Disclaimer This movie is an educational resource only and should not be used to manage Orthopaedic Health. All decisions about management of Scapula Fractures must be made in conjunction with your Physician or a licensed healthcare provider.
MULTIMEDIA HEALTH EDUCATION MANUAL TABLE OF CONTENTS SECTION CONTENT 1. Normal Shoulder Anatomy a. Introduction b. Normal Shoulder Anatomy 2. Scapula Fracture a. Symptoms b. Diagnosis c. Conservative Treatment 3. Treatment Options a. Introduction b. Surgical Treatment c. Post Operative Care d. Risks and Complications
INTRODUCTION Shoulder fractures occur from a break in one or more of the bones of the shoulder joint. The most common shoulder bone fractured is the clavicle, while the least common shoulder bone fractured is the scapula. This learning module focuses on scapular fractures, fractures of the shoulder blade. In order to understand scapular fractures, it is important to understand the normal anatomy of the shoulder.
Unit 1: Normal Shoulder Anatomy Introduction The shoulder in the human body consists of the following bones: Humerus (Upper arm bone) Scapula (Shoulder blade) Clavicle (Collar bone) Coracoid process Acromion Glenoid Normal Shoulder Anatomy The shoulder is the most flexible joint in the body making it susceptible to instability and injury. The shoulder is a "ball-and-socket" joint. (Fig. 1) A "ball" at the top of the upper arm bone (the humerus) fits neatly into a "socket," called the glenoid, which is part of the shoulder blade (scapula). Three bones come together to form the shoulder joint: collarbone (clavicle), the shoulder blade (scapula), and the upper arm bone (humerus). Shoulder Bones Humerus The humerus provides attachment to muscles of the upper arm. The humeral head forms the ball of the ball-and-socket shoulder joint. (Refer fig. 2) Humerus (Fig. 2) Scapula The scapula (shoulder blade) is a flat, triangular bone providing attachment to the muscles of the back and neck. Scapula (Refer fig. 3) (Fig. 3)
Clavicle The clavicle is an S-shaped bone that connects the shoulder girdle to the trunk. It maintains the shoulder in a functional position with the axial skeleton and allows varied arm positions in sports. In addition to its structural function, the clavicle protects major underlying nerves and blood vessels as they pass from the neck to the axilla. (Refer fig. 4) Coracoid Process The coracoid process is the extension of the scapula or shoulder blade around the shoulder joint at the front (Refer fig. 5) Unit 1: SCAPULA FRACTURE Normal Shoulder Anatomy Clavicle (Fig. 4) Coracoid Process (Fig. 5) Acromion The acromion is the extension of the scapula or shoulder blade around the shoulder joint at the rear which forms a roof. This is also called the acromial process (Refer fig. 6) Glenoid The glenoid is the depression at the end of the scapula that forms the socket of the ball and socket joint. (Refer fig. 7) Acromion (Fig. 6) Glenoid (Fig. 7)
Shoulder Soft Tissue Anatomy Unit 1: SCAPULA FRACTURE Normal Shoulder Anatomy The scapula provides bony attachment to a total of 18 different muscles. Rotator Cuff The rotator cuff refers to a group of four tendons that attach four shoulder muscles to the upper arm or humerus and hold it in the shoulder joint. Many shoulder problems are caused by injuries to the rotator cuff (Refer fig. 8) Biceps Tendons The biceps tendon is a long cord-like structure which attaches the biceps muscle to the shoulder and helps to stabilize the joint. (Refer fig. 9) (Fig. 8) (Fig. 9) Coracoclavicular Ligament Ligaments connect bone to bone, and coracoclavicular ligament connects the corocoid process of the scapula to the clavicle. (Refer fig. 10) (Fig. 10) Acromioclavicular Ligament Ligaments connect bone to bone, and acromioclavicular ligament connects the Acromion process to the clavicle. (Refer fig. 11) (Fig. 11)
Unit 1: Normal Shoulder Anatomy Glenoid Labrum The Glenoid labrum is a ring of fibrous cartilage surrounding the glenoid for stabilization of the shoulder joint. (Refer fig. 12) (Fig. 12) Capsula The capsule that surrounds the shoulder joint consists of very strong ligaments that helps to keep the ball and socket normally aligned. (Refer fig. 13) (Fig. 13)
Unit 2: Scapula Fracture Symptoms Scapular fractures are uncommon but do occur and require a large amount of force to fracture. They are usually the result of intense trauma, such as a high speed motor vehicle accident or a fall from height onto one s back. They can also occur from a fall on an outstretched arm if the humeral head impacts on the glenoid cavity. Symptoms of a scapular fracture can include the following: Pain: Usually severe and immediate following injury to the scapula. Swelling: The scapular area quickly swells following the injury. Bruising: Bruising occurs soon after injury. Impaired Mobility: Decreased range of motion of the joint occurs, often with inability to straighten the arm. Numbness: Numbness, tingling, or coldness of the hand and forearm can occur if blood supply is impaired or nerves are injured. Popping Sound: A cracking or popping sound, also referred to as crepitus, can often be heard or felt at the time of the fracture. Diagnosis Scapular Fractures should be evaluated by an Orthopaedic surgeon for proper diagnosis and treatment. Your surgeon will perform the following: Medical History Physical Examination Diagnostic Studies may include: X-rays: A form of electromagnetic radiation that is used to take pictures of bones. (Refer fig. 14) (Fig. 14)
Unit 2: Scapula Fracture CT scan: This test creates images from multiple x-rays and shows your physician structures not seen on regular (Refer fig. 15) (Fig. 15) MRI: Magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments. (Refer fig. 16) (Fig. 16) Conservative Treatment Most scapular fractures are not significantly displaced due to the strong supporting soft tissue structures surrounding it. Therefore, a majority of scapular fractures are treated conservatively and with early motion to reduce the risk of stiffness and will usually heal without affecting shoulder movement. Conservative treatment options include: Immobilization A sling is used for comfort and to support the shoulder to allow healing to take place. This is usually worn about 3-6 weeks depending on the type of fracture and Prescription Medications Pain medications will be prescribed for your comfort during the healing process. Physical Therapy Early progressive range of motion exercises are essential in restoring full shoulder function. Your physician will most likely refer you to a Physical Therapist for instruction on proper exercises and early motion of the shoulder to prevent complications.
Unit 3: Treatment Options Surgical Introduction Fractures of the scapula involving the neck or glenoid or with severe displacement have been associated with poor outcomes when treated non-operatively. Scapula fracture repair can be performed minimally invasive. Minimally invasive ORIF (open reduction internal fixation) surgery uses smaller incisions than a traditional open surgery. Minimally invasive incisions are limited to where surgical plates will be placed instead of a traditional incision which can be large. The benefits of minimally invasive surgery include smaller incisions, faster healing, a more rapid recovery, and less scarring. (Refer fig. 17) Surgical Treatment SCAPULA FRACTURE (Fig. 17) Minimally Invasive ORIF Scapular Fracture Repair surgery is performed under sterile conditions in the operating room with the patient under general anesthesia. The surgeon makes small incisions around the shoulder area. Each incision is called a window. (Fig. 18) Your surgeon then locates the fracture by carefully sliding in between the muscles of the scapula. This technique allows the surgeon to see the fracture without cutting directly through the muscles. (Fig. 19)
Unit 3: SCAPULA FRACTURE Treatment Options Your surgeon uses special instruments to reduce the fracture. Plates and screws are then inserted into the bone to hold the fracture together. (Fig. 20) After reducing the fracture, the incisions are closed by suturing or by tape. Minimally invasive ORIF is much less traumatic to the muscles, ligaments, and tissues than the traditional method of surgically opening the shoulder with long incisions. (Fig. 21) (Fig. 22) (Fig. 23)
Post Operative Care Unit 3: SCAPULA FRACTURE Treatment Options After surgery your surgeon will give you guidelines to follow. Common postoperative guidelines include: A bandage will be around the operated shoulder and a sling will be in place after surgery to support the shoulder. It is NORMAL for the shoulder to swell after the surgery. Your surgeon may recommend applying ice packs to the area to help reduce swelling. Keep the incision area clean and dry. You may shower once the dressings are removed unless otherwise directed by your surgeon. You will be given specific instructions regarding activity and rehabilitation. Physical Therapy is usually ordered to restore shoulder function and strength. It is imperative that you follow your exercise plan to improve motion and strength in the shoulder and prevent stiffness. Your surgeon will prescribe pain medications to keep you comfortable at home. (Fig. 24)
Unit 3: SCAPULA FRACTURE Treatment Options Eating a healthy diet and not smoking will promote healing. (Fig. 24) Risks and Complications As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to shoulder surgery. Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Allergic reaction to medications Blood loss requiring transfusion with its low risk of disease transmission Heart attack, strokes, kidney failure, pneumonia, bladder infections (Fig. 25) Complications from nerve blocks such as infection or nerve damage Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or
Unit 3: SCAPULA FRACTURE Treatment Options The majority of patients suffer no complications following Scapular Fracture repair surgery, however, complications can occur and include: Infection Infections can occur superficially at the incision sites or in the joint space of the shoulder, a more serious infection. Nerve Damage On rare occasions a nerve may be injured due to pressure from retractors or if the nerve is severed during the surgery. Trauma to the nerves can cause numbness, tingling, pain, and weakness. Hematoma A collection of blood caused by excess bleeding into the joint after the surgery is completed. This may require another surgery to irrigate the joint and evacuate the blood. This complication occurs more frequently in the obese patient due to the excess fat tissue. Shoulder Stiffness While some loss of motion to the shoulder is normal, one of the most common risks following shoulder fracture repair surgery is shoulder stiffness. Early motion is encouraged as a result. It is imperative that you follow your therapists guidelines to ensure a good outcome. Risk factors that can negatively affect adequate healing after surgery include: (Fig. 26)
Unit 3: Disclaimer Summary A good knowledge of this procedure will make the stress of undertaking the procedure easier for you to bear. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery. Disclaimer Although every effort is made to educate you on Scapular Fractures, there will be specific information that will not be discussed. Talk to your doctor or health care provider about any questions you may have. You must not proceed until you are confident that you understand this procedure, particularly, the complications.
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