Early Clinical Efficacy of Small Incision Reduction and Superior Closed Pin Fixation of Goss-Ideberg Type III Glenoid Fractures using X-ray and CT Scan.

BACKGROUND: Imaging techniques such as X-rays and 3D Computed Tomography (CT) are used to diagnose and evaluate a patient's shoulder before and after surgery. Identifying the kind, location, and severity of a shoulder fracture helps surgeons choose the right treatment and surgery. OBJECTIVES: The study examines the effectiveness of small incision reduction and superior closure pinning in treating Ideberg type III glenoid fractures identified by X-ray and CT scans. MATERIALS AND METHODS: From October 2017 to June 2022, 40 patients with Ideberg type III glenoid fractures underwent mini-incision reduction and superior closed pinning fixation using the Anterior (AA) and Posterior (PA) approaches. Pre- and post-surgery shoulder scores and imaging data were analyzed. Outpatient review and shoulder anteroposterior radiographs were collected at 1, 3, 6, and 12 months after surgery. We assessed shoulder joint function using the American Shoulder and Elbow Society (ASES) shoulder score, VAS score, Constant-Murley Shoulder Outcome (Constant) score, and DASH score. RESULTS: A total of 40 patients were monitored for 14-16 months, averaging 15.2 ± 0.3 months. All fractures were healed between 14-25 weeks from X-rays, averaging 17.6 ± 5.4 weeks. Both the AA and PA groups had similar shoulder score changes. However, the AA group did better. In all cases, ASES shoulder scores were outstanding at 80%. Radiographs demonstratedno traumatic arthritis or internal fixation failure consequences like screw loosening or breakage. CONCLUSION: It was concluded that Ideberg type III glenoid fracture reduction with an anterior small incision and superior closed pinning hollow lag screw internal fixation could be successful.

Finite element analysis of the treatment of a minimally invasive approach combined with a novel anatomical locking plate for scapular body fractures.

BACKGROUND: The minimally invasive approach for the treatment of displaced scapular neck or body fractures has the advantages of less trauma and minimal muscle dissection. In clinical practice, the minimally invasive approach combined with an anatomical locking plate has been used to treat scapular body fractures. In addition, we have made minor modifications to the minimally invasive approach. However, the biomechanical study about the approach combined with an anatomical locking plate in treating scapular body fractures was limited. METHODS: Finite element analysis (FEA) was used to conduct the biomechanical comparison between the anatomical locking plate (AP model) and reconstructive plate (RP model) in the treatment of scapular body fractures through the modified minimally invasive approach. A healthy male volunteer with no history of scapula or systemic diseases was recruited. High-resolution computed tomography images of his right scapula were obtained. Two scapula models were constructed and analyzed by the software of Mimics 21.0, Geomagic Wrap 2021, SolidWorks 2021, and ANSYS Workbench 2022, respectively. RESULTS: Through static structural analysis, in terms of equivalent von Mises stress, equivalent elastic strain, and total deformation, the AP model exhibited superior safety characteristics, enhanced flexibility, and anticipated stability compared with the RP model. This was evidenced by lower maximum stress, lower maximum strain and displacement. CONCLUSION: The minimally invasive approach combined with an anatomical locking plate for scapular body fractures had better biomechanical stability. The study provided a biomechanical basis to guide the clinical treatment of scapular body fractures.

The Scapular Skiver Screw: A Useful Fixation Technique for Inferior Glenoid and Scapular Neck Fractures.

SUMMARY: The inferior glenoid and scapular neck are common locations for scapular fractures. Operative exposures for reduction and fixation can be challenging, and frequently, the proximal fracture planes are not conducive to optimal fixation with a plate alone. The purpose of this article was to describe a new technique for enhancing fixation in specific inferior glenoid fractures using a single cortical lag screw.

[Effectiveness analysis of double EndoButton suture fixation Latarjet procedure for treatment of anterior shoulder dislocation with glenoid bone defect caused by military training injuries].

Objective: To investigate the effectiveness of double EndoButton suture fixation Latarjet procedure in the treatment of shoulder anterior dislocation with glenoid bone defect caused by military training injuries. Methods: The clinical data of 14 patients with anterior shoulder dislocation with glenoid bone defect due to military training injuries who met the selection criteria and admitted between August 2021 and December 2022 were retrospectively analyzed. All patients were male, the age ranged from 21 to 38 years, with an average of 26.8 years. The time from initial dislocation to operation was 6-15 months, with an average of 10.2 months. Anterior shoulder dislocation occurred 5-12 times, with an average of 8.2 times. All glenoid bone defects were more than 10%, including 5 cases of 10%-15%, 8 cases of 15%-20%, and 1 case of 24%. All patients were treated by double EndoButton suture fixation Latarjet procedure. The operation time and complications were recorded. The shoulder function and pain were evaluated by the American Association for Shoulder and Elbow Surgery (ASES) score, Rowe score, Instability Severity Index Score (ISIS), and visual analogue scale (VAS) score before and after operation. The range of motion of the shoulder was recorded, including forward flexion, 0° external rotation, and abduction 90° external rotation. The position, healing, and resorption of the bone mass were evaluated by three-dimensional CT of shoulder joint after operation. Results: All patients successfully completed the operation, and the operation time was 100-150 minutes, with an average of 119.7 minutes. There was no complications such as infection, vascular and nerve injury. All patients were followed up 12-20 months, with an average of 15.6 months. During the follow-up, 4 patients had bone mass separation, absorption, and recurrent anterior dislocation, and the shoulder joint fear test was positive. Imaging of the remaining patients showed that the bone mass healed well, no anterior dislocation recurrence occurred, and the healing time was 3-7 months (mean, 4.7 months). At last follow-up, the range of motion, ASES score, Rowe score, ISIS score, and VAS score of the patients significantly improved when compared with those before operation ( P<0.05). Conclusion: The effectiveness of double EndoButton suture fixation Latarjet procedure for the treatment of anterior shoulder dislocation with glenoid bone defect caused by military training injury is satisfactory.

[Acupuncture combined with tuina therapy for stiff neck with levator scapula injury type: a randomized controlled trial].

OBJECTIVE: To observe the clinical efficacy of acupuncture combined with tuina therapy for stiff neck with levator scapula injury type. METHODS: A total of 162 patients with stiff neck of levator scapula injury type were randomly divided into an acupuncture combined with tuina group (combined group, 52 patients), a tuina group (55 patients), and an acupuncture group (55 patients). The patients in the acupuncture group received acupuncture on the affected side's Houxi (SI 3), inserting the needle 10 to 20 mm towards Laogong (PC 8) with strong or moderate stimulation, and patients were instructed to move their neck, shoulders, and upper limbs during the process, with the needle retained for 2 to 3 min. The patients in the tuina group received strong stimulation pressing on tender points to release the starting and ending points of the trapezius muscle with modified techniques. The combined group first received tuina therapy, followed immediately by acupuncture treatment at the Houxi (SI 3). Treatments were administered every other day for a total of three sessions. Before treatment and on 1, 3, and 7 days after treatment, the simple McGill pain questionnaire (SF-MPQ) scores [including the pain rating index (PRI), visual analogue scale (VAS), and present pain intensity (PPI) scores] of the head, neck and shoulder, cervical spine mobility scores were observed, and the clinical efficacy and safety of each group were evaluated. RESULTS: On the 1, 3, and 7 days after treatment, the SF-MPQ, PRI, VAS, and PPI scores of the head, neck, and shoulder in all groups were significantly reduced (P<0.01). On the 1 and 3 days after treatment, the above scores in the combined group were lower than those in the tuina group and the acupuncture group (P<0.05, P<0.01). On the 7 days after treatment, the above scores in the combined group were lower than those in the acupuncture group (P<0.01). On the 3 days after treatment, the SF-MPQ, PRI, and VAS scores in the tuina group were lower than those in the acupuncture group (P<0.01). On the 7 days after treatment, the SF-MPQ, PRI, VAS, and PPI scores in the tuina group were lower than those in the acupuncture group (P<0.01, P<0.05). On the 1, 3, and 7 days after treatment, the cervical spine mobility scores in each group were decreased compared to those before treatment (P<0.01). On the 3 days after treatment, the cervical spine mobility score in the combined group was lower than that in the acupuncture group and the tuina group (P<0.01). On the 1, 3, and 7 days after treatment, the cured rate in the combined group was higher than that in the tuina group and the acupuncture group (P<0.01). During the treatment period, no serious adverse reactions occurred in any group. CONCLUSION: Acupuncture combined with tuina therapy could effectively improve stiff neck with levator scapula injury type, alleviate patient pain, restore cervical spine mobility, and clinically outperform both tuina and acupuncture therapy alone.

Scapula fractures: functional anatomy, clinical assessment and management.

Fractures of the scapula are rare injuries, accounting for 3-5% of all shoulder girdle fractures. They are frequently the result of high energy trauma and often present with concurrent and life-threatening injuries to adjacent structures, leading to significant morbidity and mortality. Patients presenting with scapula fractures must receive a thorough and systematic clinical assessment as directed by national trauma guidelines. Appropriate imaging is essential in delineating fracture morphology and should at the very least include anteroposterior, anteroposterior oblique (Grashey) and axillary or scapula 'Y' view of the shoulder. Computed tomography imaging with three-dimensional reconstruction allows better delineation of the fracture morphology and helps with surgical planning. A lack of randomised controlled trials comparing the efficacy of conservative and operative management of scapula fractures has resulted in limited consensus for surgical indications. Nevertheless, most extra-articular fractures can be managed conservatively while intra-articular fractures of the glenoid frequently require surgical fixation.

The Effects of Pulmonary Risk Factors and Combination Thoracic Osseous Fractures on Mortality and Outcomes of Surgical Stabilization of Rib Fractures.

BACKGROUND: Rib fixation for traumatic rib fractures is advocated to decrease morbidity and mortality in select patient populations. We intended to investigate the effect of combination osseous thoracic injuries on mortality with the hypothesis that combination injuries will worsen overall mortality and that SSRF will improve outcomes in combination injuries and in high-risk patients. METHODS: Patients with rib fractures were identified from the Trauma Quality Improvement Project registry from 2019. Patients were then divided into rib fracture(s) alone or in combination with sternal, thoracic vertebra, or scapula fracture. Patients were also categorized into those with COPD and smokers. Patients with AIS >3 outside of thorax were excluded. Patients were subcategorized into those who had rib fixation verse nonoperative management for all subgroups. Analysis was performed to evaluate the efficacy of rib fixation. RESULTS: A total of 111,066 patients were included for analysis. The overall mortality was 1.4%. Patients with COPD had over double the mortality risk, with an overall mortality of 3.4%. Combination injuries did not appear to increase mortality. SSRF did not decrease mortality; however, the number of patients in this group was too small to complete statistical analysis. The overall complication rate was 0.43%. There was a trend towards an increase in extrapulmonary complications in the group that underwent surgical fixation. DISCUSSION: Mortality from rib fractures with concomitant osseous thoracic fracture appears to be low. However, mortality is increased in patients with COPD regardless of rib fracture pattern. The number of patients who underwent SSRF was too small to make a statistical comparison.

Scapular fractures: A regional and rural perspective.

INTRODUCTION: Scapular fractures (SFs) have historically been associated with severe trauma and multiple injuries. Recent studies have demonstrated improved outcomes. However, SFs have never been studied from a strictly rural or Australian perspective. OBJECTIVE: The study's objective was to assess whether associations still exist between a fractured scapula and trauma scores, mortality rates, and other commonly associated injuries in a regional Australian trauma centre. DESIGN: The study design examined prospectively collected data from a regional hospital between the years 2012 to 2021 presenting to the emergency department with traumatic SFs. Primary outcomes of interest were mortality rate, method of injury, ISS scores, and associated injuries. FINDINGS: One hundred and five patients had a SF. The median age was 49 with 93 (89%) being male. Most fractures were located in the body of the scapula (80%). The primary mechanism of injury was motorbike accidents (36%), falls (24%), and motor vehicle accidents (22%). Two patients died from their injuries (1.9%). Thirty-four percent demonstrated mild trauma scores, with 36% moderate, 28% severe, and 1.9% critical. Commonly observed associated injuries included chest wall fractures, vertebral fractures, thoracic injuries, brain injury, and abdominal trauma. DISCUSSION: A minority of SFs were associated with severe or critical trauma, and overall, patients who sustained a SF had a low mortality rate. These findings suggest that patients from regional areas have similar outcomes to those from more urban centres in other parts of the world. CONCLUSION: Given these results, a re-examination of whether SFs are a reliable marker of severe trauma should be considered.

Do preoperative scapular fractures affect long-term outcomes after reverse shoulder arthroplasty?

BACKGROUND: Postoperative scapular stress fractures (SSFs) are a formidable problem after reverse shoulder arthroplasty (RSA). Less is known about patients who have these fractures preoperatively. The primary aim of this study was to examine postoperative satisfaction in patients undergoing primary RSA who have preoperative SSF and compared to a matched cohort without preoperative fracture. The secondary aim was to examine the differences in patient-reported outcomes between and within study cohorts. METHODS: A retrospective chart review of primary RSAs performed by a single surgeon from 2000 to 2020 was conducted. Patients diagnosed with cuff tear arthropathy (CTA), massive cuff tear (MCT), or rheumatoid arthritis (RA) were included. Five hundred twenty-five shoulders met inclusion criteria. Fractures identified on preoperative computed tomography scans were divided into 3 groups: (1) os acromiale, (2) multifragments (MFs), and (3) Levy types. Seventy-two shoulders had an occurrence of SSF. The remaining 453 shoulders were separated into a nonfractured cohort. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and visual analog scale (VAS) scores were compared pre- and postoperatively in the total fracture group and the nonfractured group cohort. The multifragment subgroup was also compared to the pooled Os/Levy subgroup. RESULTS: The total incidence of SSF in all shoulders was 13.7%. There was a difference in satisfaction scores at all time points between the nonfracture (7.9 ± 2.8) and total fracture group (5.4 ± 3.6, P < .001, at last visit). There was also a greater ASES total score in the nonfractured group vs the total fracture group at the final visit (69.4 ± 23.4 and 62.1 ± 24.2; P = .02). The MF group had worse ASES functional or VAS functional scores than the Os/Levy group at all time points: at 1 year, ASES function: MF 24.2 ± 14.5 and Os/Levy 30.7 ± 14.2 (P = .045); at 2 years, ASES function: MF 21.4 ± 14.4 and Os/Levy 35.5 ± 10.6 (P < .001); and at last follow-up, VAS function: MF 4.8 ± 2.8 and Os/Levy 6.4 ± 3.2 (P = .023). DISCUSSION: Scapular fractures were proportionally most common in patients diagnosed with CTA (16.3%) compared with a 9.2% and 8.6% incidence in patients diagnosed with MCT and RA, respectively. Patients with preoperative SSF still see an improvement in ASES scores after RSA but do have lower satisfaction scores compared with the nonfractured cohort. The multifragment fracture group has lower functional and satisfaction scores at all postoperative time points compared with both the nonfracture and the Os/Levy fracture group.

Robert H. Cofield, MD, Award for Best Oral Presentation 2023: Up to 8 mm of glenoid-sided lateralization does not increase the risk of acromial or scapular spine stress fracture following reverse shoulder arthroplasty with a 135° inlay humeral component.

BACKGROUND: Glenoid-sided lateralization in reverse shoulder arthroplasty (RSA) decreases bony impingement and improves rotational range of motion, but has been theorized to increase the risk of acromial or scapular spine fractures (ASFs). The purpose of this study was to assess if glenoid-sided lateralization even up to 8 mm increases the risk for stress fracture following RSA with a 135° inlay humeral component. METHODS: A retrospective review was performed from a multicenter prospectively collected database on patients who underwent primary RSA from 2015 to 2021. All RSAs were performed with a 135° inlay humeral component. Varying amounts of glenoid lateralization were used from 0 to 8 mm. Preoperative radiographs were reviewed for the presence of acromial thinning, acromiohumeral distance (AHD), and inclination. Postoperative implant position (distalization, lateralization, and inclination) as well as the presence of ASF was evaluated on minimum 1-year postoperative radiographs. Regression analyses were performed on component and clinical variables to assess for factors predictive of ASF. RESULTS: Acromial or scapular spine fractures were identified in 26 of 470 shoulders (5.5%). Glenoid-sided lateralization was not associated with ASF risk (P = .890). Furthermore, the incidence of fracture did not vary based on glenoid-sided lateralization (0-2 mm, 7.4%; 4 mm, 5.6%; 6 mm, 4.4%; 8 mm, 6.0%; P > .05 for all comparisons). RSA on the dominant extremity was predictive of fracture (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.20-5.75; P = .037), but there was no relationship between patient age, sex, preoperative acromial thinning, or diagnosis and risk of fracture. Although there was no difference in mean postoperative AHD between groups (P = .443), the pre- to postoperative delta AHD was higher in the stress fracture group (2.0 ± 0.7 cm vs. 1.7 ± 0.7 cm; P = .015). For every centimeter increase in delta AHD, there was a 121% increased risk for fracture (OR 2.21, 95% CI 1.33-3.68; P = .012). Additionally, for every 1-mm increase in inferior glenosphere overhang, there was a 19% increase in fracture risk (P = .025). CONCLUSION: Up to 8 mm of glenoid-sided metallic lateralization does not appear to increase the risk of ASF when combined with a 135° inlay humeral implant. Humeral distalization increases the risk of ASF, particularly when there is a larger change between pre- and postoperative AHD or higher inferior glenosphere overhang. In cases of pronounced preoperative superior humeral migration, it may be a consideration to avoid excessive postoperative distalization, but minimizing bony impingement via glenoid-sided lateralization appears to be safe.

Three-Dimensional Mapping of Scapular Body, Neck, and Glenoid Fractures.

OBJECTIVES: The purpose of this study was to report patterns of scapular fractures and define them with a contemporary methodology. METHODS: . DESIGN: Retrospective study, 2015-2021. SETTING: Single, academic, Level 1 trauma center. PATIENT SELECTION CRITERIA: Consecutive patients ≥18 years, presenting with unilateral scapula fracture, with thin-slice (≤0.5-mm) bilateral computed tomography (CT) scans of the entirety of both the injured and uninjured scapulae. OUTCOME MEASURES AND COMPARISONS: Thin-slice (0.5-mm) CT scans of injured and normal scapulae were obtained to create three-dimensional (3D) virtual models. 3D modeling software (Stryker Orthopedics Modeling and Analytics, Stryker Trauma GmbH, Kiel, Germany aka SOMA) was used to create a 3D map of fracture location and frequency. Fracture zones were delineated using anatomic landmarks to characterize fracture patterns. RESULTS: Eighty-seven patients were identified with 75 (86%) extra-articular and 12 (14%) intra-articular fractures. The dominant fracture pattern emanated from the superior lateral border (zone E) to an area inferior to the spinomedial angle (zone B) and was present in 80% of extra-articular fractures. A second-most common fracture line propagated from the primary (most-common) line toward the inferior medial scapular border with a frequency of 36%. Bare zones (with 1 or no fractures present) were identified in 4 unique areas. Furthermore, intra-articular fractures were found to be heterogenous. CONCLUSIONS: The 3D fracture map created in this study confirmed that extra-articular scapular fractures occur in certain patterns with a relatively high frequency. Results provide greater insight into scapular fracture locations and may help to study prognosis of injury and improve treatment strategy including operative approaches and surgical tactics.

Ipsilateral fractures of the acromion and coracoid processes of the scapula.

A fracture of the acromion and coracoid processes of scapula is rarely seen in the outpatient clinic, due to the acromion's anatomical position and shape, as well as the strong ligaments and muscles that are attached to it. These fractures are caused by either direct or indirect high-energy trauma injuries to the shoulder joint, leading to severe pain and a grossly restricted range of motion. Several acromial classifications were reported, but this type of longitudinal plane fracture of the acromion process in our case is yet to be described in the current literature. We present a rare combination of the coracoid process and unstable acromion bony projection fractures that have not previously been noted for this type of fracture. The closest to this is Kuhn's type III classification. A 51-year-old male presented to our emergency department complaining of the right shoulder pain and difficulty raising his arm following a 2-wheeler accident. The patient was managed by open reduction and internal fixation with 3 cannulated cancellous screws fixation and progressed well with no postoperative complications. He was asymptomatic postoperatively and regained full range of motion after 4 months.

Efficacy analysis of axillary approach in the treatment of Ideberg type I and II scapular glenoid fractures: Case series.

RATIONALE: To investigate the clinical efficacy of the axillary approach in the surgical treatment of Ideberg type I and II scapular glenoid fractures. PATIENT CONCERNS AND DIAGNOSIS: Retrospective analysis of 13 cases of scapular glenoid fracture treated in the affiliated Hospital of Jining Medical College, Jiaxiang County People hospital, Zoucheng City people Hospital, Yanzhou District People Hospital, and Juancheng County people Hospital from December 2020 to January 2022. Eight males (including 1 bilateral) and 5 females, with an average age of 57.5 years (range from 33 to 75 years). According to Ideberg classification, there were 10 cases of type I a, 1 case of type I a combined with type I b, and 2 cases of type II. All patients were treated with axillary approach surgery and 7 patients with combined anterior shoulder dislocation were treated by first-stage manipulation and second-stage reoperation. Seven patients were fixed with a wire anchor, 3 patients with type I a were fixed with a "T" plate, and 5 patients were complicated with rotator cuff tear and were repaired with a wire anchor. At the last follow-up, the Constant-Murley shoulder function score, visual analog score, DASH score, and Hawkins grade were used to evaluate shoulder function, pain, and stability after treatment. INTERVENTION: The intervention was to treat patients with Ideberg type I and II scaphoid fractures using an axillary approach. OUTCOMES: All 13 patients in this group were followed up thoroughly, and the follow-up time was 12 to 25 months, with an average of 18.6 months. The operation time was 65 to 135 minutes, with an average of 85.6 minutes. Intraoperative blood loss ranged from 20 to 120 mL, averaging 55.6 mL. The duration of hospitalization ranged from 7 to 22 days, with an average of 9.6 days. The surgical incisions of all patients were grade-A healing. Bone healing of glenoid fractures was observed 3 months after the operation. LESSONS: The axillary approach for Ideberg type I and II scapular glenoid fractures is a feasible surgical approach with complete access through the muscle gap, minimal surgical trauma, mild postoperative pain, and satisfactory clinical results.

Nonunion of the so-called acromion: a systematic review with consideration of the terminology.

INTRODUCTION: There is no widely accepted standard for the classification and treatment of traumatic acromion/scapular spine fracture nonunion due to the scarcity of this condition and the confusion of terminology. MATERIALS AND METHODS: PubMed and Scopus were searched using "scapular fracture" and "acromion fracture" or "scapular spine fracture" as search terms. The inclusion criteria were English full-text articles concerning acromion/scapular spine fracture nonunion that described patient characteristics and presented appropriate images. The exclusion criteria were cases without appropriate images. Citation tracking was conducted to find additional articles and notable full-text articles written in other languages. Fractures were classified using our newly proposed classification system. RESULTS: Twenty-nine patients (19 men, 10 women) with 29 nonunions were identified. There were four type I, 15 type II, and 10 type III fracture nonunions. Only 11 fractures were isolated. The mean period from initial injury to final diagnosis was 35.2 ± 73.2 months (range 3-360 months) (n = 25). The most frequent cause of delayed diagnosis was conservative treatment for fracture in 11 patients, followed by oversight by the physician in 8. The most common reason for seeking medical advice was shoulder pain. Six patients received conservative therapy, and 23 received operative treatment. Fixation materials included various plates in 15 patients, and tension band wiring in 5. Bone grafting was performed in 16 patients (73%, 16/22). Of the 19 surgically treated patients with adequate follow-up, the outcome was rated excellent in 79%. CONCLUSIONS: Isolated acromion/scapular spine fracture nonunion is rare. Fracture type II and III, arising in the anatomical scapular spine, accounted for 86% of the fractures. Computed tomography is required to prevent fracture oversight. Surgical therapy produces good stable results. However, it is important to select the appropriate surgical fixation method and material after considering the anatomical characteristics of the fracture and stress on the fractured portion. LEVEL OF EVIDENCE: V.

Managing Scapular Dyskinesis.

Scapular dyskinesis, the impairment of optimal scapular position and motion, is common in association with shoulder injury. A comprehensive evaluation process can show the causative factors and lead to effective treatment protocols. The complexity of scapular motion and the integrated relationship between the scapula, humerus, trunk, and legs suggest a need to develop rehabilitation programs that involve all segments working as a unit rather than isolated components. This is best accomplished with an integrated rehabilitation approach that includes rectifying deficits in mobility, strength, and motor control but not overtly focusing on any one area.

Deltoid-Sparing Modified Judet Approach: Technique and Clinical Series.

SUMMARY: Posterior approaches provide the mainstay for treatment in most of the scapula body and neck fractures, even those associated with many intraarticular variants. Several posterior approach modifications for minimizing soft-tissue damage and limiting muscular detachment, have previously been described in the literature; however, little or no clinical evidence is available specifically applied to the various approaches.In this study, we describe complete sparing of the deltoid muscle origin during the "modified Judet" approach. The modified approach as previously described detaches the deltoid origin. Deltoid sparing allows for satisfactory visualization and fixation of extra-articular scapula fractures and even some intraarticular variants. The purpose of this article was to describe the deltoid-sparing modified Judet approach and report clinical outcomes for 23 patients after surgical treatment.

The relationship between the presence of scapula fracture and mortality and morbidity in cases with blunt thoracic trauma.

BACKGROUND: Scapula fractures (SFs) occur as a result of high-energy trauma and are significant in terms of life-threatening injuries. There are few studies showing the relationship between SFs and mortality and morbidity in patients with blunt thoracic trauma (BTT). Our study aims to investigate the relationship between SF and mortality and morbidity in BTT. METHODS: Adult patients admitted to the emergency department of Kahramanmaras Sutcu Imam University, School of Medicine with BTT between January 2019 and April 2021 were retrospectively scanned from hospital records. Patients' age, gender, trauma mechanism, additional organ injuries, need for intensive care, length of hospital stay, morbidity, and mortality rates were recorded. Statistical results were expressed as frequency, percentage, and mean±standard deviation (min-max). In comparisons between groups, p<0.05 was accepted as the significance level. RESULTS: Two hundred and thirty-eight cases were included in our study. The scapular fracture was present in 86 cases (36.1%). About 43% of the cases with SFs were falling from a height. Intrathoracic injuries accompanying SF were determined as rib fracture, lung contusion, pneumothorax, hemothorax, and sternum fracture, respectively (91.9%, 80.2%, 41.9%, 37.2%, and 15.1%). Extrathoracic injuries associated with SF were vertebral fractures, intracranial injuries, clavicle fractures, extremity fractures, and intra-abdominal injuries (18.6%, 16.3%, 12.8%, 10.5%, and 5.8%), respectively. When the groups with and without SF were compared, a statistically significant relationship was found between SF and the number of rib fractures, lung contusion, pneumothorax, and hemothorax (p<0.001, p=0.001, p=0.001, p=0.001). In extrathoracic injuries, there was a significant relationship between SFs and vertebral fractures, intra-cranial injuries, and clavicle fractures (p=0.004, p<0.001, p=0.005). There was no difference observed between the groups regarding sternum fractures, extremity fractures, and intra-abdominal organ injuries (p=0.288, p=0.682, p=0.261). In cases with accompanying SF, there was a significant difference in terms of length of hospital stay, need for intensive care, and mortality (p<0.001, p=0.001, p=0.002). CONCLUSION: The most common intrathoracic injuries accompanying SFs were rib fractures and lung contusion, and the most common extrathoracic injuries were vertebral fractures and intracranial injuries. Moreover, it was found that SF was highly correlated with length of hospital stay, need for intensive care, and mortality. The most common cause of mortality was found to be intracranial hemorrhage. Imaging of other systems is important in cases with SFs. Particular attention should be paid to head-and-neck injuries.

Operative treatment of complex intra-articular scapular fractures: long-term functional outcomes in a single-center study.

BACKGROUND: Scapula fractures occur in the setting of high-energy trauma. Operative treatment of complex intra-articular scapular fractures can result in adequate surgical and functional outcomes. MATERIALS AND METHODS: Twenty-seven patients with complex, displaced intra-articular scapular fractures with or without involvement of the scapular body, were treated operatively in a single trauma center between 2010 and 2021. Associated injuries such as ipsilateral upper limb fractures and nerve injuries were identified in the majority of the patients. Fixation with anatomical medial and lateral border precontoured plates was utilized following posterior modified Judet approach or/and anterior deltopectoral approach. Functional outcome was assessed using the Oxford Shoulder Score and detailed shoulder range of motion and return to work/activities data were obtained. RESULTS: At a mean follow-up of 69 months (range 4-135 months), individual functional outcomes for 25 of the 27 patients revealed a mean Oxford Shoulder Score of 33 (69%), mean active flexion of 120 degrees, active abduction of 110 degrees, mean active external rotation of 35 degrees and mean internal rotation to the level of T5. All patients were pain-free at the latest follow-up, and 23 of 25 had returned to their preinjury occupation and activities. CONCLUSION: Operative treatment for these complex injuries is a viable option at centers equipped to handle critically ill patients and can result in satisfactory range of motion and functional score measurements along with a relatively low number of complications.

The Independent Double-Row (IDR) Bony Bankart Repair Technique.

A displaced anterior glenoid rim fracture, the so-called bony Bankart lesion, occurs after a traumatic shoulder dislocation resulting from a high energy trauma and is associated with recurrent shoulder instability. Different surgical techniques have been described in the literature to address this pathology, including open reduction and fixation, as well as arthroscopic transosseous, and single-row or double-row approaches with the use of suture anchors. However, there is currently no gold standard of treatment and the stability of fixation and the healing of the bony fragment are still a concern. The purpose of this report was to introduce an arthroscopic independent double-row (IDR) bony Bankart repair technique for fixation of large glenoid fractures.

Stability, deformity, and fixation of the floating shoulder: a cadaveric biomechanical study.

BACKGROUND: Floating shoulder injuries cause instability and deformity due to disruptions of the scapula, clavicle, and superior shoulder suspensory complex ligaments (SSSC). Resulting deformity of the glenopolar angle (GPA) has not previously been established, nor has the impact on stability and deformity when surgical fixation is performed. This study sought to quantify stability and deformity for multiple injury patterns and the improvement to these parameters provided by clavicle and coracoclavicular (CC) ligament fixation. METHODS: Fourteen cadaveric specimen upper extremities were used, which included the entire upper extremity, scapula, clavicle, and cranial-most ribs. After being mounted upright, a scapular neck fracture was created, followed by either a midshaft clavicle fracture or sectioning of the acromioclavicular and coracoacromial ligaments. Subsequent sectioning of the other structure(s) followed by the CC ligaments was then performed. In all specimens, the clavicle was then plated, followed by a CC ligament repair. At each step, a radiograph in the AP plane of the scapula was taken to measure GPA and displacement of the glenoid fragment using radiopaque markers placed in the scapula. These radiographs were taken both unloaded and with a 100-N applied medializing force. RESULTS: When evaluating deformity related to sectioning, the GPA was reduced when the CC ligaments were sectioned compared to an isolated scapula fracture (P = .022) and compared to a combined scapula and clavicle fracture (P = .037). For stability, displacement with a 100-N force was significantly increased when the CC ligaments were sectioned compared to an isolated scapula fracture (P = .027). In cases of an ipsilateral scapula neck and clavicle fracture with intact ligaments, fixation of the clavicle alone provided a statistically significant improvement in the GPA (P = .002); but not in reduction of displacement (P = .061). In cases of an ipsilateral scapula neck and clavicle fracture with concomitant disruption of the coracoacromial, acromioclavicular, and CC ligaments, the GPA was improved by clavicle fixation (P < .001) and increasingly so by subsequent CC ligament repair (P < .001). Displacement was also improved in these 2 states (P < .001, P = .008, respectively). DISCUSSION: This biomechanical study confirmed the importance of the acromioclavicular, coracoacromial, and CC ligaments in conferring stability in SSSC injuries. Disruption of the CC ligaments created significant deformity of the GPA and instability with a medializing force. Clinical treatment should consider the integrity of these ligaments and their repair in conjunction with clavicle fixation, knowing that this combination should restore a biomechanical state equivalent to an isolated scapula fracture.