A seventy-two-year-old woman with Alzheimer disease was brought to the
emergency department at our hospital after being struck by a car while
crossing the street. Physical examination revealed deformity of the right
tibia and tenderness over the posterior aspect of the left shoulder. There was
no evidence of acute respiratory distress or shortness of breath, and the
partial oxygen saturation on room air was 98%. Neurovascular examination
revealed normal findings in all four extremities. A comminuted midshaft right
tibial fracture was diagnosed on plain radiographs. The initial chest
radiograph demonstrated multiple left-sided rib fractures without any obvious
hemothorax or pneumothorax (Fig.
1). There was suspicion of a left scapular fracture. A
computerized tomographic scan of the chest was performed (Figs.
2,
3, and
4). Three-dimensional
reconstruction demonstrated a comminuted scapular body and neck fracture.
There was an incomplete sagittal split immediately below a transverse fracture
that separated the superior and inferior aspects of the scapula (Figs.
3 and
4). The proximal aspect of the
lower lateral column was noted to be trapped within the thoracic cage by a
displaced, fractured rib (Fig.
2). No evidence of pneumothorax or hemothorax was noted on the
computed tomography scan.
The left arm was placed in a sling for comfort. On the second hospital day,
the patient underwent uncomplicated closed tibial nailing.
Operative management was recommended for pain control and prevention of
long-term pulmonary complications, functional limitations, and anticipated
difficulty with late reconstruction should nonoperative management fail. The
family equivocated for several days while weighing the risks and benefits of
surgical intervention and then consented to surgery, despite the patient's
limited ability to participate in any postreconstructive rehabilitation. On
the seventh day after the injury, the patient underwent open reduction and
internal fixation of the left scapula through a Judet posterior
approach3. She was
sedated, intubated, and ventilated. With the patient placed midway between a
lateral decubitus position and a prone position, an inverted L-shaped incision
was made along the medial border of the scapula and then laterally along the
scapular spine.
The Judet approach was chosen because it allowed more options for fixation.
The deltoid origin along the scapular spine was minimally released and the
infraspinatus was turned back on its neurovascular pedicle. The entrapped
lateral column could not be freed until the soft tissue over the rib was
released. The intrathoracic fracture fragment had penetrated the thoracic
cavity through a segmental rib fracture and was locked on the anterior surface
of the more inferior rib (Fig.
2).
A chest tube was placed through a separate intercostal space to drain the
pleural effusion and any hemothorax that might develop after reduction of the
displaced rib. The osseous fragments were then reduced under direct
visualization with fluoroscopic assistance and were fixed in a medial-inferior
to lateral-inferior fashion. Medially, a twelve-hole straight reconstruction
plate was bent into an L shape so that it could be secured along both the
scapular spine and the medial border. Laterally, a curved six-hole pelvic
reconstruction plate was secured with bicortical screws. The central part of
the scapular body was thin and recessed. Anatomic reduction and fixation was
obtained with use of a buttress one-third tubular plate, which was applied
over this central fragment and fixed to the reconstruction plates, thereby
forming an H-type construct (Fig.
5). The rib returned to its normal anatomic position when released
from the scapula. The arm could then be put through a full range of motion
without difficulty. On the third postoperative day the chest tube was removed,
and two days later the patient was released to a rehabilitation hospital. At
the three-month follow-up visit, the patient demonstrated full range of motion
and strength of the left arm and shoulder. Radiographs demonstrated adequate
alignment of the scapula but union of the fracture was difficult to assess
(Figs. 6-A and 6-B). No
additional follow-up has occurred as of the time of writing.