Classifications of scapular fractures

12.1 Classification of scapula fractures according to Euler and Ruedi [37]

Basically scapular fractures can be classified into intracapsular and extracapsular fractures. This classification is to be geared to anatomical structures and represents an ascending order of the injury severity. The aim is to give a prognosis to the expected loss of function (Fig. 47).

■ A Fractures of the body

Scapula blade, isolated or comminuted

■ B Fractures of the processes

B1 Spine

B2 Coracoid process B3 Acromion

■ C Fractures of the scapular neck

C1 Anatomical neck C2 Surgical neck C3 Surgical neck with a) Fracture of the clavicle and the acromion b) Tear of the coracoclavicular and coracoacromial ligaments

■ D Articular fractures

D1 Glenoid rim fracture D2 Fracture of the glenoid fossa a) With inferior fragment of the glenoid b) With horizontal split of the scapula c) With coracoglenoideal bloc formation d) Comminuted fractures

D3 Fracture combination with scapula neck fracture and fracture of the body respectively

■ E Fracture combination with humeral head fractures

Scapula Inferior Fracture MalunionScapular Anatomical Neck Fracture

Fig. 47. Classification of scapular fractures, a Scapular fractures, group A, fractures of the body (a); and group B, fractures of the processes: B1, spine (fa), B2, coracoid process (d); B3, acromion (c), b Fracture of the anatomic neck, medial impression (C1 a). c Fracture of the anatomic neck, lateral tilt of the glenoid (C1 b). d Fracture of the surgical neck (C3a). With concomitant clavicular fracture the coracoclavicular and coracoacromial ligaments remain intact. e Fracture of the surgical neck with dislocation (C3b). The coracoclavicular and coracoacromial ligaments are torn. f Glenoid fractures (group D). Glenoid rim fracture (D/). g Glenoid fracture: fracture of the glenoid fossa with inferior glenoid fragment (D2a). h Glenoid fracture with horizontal split of the scapula (D2fa). i Glenoid fracture with coracoglenoideal bloc formation (D2c). (From [37])

Fig. 47. Classification of scapular fractures, a Scapular fractures, group A, fractures of the body (a); and group B, fractures of the processes: B1, spine (fa), B2, coracoid process (d); B3, acromion (c), b Fracture of the anatomic neck, medial impression (C1 a). c Fracture of the anatomic neck, lateral tilt of the glenoid (C1 b). d Fracture of the surgical neck (C3a). With concomitant clavicular fracture the coracoclavicular and coracoacromial ligaments remain intact. e Fracture of the surgical neck with dislocation (C3b). The coracoclavicular and coracoacromial ligaments are torn. f Glenoid fractures (group D). Glenoid rim fracture (D/). g Glenoid fracture: fracture of the glenoid fossa with inferior glenoid fragment (D2a). h Glenoid fracture with horizontal split of the scapula (D2fa). i Glenoid fracture with coracoglenoideal bloc formation (D2c). (From [37])

Glenoid FractureScapular ApophysisFractures The Scapula Ideberg

12.2 Classification of scapular fractures according to DeCloux and Lemerle [30]

DeCloux and Lemerle [30] divided the scapular fractures anatomically into three types (Fig. 48):

■ Type II: fractures of the apophysis

■ Type III: fractures through the superior lateral angle

Scapular Apophysis
Fig. 48. Classification of scapular fractures. (From [30])

12.3 Classification of scapular fractures according to Zdravkovic and Damholt [143]

Zdravkovic and Damholt specified the type III scapular fractures according to DeCloux by describing the site of fracture and the degree of displacement measured in mm on the X-ray films.

Site of fracture:

■ Anatomical neck

■ Surgical neck

■ Surgical neck+glenoid cavity

Degree of displacement (mm):

12.4 Classification of intraarticular scapular fractures according to Ideberg et al. [61]*

Intraarticular fractures were classified into five main types based on conventional AP and lateral radiographs (Fig. 49). Chip fragment fractures, often seen in shoulder dislocations, are included in this classification as fracture type 1, with subdivision into two types, depending on whether the size of the fragment is less or equal (type 1 A) or larger (type 1 B) than 5 mm when measured directly on the film.

■ Type 1: anterior glenoid rim fracture. Type 1A with a fracture fragment of 5 mm or less, and type 1 B with a fracture fragment larger than 5 mm.

■ Type 2: inferior glenoid fracture involving part of the neck.

■ Type 3: superior glenoid fracture extending through the base of the coracoid process.

■ Type 4: horizontal fracture involving both scapula neck and body. Fracture line always runs inferior to the spine of the scapula.

■ Type 5: horizontal fracture (as in type 4), with an additional complete or incomplete neck fracture.

Scapular Fracture Classification
Fig. 49. Classification of intraarticular scapular fractures. (From [61])

12.5 Classification of fractures of the glenoid cavity according to Goss [48]

Fractures of the glenoid cavity make up 10% of scapular fractures, no more than 10% of which are significantly displaced.

This classification scheme outlines the various mechanisms of injury and fracture patterns that can occur. For the purpose of this discussion, one need consider only whether the glenoid rim or the glenoid fossa is fractured. Fractures of the glenoid rim occur when a laterally applied high energy force drives the humeral head against the glenoid margin.

Fracture of the glenoid fossa occurs when a laterally applied high-energy force drives the humeral head directly into the glenoid cavity. The fracture generally begins as a transverse disruption, which then propagates in one of several possible directions depending on the vector of the traumatic force. The degree of resultant incongruity of the articular surface is of prime concern.

The author distinguishes six different types of glenoid fractures (Fig. 50):

■ Type I: glenoid rim fractures Type I a: anterior rim fracture Type I b: posterior rim fracture

■ Type II: fracture line through the glenoid fossa exiting at the lateral border of the scapula

■ Type III: fracture line through the glenoid fossa exiting at the superior border of the scapula

■ Type IV: fracture line through the glenoid fossa exiting at the medial border of the scapula

■ Type Va: combination of types II and IV

■ Type Vb: combination of types III and IV

■ Type VI: comminute fracture

Scapular Neck Fractures

12.6 Classification of glenoid neck fractures according to Goss [48]

Fractures of the glenoid neck make up 25% of scapular fractures; of that number, 10% or fewer (2.5% of the total) are significantly displaced.

This classification scheme is based on whether these injuries are minimally or significantly displaced. If significant displacement exists, it may be in either the translational or the rotatory plane.

Fractures of the glenoid neck may be caused by a direct blow over the anterior or posterior aspect of the shoulder, a fall on an outstretched arm, or a fall on the superior aspect of the shoulder. Displacement may occur if the fracture is complete, with the fracture line exiting through both the lateral and superior scapular margins. If the superior support structures (the clavicle-AC-joint-acromion strut or the coracoid process-coracoclavicular ligaments linkage) are disrupted, displacement is especially likely.

Two different types of glenoid neck fractures have to be distinguished (Fig. 51):

■ Type I includes all minimally displaced fractures.

■ Type II includes all significantly displaced fractures (either transla-tional of angulatory displacement).

Superior Shoulder Suspensory Complex
Fig. 51. Classification of fractures of the glenoid neck. AP anteroposterior. (From [48])

12.7 Types of traumatic ring/strut disruption of the superior shoulder suspensory complex according to Goss [47, 48]

The superior shoulder suspensory complex (SSSC) is a bone-soft-tissue ring at the end of a superior and an inferior bone strut (Fig. 52 a). The ring is composed of the glenoid process, the coracoid process, the cora-coclavicular ligaments, the distal clavicle, the AC joint, and the acromial process. The superior strut is the middle third of the clavicle. The inferior strut is the lateral scapular body and spine. Each individual structure has its own particular functions. The complex as a whole maintains a normal stable relationship between the scapula and upper extremity and the axial skeleton, allows limited motion to occur through the AC joint and the coracoclavicular ligaments, and provides a firm point of attachment for several soft-tissue structures. Traumatic disruptions of one of the components of the SSSC (Fig. 52 b) are common. They tend to be minor injuries, however, since such single disruptions usually do not significantly compromise the overall integrity of the complex. If the traumatic force is sufficiently severe or adversely directed, the ring may fail in two or more places (termed a "double disruption"), a situation in which significant displacement at both the individual sites and of the SSSC as a whole frequently occurs. Similarly, a disruption of one portion of the ring combined with a fracture of one of the struts or fractures of both struts also creates a potentially unstable anatomic situation. This, in turn, often leads to adverse long-term functional consequences, including delayed union, nonunion, and malunion; subacromial impingement; decreased strength and muscle-fatigue discomfort due to altered shoulder mechanics; neurovascular compromise due to a drooping shoulder; and glenohumeral degenerative joint disease. Consequently, injuries of the SSSC need to be carefully evaluated for the presence of a double disruption. Computed tomography with reconstructions is often necessary to make a definitive diagnosis. If unacceptable displacement is present, surgical reduction and stabilization of one ore more of the injury sites is necessary. Frequently, operative management of one of the injury sites will satisfactorily reduce and stabilize the second disruption indirectly. Fractures of the glenoid, coracoid, and acro-

Shoulder Suspensory Complex

Fig. 52. a Superior shoulder suspensory complex. A AP view of the bone/soft tissue ring and superior and inferior bone struts. 6 Lateral view of the bone/soft tissue ring. b Types of traumatic ring/strut disruptions. Single disruptions of the bone/soft tissue ring may be a break (A) or a ligament disruption (6). Double disruptions of the bone/soft tissue ring may be a double-ligament disruption (Q, a double break (D), or a combination of a bone break and a ligament disruption (£). Other double disruptions may be a break of both struts (F or a break of one strut and a ring disruption (G)

Fig. 52. a Superior shoulder suspensory complex. A AP view of the bone/soft tissue ring and superior and inferior bone struts. 6 Lateral view of the bone/soft tissue ring. b Types of traumatic ring/strut disruptions. Single disruptions of the bone/soft tissue ring may be a break (A) or a ligament disruption (6). Double disruptions of the bone/soft tissue ring may be a double-ligament disruption (Q, a double break (D), or a combination of a bone break and a ligament disruption (£). Other double disruptions may be a break of both struts (F or a break of one strut and a ring disruption (G)

mial process may each be part of a double disruption and require surgical management. All of the various combinations cannot be detailed, and some are extremely rare.

■ Single disruptions

Type A: single disruption by a break

Type B: single disruption by a ligament disruption

■ Double disruptions

Type C: double-ligament disruption Type D: double break

Type E: combination of bone break and a ligament disruption

Type F: break of both struts

Type G: break of one strut and a ring disruption

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