Complex Glenoid Fracture
By Ehab Mahmoud Farhan MD,FRCS, Consultant of Orthopaedics KFH, Medina,KSA.
Sowelyeh M. Al-Rehili MD,FRCS,Chief of Orthopaedics KFH,Medina,KSA.
Hamdy Abdel Motaal , M.Sc , Consultant Orthopedics KFH , Medina , KSA
Fractures of the scapula comprise 1% of all fractures, and fracture of the glenoid process accounts for approximately 10% of scapular fractures.
Although more than 90% of glenoid fractures are minimally displaced and can be treated conservatively. There are still 10% which are significantly displaced and require surgical reconstruction.
There are some indications for surgical intervention in fractures of the glenoid fossa,
1. Articular step-off 5 mm or more.
2. Sever displacement of the fragments that a non-union is likely.
3. Fracture pattern that allows displacement of the humeral head out of the center of glenoid cavity.
Sever comminution of glenoid fracture.
Sever comminution of surrounding osseous structures.
Intra-articular glenoid fractures were classified by Ideberg based on anterior and posterior glenoid rim fracture (type I), horizontal fracture involving the inferior glenoid (type II ), superior glenoid fracture (type III), scapular neck and body fractures (type IV), and comminuted fracture (type v) .
A 20 years college student, who presented to the emergency room with a type IV glenoid fracture post RTA. On examination the RT. shoulder region was swollen and tender but his distal neurovascular circulation was intact, and his general condition was stable.
Scapular trauma series showed type IV glenoid fossa fracture with posterior dislocation of the gleno-humeral joint, CT with 3D was required to define the extent of the injury and allow optimum preoperative planning if required.
A decision of operative reconstruction to the glenoid fossa was taken in light of the available images, age of the patient, and being RT. shoulder in a right handed student.
My goal was to reconstruct the articular surface and achieve stable gleno-humeral joint and rigid fixation to the scapular neck fracture.
Posterior approach was chosen for easy accessibility to the posterior and superior fragments, the body and neck fractures, and also for being a posterior shoulder dislocation.
My plane was to reduce the articular fragments to anatomical position and to have temporary fixation using K-wires, followed by lag screw fixation and correct the neck anteversion angle and fix it with 3.5 reconstruction plate contoured in a way to follow the lateral border of the scapula, neck, and root of the spine of scapula.
The patient was placed in a semi-prone position, bony landmarks included the acromion process, coracoid process, and spine of scapula. The skin incision started as lateral as the tip of the acromion process and carried medially following the spine of the scapula to the medial border of the scapula, the deltoid muscle fibres cut in line with the skin incision and retracted inferiorly, the tendon for infraspinatous muscle is an important landmark in this approach and it should be dissected carefully and cut about 1.5 cm from itís insertion in the greater tuberosity. The interval between the infraspinatous and teres minor should be developed with careful dissection subperiosteal, and avoid vigorous retraction in this area.
The posterior shoulder capsule was opened longitudinally and humeral head retractor inserted to see the articular surface. 2 K-wires were inserted to the posterior and superior fragments and manipulated till anatomical reduction achieved and the K-wires advanced more, followed by insertion of a lag screw.
The scapular neck fracture then reduced and the anteversion angle corrected and a 3.5 reconstruction plate and screws was used for fixation. The capsule closed carefully and the infraspinatous tendon repaired and shoulder stability examined. Wound closed in layers over suction drain and the arm protected in arm swath.
Post operative course:
The suction drain removed after 48 hours and pendulum exercises started at week one, followed by passive stretching exercises in all directions. Light use of the arm while sitting was allowed during week 3&4 .
A/P & lateral views to the shoulder at 2 weeks interval to ensure maintainace of reduction.
After 6 weeks patient regained almost full range of motion, and light use of the arm allowed without protection.
This case has been admitted and managed at King Fahd Hospital in Medina, KSA. The hospital is considered as a trauma center, and according to the statistics, there were more than 5000 cases treated in the orthopaedic department during the last year.
Most of the orthopaedic surgeons used to treat the worst scapular fractures conservatively. However, with good understanding to the anatomy of the shoulder region and thorough clinical and radiological examination, together with good preoperative planning and nothing weighs a knowledgeable assistant for sure. The decision of open reduction and internal fixation for complex scapular fractures is an easy decision to take, but we should stick to the indications mentioned earlier, bearing in mind that even with the best hands the surgical outcome is usually not satisfactory.
I think we should expand our view to the complex scapular fractures to involve more closed techniques and minimal invasive surgeries and arthroscopic assisted reductions and percutaneous fixation techniques without widening the spectrum of indications.
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