ch 49 Scapula fracture Flashcards
anatomy
fossae cranial and caudal: origin for the supraspinatus and infraspinatus muscles,
acromion: origin of the acromial head of the deltoideus muscle
supraglenoid tuberosity: which is the origin of the biceps brachii muscle
glenoid cavity: articulation with the humeral head
superfical muscles
deeper muscles
muscular protection both medially (subscapularis and serratus ventralis muscles) and laterally (omotransversarius, supraspinatus, infraspinatus, deltoideus, trapezius, triceps, and teres minor muscles).
nerves
suprascapular nerve
- emerges cranially from the scapular notch
- travels caudally to wrap distal to the scapular spine, deep to the acromion.
axillary nerve
- emerges from the caudal border of the subscapularis muscle
- crosses the caudal aspect of the scapulohumeral joint
What percentage of scapular fractures have concurrent injuries?
56 - 70%
thoracic injury, fractures of other bones, and neurologic
What is the anatomical classification system of scapular fractures?
Type I: Fractures of the body and spine
Type II: Fractures of the neck
Type III: Glenoid fractures
What is the fracture classification scheme as described by Cook et al?
From least to most severe:
- Stable, extra-articular
- Unstable, extra-articular
- Intra-articular
What muscles are encountered during the lateral approach to the shoulder?
Omotransversarius and trapezium
Deltoideus
Supraspinatus and infraspinatus
After incision of the deep fascia along the spine of the scapula, the omotransversarius and trapezius muscles are retracted cranially, and the spinous head of the deltoideus muscle is retracted caudally.7 The supraspinatus and infraspinatus muscles are elevated
conservative for body #
- Velpeau sling improves patient comfort and minimizes the likelihood of further fracture displacement.
- maintained, along with strict confinement, for 3 to 4 weeks.
- To minimize the risk for flexural contracture of the carpus, some authors advocate not including the flexed carpus in the bandage
- Conservative management is often successful because the extensive muscle-derived blood supply = favorable environment for bone healing.
What are the surgical options of fixation of scabular body fractures?
- Plate fixation (Thicker bone at base of spine), a screw angled at 45 degrees to the scapular spine, bone depth was greater cranially in the distal half of the scapular spine and caudally in the proximal half of the scapular spine.
- The implication: fractures within the proximal half should be plated caudally, and fractures in the distal half should be plated cranially.
- Interfragmentary cerclage (not prevent bending, thus sling needed)
- Partial or total scapulectomy - can remove 60% and retain excellent function
- Double plating was stronger but not stiffer and both failed by bending at much greater than clinically expected loads
No significant benefit has been shown with locking plate however study had multiple flaws i.e intact scapulas
What are the fixation options for fracture of the acromion?
deltoideus muscle exerts a primarily tensile force on the acromion
2 K-wires and figure of 8 tension band
Interfragmentary wires
Single interfragmentary wire
What are the fixation options of scapular neck fractures?
distal neck segment, containing glenoid, is typically displaced medially
Approach laterally or craniolaterally
Osteotomy of acromion usually required (or tenotomy of deltoid, or muscle seperation approach)
Osteotomy of greater tubercle of humerus sometimes required
Cross-pins (substantial exposure is necessary )
Divergent pins
Plate (T- ot L-shaped)
Only after atrophy of the supraspinatus and infraspinatus muscles occurs is suprascapular nerve injury readily evident.
Velpeau sling is advised for approximately 4 weeks with conservative management, and for approximately 2 weeks with surgical stabilization.
What percentage of scapular fractures are articular?
28%, most commonly cranial glenoid
When does the acccessory ossification of the supraglenoid tuberosity fuse?
By 5mo
How do you approach a supraglenoid tuberosity fracture?
What are the repair options?
most common: cranial glenoid fractures 58%, and Y fractures 23%
Approach
- Cranial approach with osteotomy of greater tubercle
- OR - Longitudinal myotomy of supraspinatus muscle from midbelly to humeral insertion
Fixation
- Interfragmentary lag screw and antirotation wire
- 2 K-wires and tension band
- fragment excision and tenodesis (biceps)
pull of the tendon of the biceps brachii muscle, which originates on the supraglenoid tuberosity, results in distal displacement of the fracture fragment.
intra-articular fractures
What are the surgical options for a T/Y-fracture of the glenoid?
Craniocaudal lag screw for anatomical reconstruction of articular surface anf then correct neck fracture as previously described
Fractures of medial/lateral labrum can be fixed with lateromedial lag screws if sufficient bone stock
Excision of the glenoid (excisional arthroplasty)
Partial scapulectomy
Arthrodesis
most dogs with intra-articular fractures had residual lameness.
partial scapulectomy - in a cat.
A caudolateral approach to the shoulder
The caudal aspect of the medial glenohumeral ligament was then incised near its scapular attachment and the caudodistal portion of the scapula excised with rongeurs (30% of the glenoid). The portion of the caudal glenohumeral ligament attached to the humerus was sutured to the subscapularis muscle using a locking loop pattern to prevent medial shoulder instability.
How do you treat scapular avulsion?
Caused by rupture of serratus ventralis +/- trapezius, rhomboideus
Fixation:
- 20-22g cerclage wire around 5th/6th/7th rib and through holes in caudodorsal border of scapula
- +/- reattachment of serratus ventralis through drill holes at craniodorsal scapula
- Velpeau sling 2-3wk
- Prognosis excellent
What is this condition?
Is it clinically significant?
Ununited accessory ossification center of the caudal glenoid
Can cause lameness if unstable
Requires arthroscopy to determine stabiliy and can be removed if unstable
Outcome of Supraglenoid Tubercle Fractures
in 12 Dogs
Kulendra 2019
articular and classified as type III fractures, hyperflexion of joint
retrospectively for cases of supraglenoid tubercle fracture (n = 12).
Overall success rate was 9/12. Major complication rate was 2/12 and minor
complication rate was 9/12. All fractures that had major complications were comminuted.pin and tension band wire (n ¼ 5), lag screw (n ¼ 2),
plate fixation (n ¼ 2), fragment removal (n ¼ 2) and conservative management (n ¼ 1).
Chronically lame caseswere treated by fragment removal,
in line with the current recommendations in the literature
Good outcomes can be achieved following fractures of the
supraglenoid tubercle, although cases with comminution have a higher complication
rate. Further research into the optimal method of fixation