Scapula fractures comprise the body (45%) and glenoid (35%), with 0.4–1% of cases accounting for floating shoulder ^[1]. The broad spectrum of scapula fractures puts the treating surgeon in a quandary, with most cases being managed non-operatively owing to clinical inexperience or priority given to associated injuries ^[2]. Distributed and incoherent literature brings no resolve to the predicament of selecting accurate management. This retrospective descriptive case series depicts varied fracture patterns of the scapula and illustrates case-specific surgical approaches, reduction techniques, implant choice, and placement with different modalities of scapula fracture fixation.

After obtaining Institutional Ethics Committee approval at a teaching tertiary care centre, fifteen patients with scapula fracture (14 males and 1 female, average age 32.5 years) following high-energy trauma were selected over 1 year. Inclusion and exclusion criteria were used, and the selected patients included both extra-articular and intra-articular fracture varieties, with some having concurrent acromion, coracoid, or clavicle fractures. After availing the patient’s consent and pre-surgical fitness, they were operated on for open reduction and internal fixation by a single experienced surgeon. The surgical approach was tailored for each case, and fixation was achieved using a combination of different orientations of plates and screw placement, resulting in varied fixation modalities for different patterns of scapula fractures. Restoration of bony anatomy and Cole’s criteria were assessed in plain radiographs as the post-operative and 6-month follow-up radiological outcome measures. Functional assessment was done by evaluating the patients and interpreting the Constant-Murley Score (CMS) at a single 6-month follow-up.

Inclusion criteria: 

1. Age >18 years
2. Operative scapular fractures based on Cole’s operative criteria ^[3]
3. Floating shoulder (Superior Shoulder Suspensory Complex [SSSC] injury).

Exclusion criteria:

1. Severely comorbid conditions due to trauma or chest trauma or those requiring intensive care
2. Polytrauma cases
3. Patients not meeting the surgical indication and managed conservatively
4. Patients medically unfit for surgery
5. Non-consenting patients.

Case-1: Biplanar lateral pillar construct: 

An Ideberg type 5a intra-articular fracture with extra-articular extension may be fixed with a posterior surface 3.5 mm dynamic compression plate (DCP) augmented with a lateral surface 3.5 mm semi-tubular plate using a long (55 mm) subglenoid screw for simultaneous intra-articular fixation. Simultaneous use of lateral and posterior plates over the lateral border makes a stronger biplanar construct. Placing a lateral surface plate along the lateral border may require medialisation of the quadrangular space to expose the glenoid neck, that is, elevating the long head of the triceps off the lateral border, sparing the origin at the infraglenoid tubercle ^[4]. The medial border is fixed using a contoured 3.5 mm reconstruction plate (Fig. 1). The preferred sub-glenoid screw directed (towards the coracoid base) usually ranges from 35 mm to 60 mm, the most common being 55 mm, through a semi-tubular or reconstruction plate along the lateral border to augment the posterior surface fixation, making a stronger and more stable biplanar construct.

Case-2: Reduction manoeuvre: 

Ideberg type 2 intra-articular glenoid fractures in the axial plane are often irreducible, despite adequate exposure through the posterior approach. Using the coracoid as a fulcrum to achieve reduction by the Kapandji lever technique has a utilitarian benefit in such cases (Fig. 2). 6-month follow-up CMS – 82.

Case-3: Fixation through reverse Judet approach: 

Ideberg Type 5a fracture fixed with anatomical posterior and medial plates with a 3.5 mm cortical screw for glenoid fixation, using the reverse Judet approach ^[5], which aids in reduction of the lateral pillar by allowing medial release and simultaneous visualization of both the medial and lateral pillars (Fig. 3).

6-month follow-up CMS – 88.

Case 4: Lost K-wire technique:

Fixation of the extra-articular fracture with lateral border comminution with a K-wire, augmented by final fixation with a 3.5 mm lateral surface plate and a 3.5 mm Ellis T plate distally near the inferior angle through the Brodsky approach or temporary fixation over the medial border through the reverse Judet approach, is typical for comminuted fractures and aids in the reconstruction of the lateral and medial bony pillars. Angulation and medialisation may not be corrected unless fracture fragments over the body and medial border are not completely freed of soft-tissue pull ^[6] (Figs. 4 and 5). 6-month follow-up CMS – 88.

Case 5: Bi-planar lateral pillar construct with arthrotomy:

The Ideberg Type 5c combined extra-articular and intra-articular fracture fixation, using a 2.7 mm semi-tubular plate over the posterior surface, augmented with a 3.5 mm long DCP along the lateral surface with a subglenoid screw through the modified Judet approach. Posterior joint arthrotomy was done in line with the posterior glenoid rim, and final fixation was achieved with a small posterior glenoid plate while keeping the posterior and lateral surface plate in situ (Fig. 6). 6-month follow-up CMS – 92.

Case-6: Contoured distal lateral pillar plate: 

An extra-articular fracture with scapular body comminution and angulation was fixed using a medial anatomical plate, proximal lateral surface 3.5 mm semi-tubular plate, and distal posterior surface 3.5 mm reconstruction plate. The distal lateral border was fixed using a 3.5 mm reconstruction plate – proximally aligned along the lateral surface and twisted at 90° distally to contour along the posterior surface to achieve stable fixation of the lateral pillar (Fig. 7).

6-month follow-up CMS – 90.

<H2>Case-7: Associated coracoid base fracture

An Ideberg type 5c comminuted scapular body, segmental lateral border with medial extension and coracoid base fracture were fixed using lateral and posterior plates for the lateral pillar, a medial anatomical plate for the medial pillar and a coracoid base screw through a half-sabre incision (Fig. 8). 6-month follow-up CMS – 82.

Case-8: Associated acromion fracture:

An Ideberg type 5a fracture was fixed using a posterior and lateral surface plate with a long (60 mm) sub-glenoid screw and acromion fixation using a plate with tension band wiring through the reverse Judet approach (Fig. 9). 6-month follow-up CMS – 78.

Case 9: Temporary fixation, associated acromion fracture:

A comminuted Ideberg type 5a fracture was temporarily fixed with two posterior surface 3.5 mm semi-tubular plates and removed after final fixation with a 3.5 mm semi-tubular plate over the lateral surface with a long subglenoid screw and a 3.5 mm semi-tubular plate for the acromion, all by a single reverse Judet approach. Screw sizes over the medial and lateral border posterior plates range from 12 mm at thin cortices to 16 mm at thick cortices (Fig. 10). 6-month follow-up CMS – 86.

Case-10: Percutaneous glenoid fixation. 

Arthroscopy-assisted percutaneous fixation ^[7] for Ideberg type 3 displaced glenoid fractures through a superior or posterior portal aids in achieving accurate reduction of the glenoid articular margin and allows stable fixation while avoiding drawbacks associated with open dissection (Fig. 11). 6-month follow-up CMS – 90.

Case-11: Associated clavicle fracture (SSSC injury – floating shoulder): 

An extra-articular comminuted glenoid neck fracture with medial border, acromion, and clavicle fractures was managed with lateral and medial pillar acromion plating through the reverse Judet approach and anterior clavicle plating (Fig. 12). 6-month follow-up CMS – 88.

Scapula fractures, often prone to “benign neglect”, if managed conservatively, may lead to loss of shoulder function due to malalignment or arthrosis, scapula-thoracic dyskinesia, and impingement pain. Operative fixation of scapula fractures, when indicated, is crucial for a satisfactory clinical outcome, as evident in studies by Herrera et al. ^[8], Bartoníček and Frič ^[9], Cole et al., and Schroder et al. ^[10]. The functional outcomes depend on a thoughtful management protocol designed on a cumulative consideration of patient profile, fracture pattern, and associated injuries. Surgical management often comes with challenges in the form of preoperative planning, surgical exposure, intraoperative handling of vital structures, accurate reduction, and strong fixation. This case series delves into various cases of scapular fractures and narrates how each was managed for the sake of reference of fellow orthopaedic surgeons. Choosing the right patient according to fracture classification, operative indication, patient bio-profile, and injury characteristics is vital. Furthermore, the most essential part of preoperative planning is selecting the most suitable approach – one which provides the most abundant exposure, allows easy manipulation of fracture fragments, and helps achieve varied hardware implantation. Taking any posterior approach to the scapula essentially involves dissection along the interval of the infraspinatus and teres minor. This interval may be identified by two methods: either looking for the direction of fibres starting laterally and tracing them medially, or alternatively, locating the teres minor fibre’s origin over the inferior angle of the scapula and tracing its run at a greater angle towards the humeral head. Authors found the reverse Judet approach aids in several aspects, which are as follows:

Merits of the reverse Judet approach: 

• Greater exposure of multiple anatomical structures at once
• Both extra-articular and intra-articular can be addressed with a single approach
• Manipulation at both medial and lateral borders together, that is, exposure of bony elements of the scapula having adequate bone stock for internal fixation
• Allows plate placement over the lateral surface while manipulating the scapular body and medial border
• Prevention of misdiagnosis of concomitant supra-scapular nerve injury through dissection of spinoglenoid notch to rule out nerve entrapment (leading cause of infraspinatus atrophy)
• Allows exposure for open wedge osteotomy to address recurrent posterior shoulder dislocation
• Allows addressing lateral body fixation without removing the deltoid from scapular spine by wide abduction of the arm, aiding early mobilization and rehabilitation, without the need to wait for muscle healing
• Allows a stronger biplanar construct
• Best suited for comminuted fractures of the scapular body involving both medial and lateral pillars, intra-articular fractures involving the body and the acromion or coracoid processes, or cases with lateral border fixation requiring medial release
• Chen ^[11] concluded that the reverse Judet approach shortens the duration of surgery, reduces blood loss, and allows sufficient exposure for reduction and achieving stable fixation, thus allowing for early functional range of motion, proving to be a safe and efficient method for surgical fixation of complicated scapula fractures.

Often overlooked, some important aspects change the outcome of any case. Priority must be given to intra-articular fracture (i.e., reduction of articular step-off) in the presence of simultaneous extra-articular fracture to avoid painful arthritis. Reduction must be assessed in three views – Grashey AP view/Neer I projection, Y (outlet) view/Neer II projection, and axillary view. Screw penetration must be checked before closure that can result in a painful range of motion and early arthritis, which is visible in the Neer I and axillary views. The rotator cuff must be repaired, and the capsule should be closed. The Allgower-Donati suture technique may be preferred to preserve lateral flap vascularisation. Of importance is avoiding vital structures around the scapula. Wijdicks et al. ^[12] have characteristically identified critical danger zones comprising neurovascular structures. This includes a 4-7 cm triangle centred along the spinoglenoid notch, constituting essentially the suprascapular nerve and the ascending branch of the circumflex scapular artery. These must be carefully handled in any posterior approach to the scapula nearing the scapular neck. In this case series, there was no complication in either of the cases, and post-operative radiological criteria were met and found to be satisfactory. Authors acknowledge limitations of this study pertaining to the small sample size and lack of long-term outcome measure, but each is of value since they provide either a newer or an augmentation of previously existing fixation methods for various scapula fractures. It is highlighted that the dissection and surgical approaches used are already existent in the literature and widely practised. Furthermore, the series does not intend to establish the superiority of any single fixation technique; rather, it showcases augmentation to existing methods of fixation and adds to the knowledge of any operating orthopaedic surgeon some reduction techniques which can come in handy in everyday surgical practice. The reduction manoeuvres and augmentation techniques for existing fixation methods provide a better reduction as measured in a post-operative radiograph and on a 6-month follow-up and allow early range of motion. Functional evaluation using the CMS at a single 6-month follow-up of all cases placed twelve patients in the very good (86–100) category, whereas three patients fell in the good category (71–85), evident of a satisfactory outcome. Authors acknowledge that the study’s small sample size (n = 15), retrospective design, single-centre setting, and single-surgeon experience limit the strength of the evidence and the generalisability of the findings. They further advocate for a cohort study with a large sample size to assess and compare the functional outcomes with radiological parameters for long-term outcomes.

The case series illustrates the fact that scapular fractures have a diverse presentation, necessitating accurate classification and fracture plane visualisation. Each pattern requires special consideration while choosing the surgical approach, appropriate reduction technique, and varied implant placement to achieve a strong and rigid fixation to meet the post-operative criteria. The presented case series demonstrates the feasibility of various reduction and fixation strategies in selected patients and provides technical insights that may assist surgeons managing similar injuries. Authors emphasise that larger prospective studies with standardised protocols, comparative cohorts, and long-term follow-up are necessary before definitive recommendations can be made.

Diverse scapula fracture patterns require varied reduction and fixation modalities practiced in different case scenarios.