjs.org.

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Topics

shoulder dislocations ; fractures, displaced ; intra-articular fractures ; shoulder dislocation reduction ; glenoid fracture ; glenoid cavity

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Vijay Kumar Badhwar MBBS, MC (Orthopaedic Surgery)

Posted on April 07, 2012

No comparison was made between surgical and conservative treatment

Dr Badhwar Nursing Home, Delhi, India

In this article no comparison was made between surgical and conservative treatment of stable displaced glenoid fractures with a gap more than 4mm. In most displaced glenoid fractures with a stable shoulder joint there are good functional results.

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Jack Anavian, Erich M. Gauger, Lisa K. Schroder, Coen A. Wijdicks, Peter A. Cole; Surgical and Functional Outcomes After Operative Management of Complex and Displaced Intra-Articular Glenoid Fractures. The Journal of Bone & Joint Surgery. 2012 Apr;94(7):645-653.

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