Pires et al.

Patient Safety in Surgery (2021) 15:6

https://doi.org/10.1186/s13037-020-00281-3

REVIEW Open Access

Current challenges and controversies in the

management of scapular fractures: a review
Robinson Esteves Pires1,2* , Vincenzo Giordano3,4, Felipe Serrão Mendes de Souza3 and Pedro José Labronici5

Abstract
Fractures of the scapula are rare and usually associated with high-energy trauma. The unfavorable scapular
anatomy, combined with the complexity of the approaches for fracture fixation, make the treatment challenging,
even for experienced surgeons. Furthermore, the literature is controversial regarding surgical indications and
rationale for treatment. The present review article was designed to address and discuss critical aspects of decision-
making for the management of scapular fractures, including surgical indications and patient safety considerations.
Keywords: Scapular fractures, Surgical decision-making, Non-operative treatment, Floating shoulder, Complications,
Patient safety

Background result of impingement, malunion, nonunion, or scapu-

Direct impact may cause fractures in all scapular re- lothoracic dyskinesis [4].
gions, but an indirect trauma caused by the humeral In the herein review, we present an overview of all
head into the glenoid fossa also may cause intra- and scapula fracture types, focusing in the treatment strategy
extra-articular scapular fractures [1–4]. for safe management of the most frequent and import-
Although radiographs are essential for diagnosis, in- ant fracture patterns.
cluding anteroposterior, lateral, and axillary views, com-
puted tomography (CT) plays a critical role in the
preoperative planning and decision-making process, es- Classification systems for scapular fractures
pecially three-dimensional (3D) reconstructions [4]. Several classification systems have been described for
Armitage et al. [5] mapped 90 scapula fractures using scapula fractures, according to the pattern, number of
3D-CT and found that 68% involved the inferior aspect fragments, location, and prognosis. The most important
of the scapula neck. Seventeen percent of fractures pre- and universally used classification systems for scapula
sented articular involvement, while 84% traversed medi- fractures will be detailed below.
ally to exit inferior to the medial extent of the scapular The first description of a classification system for frac-
spine. However, the authors highlighted that articular tures of the scapular body is credited to Petit, in 1723,
fractures did not follow a predictable pattern. who divided the body fractures into three patterns, ac-
Scapular fractures may significantly impair the normal cording to the orientation of the fracture line: transverse,
function of the shoulder girdle, causing chronic pain as a oblique, and longitudinal [6].
Ada and Miller [7] described a classification system
based on a retrospective experience of 116 scapulae. The
* Correspondence: robinsonestevespires@gmail.com authors named fractures of the acromion and coracoid
1
Departamento do Aparelho Locomotor, Universidade Federal de Minas process in types I and II, respectively. Three types of
Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, MG, Brazil neck fractures were also described, according to the
2
Serviço de Ortopedia e Traumatologia, Instituto Orizonti, Belo Horizonte,
MG, Brazil course of fracture lines: Type IIA (fractures of the surgi-
Full list of author information is available at the end of the article cal neck); type IIB (transpinous scapular neck fractures);
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Pires et al. Patient Safety in Surgery (2021) 15:6 Page 2 of 18

and type IIC (transverse fractures of the scapular body). [15] (coracoid process fractures), and Kuhn [18]
Later, Goss [8] modified the Ada and Miller [7] classifi- (acromion fractures).
cation system, excluding transpinous scapular neck frac-
tures, and including fractures of the anatomical neck. Treatment strategies for scapula fractures
The author named the IIC type a fracture of neck infer- Conservative treatment for scapular fractures
ior to scapula spine. The vast majority of scapula fractures (> 80%) are amen-
Hardegger [9–11] classification is quite similar to the able to conservative treatment and present favorable
Ada and Miller system and names two types of neck and functional outcomes [19–21]. In this scenario, the ma-
two types of glenoid fractures. jority of the isolated scapular body and glenoid neck
The revisited AO/OTA classification system for scap- fractures, as well as almost all acromion, coracoid
ula fractures is codified as following: 14 (scapula bone); process, and scapular spine fractures are adequately
A (acromion or coracoid process); B (body), and F (glen- managed nonsurgically [22]. In a systematic review of
oid fossa). Qualificators should be included according to 520 scapula fractures, Zlowodzki et al. [22] found that
the fracture location [12]. 99% of all isolated scapula body fractures and 83% of all
Bartoníček et al. [10] described an interesting classifi- glenoid neck fractures were treated nonoperatively, with
cation system for fractures of scapula body based on the excellent or good results achieved in up to 86 and 77%
findings of 187 CT scans of patients presenting fractures of the cases, respectively. Conversely, these authors ob-
in this location. The authors divided the scapular body served that 80% of all glenoid fossa fractures were man-
fractures into three major groups: fractures of the spinal aged operatively, with excellent or good results in 82%
pillar; fractures of the lateral pillar (subtypes: Two-part, of the cases.
three-part, and comminuted fractures); and fractures of Conservative treatment consists initially of pain con-
both pillars (subtypes: Fractures involving the medial trol and immobilization with a sling, followed by phys-
third of the spinal pillar and fractures involving the cen- ical therapy. Passive-assisted exercises start after pain
tral part of the spinal pillar). control (usually after 14 days). Active-assisted exercises
The Ideberg et al. [13] classification is the most ac- usually start after 21 days, according to the patient toler-
cepted system for glenoid cavity fractures of the scapula. ance. Active exercises are usually initiated after 28 days.
The authors grouped glenoid fractures based on a series Schofer et al. [23], in a retrospective cohort study of
of 338 patients. In summary, this classification that re- 51 patients with an average follow-up of 65 months,
ceived later modifications by Goss et al. [8] and Mayo showed good functional outcomes after conservative
et al. [14] divides the fracture patterns into glenoid rim treatment of scapula fractures.
fractures (type I) and glenoid fossa fracture with increas-
ing degrees of scapular neck and body involvement Surgical indications
(types II-VI). The treatment of scapula fractures has been changing
Several classification systems have been described for substantially in the last decade. Although the scapula
coracoid process fractures, including Tanton [15], Eyres has a privileged muscular envelope which uneventfully
[16], Ogawa [17], Goss [8], and AO-OTA [12]. The Bar- heals the great majority of fractures, a scapular malunion
toníček [15] classification system, based on the fracture may significantly impair the shoulder girdle function,
location and presence of comminution, is divided into causing chronic pain, aesthetic deformities, impinge-
four groups: Type I (fracture of apex); Type II (fracture ment, and scapulothoracic dyskinesis.
of beak); Type III (fracture of base); Type IV (commi- The literature is extremely controversial regarding the
nuted fracture). surgical indications for scapula fractures. Several studies
The same classification systems above mentioned also pointed out indicators for surgical management, but we
address acromion fractures [8, 12, 17–19]. are currently quite far from consensus [11, 14, 20].
Kuhn et al. [19] described the acromion fractures di- Besides patient characteristics such as age, arm domin-
vided into three categories: Type I (fractures can be with ance, previous function, and type of occupation, the rela-
or without a slight dislocation. Subtype IA depicts avul- tive operative indications are presented below:
sion and subtype IB, true fracture); Type II (fractures are
dislocated but without constraint in the subacromial  Articular displacement or gap > 4 mm;
space); Type III fractures are dislocated and constrain  Articular involvement > 20 to 25%;
the subacromial space [19].  Medialization of the scapula > 20 mm (reduced to
Even knowing that there is no ideal classification 10 mm for double disruptions and 15 mm when
for scapula fractures, our preferred systems are Barto- combined with 30o angulation);
níček et al. [10] (body fractures), Ideberg et al. [13]  Glenopolar (GP) angle ≤22°;
(glenoid fossa and rim fractures), Bartoníček et al.  Angulation ≥45°
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 3 of 18

Source: The Scapula Institute – St. Paul / Minnesota patient who underwent open reduction and internal fix-
(www.scapulainstitute.org). ation of the scapula after 21 days of trauma. The indica-
Careful evaluation of the GP angle should be per- tion for surgical treatment was based on the
formed to prevent misinterpretation of the correct meas- medialization of the glenoid (> 20 mm) and the GP angle
urement. A GP angle ranging from 30° to 45° is (20o).
considered normal20. However, Labronici et al. [20] rec- Further, Obremskey and Lyman [28] described the
ommended that, whenever possible, measurement of GP modified Judet approach, using the same skin incision
angle should be taken in neutral rotation, since rotation (so-called boomerang incision), but preserving the infra-
of the scapula can either increase or decrease the meas- spinatus attachments. The authors advocate approaching
urement, therefore leading to a possible non-ideal indi- the lateral pillar of the scapula using the interval be-
cation for surgery. tween the infraspinatus and the teres minor. If the med-
Kim et al. [21] showed a positive relationship between ial pillar of the scapula must be addressed, partial
smaller GP angle and poor Constant-Murley functional detachment of the infraspinatus should be carefully per-
outcome in floating shoulders. formed (Fig. 2). Intraoperatively, the scapular circumflex
artery should be found and ligated, as an inadvertent
Fractures of the glenoid neck and body of the scapula damage to this structure during dissection in the
Fractures of the glenoid neck and body usually result infraspinatous-teres minor interval causes a persistent
from high-energy trauma and a high degree of suspicion bleeding and increases the surgical time. Advantages of
of associated injuries must be observed [24]. Depending this modified approach include less risk of neurological
on patient characteristics, such as age, arm dominance, damage, less bleeding, and better shoulder function.
degree of previous functional activity, as well as in the Nevertheless, the large skin incision is still a major cos-
presence of the above mentioned anatomical indications, metic concern with the modified Judet approach.
surgical treatment should be beneficial to achieve favor- Salassa et al. [29], in a cadaveric study, showed that
able outcomes. the modified Judet approach without posterior deltoid
Tatro et al. [25], in a case series of 66 patients who takedown allows for safe exposure of the lateral pillar of
underwent open reduction and internal fixation (ORIF) the scapula and direct visualization of the critical neuro-
for treatment of scapular fractures (37 extra- and 29 vascular bundle. The authors recommend beginning the
intra-articular patterns), showed excellent functional exposure with the posterior deltoid origin left intact and
outcomes after long-term follow-up, ranging from 5 to only proceed with takedown if additional exposure is
10 years. Interestingly, these authors reported compar- needed, usually in complex fracture patterns.
able outcomes after intra- and extra-articular fractures. Although both classic and modified Judet approaches
For approaching both glenoid neck and scapular body are considered safe and well-stablished treatment op-
fractures, we place the patient in lateral decubitus with a tions for scapular fixation, caution must be taken to
contralateral axillary roll and the chest slightly anteriorly avoid neurovascular damage when developing the inter-
positioned. Alternatively, the patient can be positioned muscular dissection to access the lateral pillar of the
in ventral decubitus if there is no associated chest injury scapula. Costa et al. [30], in a cadaveric study, found a
or pulmonary contusion. The ipsilateral arm is properly mean distance from the infraglenoid tubercle to the axil-
draped and placed in 90o with the chest, freely resting lary nerve of 23.8-mm, and to the suprascapular nerve of
over a pillow. The C-arm is positioned over the patient. 33.2-mm.
The choice of approach and fixation strategy depend A straight simplified longitudinal approach described
on the fracture location, number of fragments, and de- by Brodsky [31] is also possible, especially for fracture
gree of displacement [26]. patterns when fixation of the medial pillar is not re-
The classic approach for scapula fracture fixation was quired. We believe that this approach is an interesting
described by Judet [27]. Although universally accepted alternative for fractures of the lateral pillar of the scapula
as a helpful and effective approach, especially for com- in association with displaced acromion fractures. In such
plex fracture patterns and delayed fixations, the classic cases, a proximal extension of the standard longitudinal
Judet involves extensile dissection of the infraspinatus straight approach is performed to allow for proper acro-
muscle, which negatively impacts the rehabilitation mion fixation. Also, the posterior glenohumeral capsule
process and increases the risk of iatrogenic damage to can be opened to allow for better articular visualization,
the suprascapular nerve due to prolonged retraction. when there is an associated articular fracture line to the
Moreover, a postoperative seroma is a relatively frequent glenoid fossa.
complication that usually requires drainage. In our prac- Gauger and Cole [32] described a minimally invasive
tice, we currently reserve the Judet approach for delayed approach to scapula neck and body fractures where inci-
fractures and malunions. Figure 1 shows a case of sions are made along the scapula borders for reduction
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 4 of 18

Fig. 1 a and b: Radiographs of the left shoulder of a 34-year-old male patient who suffered a motorcycle accident and presented a severely
displaced and comminuted infraspinous fracture of the scapula body. c, d, and e: Computed tomography with three-dimensional reconstruction.
Observe the angulation of the scapula body and the degree of glenoid medialization. f: Perioperative photography depicting the classic Judet
approach. Observe the extensile detachment of the infraspinatus muscle. g: Perioperative photography showing the closure and infraspinatus
muscle. h and i: Radiographs after three months showing the fracture healing after fixation with one-third tubular plate at the lateral pillar and a
twisted reconstruction plate at the medial pillar of the scapula. Fragment-specific fixation using 2.0-mm minifragment plates was also performed.
j, k, and l: Postoperative photographs showing complete range of motion recovery after three months of surgery

and fixation. In a case series of seven patients with a Nevertheless, generally the medial pillar has to be re-
minimum follow-up of 12 months, the authors duced and fixed with a relatively flexible implant first
highlighted that this novel technique allows adequate as it acts as a hinge to allow better manipulation, re-
visualization of fracture reduction without extensile duction, and final fixation of the lateral pillar. Reduc-
muscular or subcutaneous flaps and was associated with tion instruments such as pointed reduction clamps,
satisfactory functional outcomes (Fig. 3). bone hook, and small-diameter Schanz pins with a T-
The decision-making on where to start the fracture handle are essential to obtain satisfactory reduction
reduction (medial or lateral pillar) depends on the (Fig. 4).
fracture pattern. If the fracture is amenable for fix- An important issue regarding scapula fractures lies on
ation of just one pillar, we recommend starting the the complex and unfavorable anatomy of the scapula for
reduction on the most displaced column (usually, the proper fixation. Specially-designed pre-contoured im-
lateral). If both pillars are severely displaced, we gen- plants are not universally available. Therefore, the sur-
erally perform a modified Judet or a minimally inva- geon is frequently obligated to use implants that were
sive approach simultaneously addressing both pillars not specifically designed for scapula fractures. Hu et al.
to adequately manipulate the fracture fragments. [33], in a retrospective cohort of 37 patients, reported
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 5 of 18

Fig. 2 a: Radiograph of the right shoulder in anteroposterior view of a 24-year-old male patient who suffered a car accident and presented a
severely displaced midshaft clavicle fracture in combination with an infraglenoid fracture of the scapula body. Observe that the patient presented
a sequelae of previous proximal humeral and glenoid fractures, with no residual shoulder instability. b, c, and d: 3-D CT reconstruction showing
the medialization of the glenoid and the angulation of the scapular body. e and f: Perioperative photographs depicting the modified Judet
approach. Observe the fixation of the lateral pillar of the scapula with two plates at the interval between the infraspinatus and teres minor
muscles (e). The medial pillar of the scapula was reduced and fixed with a twisted reconstruction locking plate. Observe the minimal detachment
of the infraspinatus muscle (f). g: Perioperative fluoroscopy image showing scapula and clavicle fractures reduction and fixation. h and i:
Radiographs in anteroposterior and lateral views showing fracture healing after three months

favorable functional outcomes using distal humeral Y- Floating shoulder

type locking plates. No plate rupture and screw prolapse The definition of floating shoulder remains controver-
were observed during the 1-year follow-up. sial. Some authors described the floating shoulder when
Our fixation strategy usually combines stronger con- two or more structures of the superior shoulder suspen-
structs (3.5- or 2.8-mm locking and non-locking com- sory complex (SSSC) were disrupted [35–37].
pression and/or reconstruction plates, with 2.4- or 2.0- Bartoníček et al. [38] postulate that floating shoulder
mm minifragment plates), in a fragment-specific fixation should be considered an unstable displaced fracture of
to achieve a stable construct [34]. the anatomical or surgical glenoid neck of the scapula in
Our postoperative care includes pain control and association or not with a clavicle fracture. The authors
sling for two weeks. Passive exercises are allowed highlighted that, in cases of surgical neck fractures, there
after the first week. Active-assisted exercises are initi- must occur an associated rupture of both the coracoa-
ated after two weeks. Active exercises are allowed cromial and coracoclavicular ligaments or a fracture of
after three weeks and progressive strengthening is their osseous-equivalent structures (extra-articular or
started after six weeks. intra- or extra-articular coracoid base and acromion).
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 6 of 18

Fig. 3 a, b, and c: 3-D CT reconstruction showing a comminuted infraglenoid fracture of the scapular body in a 35-year-old male patient.
Observe the angulation of the inferior part of the scapular body and the medialization of the glenoid. d: Preoperative photography depicting the
landmarks for minimally invasive approach. e and f: Perioperative photographs showing the lateral (between infraspinatus and teres minor
muscles) and medial approaches (partial detachment of the infraspinatus). g and h: Postoperative fluoroscopy images in anteroposterior and
lateral views showing fracture reduction and fixation using 2.7 minifragment plates (medial pillar) and the unconventional use of a 2.7 fibular
plate (lateral pillar)

The combination of a midshaft clavicle fracture with a alone and, a third group, fixation of both, clavicle and
scapular body fracture is frequently misinterpreted as a scapula [39–41].
floating shoulder. This injury pattern has no influence Cunningham et al. [42], in a case series of 41 patients
on stability or displacement of the glenoid neck. Conse- presenting association of floating shoulder and flail
quently, the only fixation of the clavicle usually does not chest, compared 23 treated with operative stabilization
result in improvement of the displacement of the scap- and 18 treated non-operatively. The authors found that
ula [38]. restoration of the scapula-clavicular arch unloads of the
Although some degree of improvement of the GP flail chest and may improve respiratory function and
angle compared pre- and postoperatively was reported pain control, thereby decreasing duration of mechanical
after fixation only of the clavicle, we do not routinely ob- ventilation days and intensive care unit length of stay.
serve such improvement, which we believe can be attrib- Our treatment protocol for floating shoulder is the fix-
uted to associated capsuloligamentous injuries of the ation of the clavicle alone, if the scapular neck presents
SSSC [21]. no displacement or minimal displacement and the 3-D
The treatment of floating shoulder also remains a CT reconstruction GP angle in neutral rotation is >22o.
topic of debate. While some authors advocate conserva- Otherwise, we fix both, clavicle and scapula, starting fix-
tive treatment, others defend fixation of the clavicle ation with the clavicle, in a beach chair position. After
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 7 of 18

Fig. 4 Illustration simulating the sequence of reduction of a displaced fracture of the glenoid and body of the scapula. The reduction starts with
the placement of a Schanz screw in the body of the scapula and a traction in the caudal direction is performed to correct the length of the
lateral pillar. Then, two holes are performed with a 2.5-mm drill bit on each side of the medial pillar of the scapula and a pointed clamp is used
for medial column reduction. Following, a bone hook is used to pull the glenoid fragment in order to achieve reduction. Provisional K-wires or
miniplates may be used for reduction maintenance

clavicle fixation, we place the patient lateral to perform as the so-called false Bankart osseous lesion [43, 44].
scapula fixation, either using the modified Judet ap- Conversely, true fractures of the glenoid rim are gener-
proach or preferably a combination of minimal ap- ally larger and occur when a lateral force drives the
proaches. All efforts are made to preserve the posterior humeral head directly against this structure with or
deltoid insertion. We currently also consider restoration without a shoulder dislocation [43, 44]. Type-IA repre-
of the scapula-clavicular arch, fixing both scapula and sents an anterior rim fracture and type-IIB represents a
clavicle in patients with floating shoulder and flail chest. posterior rim fracture of the glenoid cavity [13].
The postoperative care is the same previously described Glenoid fossa fractures occur after a violent force ap-
for glenoid neck and body scapula fractures. plied laterally to the proximal part of the humerus,
which is driven into the glenoid cavity. Most articular
Fractures of the glenoid fossa and rim fractures involve only part of the glenoid fossa, with the
Displaced glenoid fossa and rim fractures are caused by intact portion of the articular surface remaining in nor-
direct high-impact lateral trauma and are preferably mal anatomical relationship with the scapular neck or
managed by open reduction and internal fixation due to scapular body [45]. A transverse fracture line traverses
a high-risk of chronic instability of the shoulder and de- the glenoid cavity and propagates in several directions,
generative joint disease [43]. Associated skeletal and dictating different fracture patterns [13, 44]. In type-II
non-skeletal injuries, mainly in the thoracic region, are fractures, the force is directed somewhat inferiorly, with
common and sometimes life-threatening43,44. The most the fracture line running to the lateral border of the
common classification system for glenoid cavity fractures scapular body and creating a displaced inferior fragment.
of the scapula was described by Ideberg et al. [13], later In type-III fractures, the force is directed somewhat su-
modified by Goss et al. [8] and Mayo et al. [14]. In this periorly, with the fracture line exiting along the superior
classification system, fractures are separated into glenoid border of the scapula and sometimes disrupting some
rim-type fractures (types IA and IB) and glenoid fossa structures of the SSSC. The fracture fragment includes
fractures (types II-VI). True fractures of the glenoid rim the coracoid process and the superior articular surface
are distinct from the small avulsion-type fractures, gen- of the glenoid cavity. In type-IV fracture the force is
erally seen after a dislocation of the humeral head, such driven centrally, and the fracture line runs across the
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 8 of 18

scapula, exiting along its medial border. The scapula is comminuted fractures of the whole scapular body.
split transversely into a smaller superior fragment and a We call this combination a complex fracture of the
larger inferior fragment. Type-V fracture is a combin- scapula, which will be addressed later in this review.
ation of types II, III, and IV fracture patterns, presenting We prefer an anterior approach for anterior fracture
three variants. In type-Va variant, the main fracture line types carrying > 20% of the glenoid fossa and avulsed
runs across the scapula, exiting along its medial border, anteroinferior glenoid rim fractures overhanging the
and a secondary fracture line runs to the lateral border scapular neck more markedly than other parts of the
of the scapula, creating a separate inferior fragment. In glenoid fossa. Patient is placed in a 30° beach-chair
type-Vb variant the main fracture line runs across the position and operated on a complete radiolucent
scapula, exiting along its medial border, and a secondary Table. C-arm imaging is checked before beginning the
fracture line runs to the superior scapular margin, creat- operative procedure. The anterior axillary incision de-
ing a separate superior fragment. In type-Vc variant, the scribed by Leslie and Ryan [47] is preferred to ap-
main fracture line runs across the scapula, exiting along proach the anterior glenoid cavity. We normally inject
its medial border, and a secondary fracture line runs to between 20 and 30 mL of 2% lidocaine with adren-
both the superior and the lateral borders of the scapular aline at 1:200,000 into the incision site to reduce
body, creating separate superior and inferior glenoid bleeding during initial dissection. After skin incision,
fragments. Type-VI fracture is a severely comminuted superficial dissection is done through the deltopec-
injury affecting the entire glenoid fossa and is termed toral interval. The conjoint tendon is retracted medi-
total glenoid fracture [45]. Despite its detailed anatom- ally using a blunt asymmetric Sofield retractor and
ical characterization, the modified Ideberg et al. classifi- the subscapularis tendon is opened to allow capsule
cation [8, 13, 14] has some limitations imposed mainly exposure. Articular joint is finally exposed and a
by the use of standard radiographs only and its purely Fukuda retractor is positioned to lateralize the hu-
descriptive nature, with little or no therapeutic or prog- merus head. The fracture is reduced under direct
nostic applicability [46]. visualization and provisionally fixed with 1.0- or 1.2-
Using 3D CT reconstructions and intraoperative mm smooth K-wires. We prefer to definitively fix the
findings, Bartoníček et al. [46] developed a classifica- fracture with 2.0-mm headless cannulated screws or
tion system of glenoid fractures with five basic types 2.0-mm cortical screws sinking the head to avoid
of injuries identified based on analysis of separated damage to the humeral head. Labrum is frequently
portion of the glenoid fossa. Basic types of glenoid ruptured and must be sutured and reinserted using
fossa fractures include fractures of the superior glen- 1.5- or 2.0-mm anchors (Fig. 5).
oid, the anterior glenoid, the posterior rim of the We prefer to use posterior approaches for posterior
glenoid, the inferior glenoid, and the entire glenoid rim fractures carrying > 25% of the glenoid fossa and for
(total glenoid fracture), which are dictated mainly by all other glenoid fossa fracture patterns. Nowadays com-
the direction of the deforming force and the position bined limited or minimally invasive approaches are pref-
of the arm at the moment of the traumatic injury. erable and were described previously in this review [31,
The superior glenoid fracture involves the upper part 32]. For isolated posterior rim fractures we prefer the
of the glenoid fossa and extends as far as the upper Brodsky [31] straight simplified longitudinal approach.
border of the scapula, with the fracture line propagat- For all other types involving a main fracture line running
ing to the supraspinous fossa (above the spinal pillar across the scapula into its medial border, we prefer the
of the scapula). The anterior glenoid fracture is small surgical windows described by Gauger and Cole
characterized by a separation of the anterior and [32]. As stated before, the medial component of the frac-
sometimes part of the lower glenoid fossa rim. The ture must be reduced and fixed with a relatively flexible
posterior glenoid fracture involves avulsion of the implant first as it acts as a hinge to allow better manipu-
posterior rim of the glenoid fossa, which can extend lation, reduction, and final fixation of the lateral compo-
as far as its lower rim. Comminution is relatively nent [48]. We prefer locked or non-locked 2.0- and/or
common in this fracture pattern, with smaller frag- 2.3-mm straight plates located over the medial ridge of
ments remaining together by the glenoid labrum. The the scapular body. For the lateral component, we gener-
inferior glenoid fracture is characterized by a separ- ally use miniplates as reduction tools before applying a
ation of the distal fragment of the glenoid fossa, with non-locked one-third tubular plate buttressing the infer-
varying extension into the lateral border of the scap- ior glenoid neck and fossa. A long 3.5-mm cortical screw
ula body. In the entire glenoid fracture, all parts of is inserted through the plate directed to the coracoid
the articular surface are separated from the scapular process (Fig. 6) [26, 34, 39] .
neck or body. Bartoníček et al. [46] identified four Postoperative radiographs and CT scan are used to as-
cases of entire glenoid fracture combined with sess both the quality of reduction and inadvertent
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 9 of 18

Fig. 5 a: Preoperative true AP and lateral scapular radiographic views of the right shoulder of a 40-years-old male patient, showing a step-off on
the anteroinferior rim of the glenoid (white arrowheads). Patient reported on a fall from stairs 48 h before. Also note the small bone fragments in
the inferior portion of the capsule (yellow arrowheads); b: Preoperative 3-D CT reconstructions showing the displaced anteroinferior glenoid rim
fracture (white arrowheads) and small bone fragments in the inferior portion of the capsule (yellow arrowheads); c: Intraoperative image showing
the anteroinferior rim fracture anatomically reduced and provisionally fixed with multiple threaded K-wires. Observe the number 2 ethibond®
sutures attached to the anterior labrum for posterior repair. * – anteroinferior glenoid rim fragment, h – humerus head; d: Intraoperative true AP
and lateral scapular fluoroscopic views of the right shoulder showing final fixation with three 2.4-mm headless screws. Labrum was repaired using
a bone anchor and unabsorbable sutures; e: Postoperative true anteroposterior and lateral scapular radiographic views of the right shoulder
demonstrating the anatomic reduction of the anterior glenoid rim; f Pictures done during the rehabilitation protocol, demonstrating a satisfactory
range of motion of the operated shoulder

articular penetration. Adequate pain control is operation. Progressive strengthening is started after this
mandatory to allow the beginning of the postoperative period until bone healing.
rehabilitation protocol. When the pain is reasonable
under control (Visual Analogue Scale (VAS) between 2 Complex fractures of the scapula
and 3), both passive and active exercises are stimulated Based on the study by Bartoníček et al. [46], we define
to regain progressive range of motion and propriocep- complex fractures of the scapula when there is an entire
tion of the operated shoulder. Also, patients are told to glenoid fracture combined with a comminuted fracture
exercise the ipsilateral elbow, wrist, and fingers. Patients of the whole scapular body. We noticed that in this
are advised to avoid heavy objects with the operated high-energy fracture morphology, patients present an el-
upper limb during a minimum of six weeks after the evated number of thoracic injuries, such as multiple rib
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 10 of 18

Fig. 6 a: Preoperative true AP, lateral scapular, and axillary radiographic views of the right shoulder of a 25-years-old male patient, showing a
displaced inferior glenoid fragment extending to the lateral pillar of the scapular neck and body. Patient reported on a fall from stairs 48 h before.
Also note the small bone fragments in the inferior portion of the capsule (yellow arrowheads); b: Preoperative CT axial cuts of the right shoulder
demonstrating the displaced inferior glenoid fracture; c: Preoperative 3-D CT reconstructions showing the displaced inferior glenoid fracture
extending to the lateral pillar of the scapular neck and body; d: Postoperative true AP, lateral scapular, and axillary radiographic views of the right
shoulder demonstrating the anatomic reduction of the inferior glenoid fracture and buttressing with a one-third tubular plate. Observe the 2.3-
mm reduction plate used to maintain the reduction during surgery. Note the long 3.5-mm screw inserted through the plate directed to the
coracoid process; e: Postoperative CT axial cuts of the right shoulder demonstrating the anatomic reduction of the inferior glenoid fracture

fractures with or without flail chest and pulmonary con- overall length of hospital stay groups were similar be-
tusion with haemopneumothorax. Also, abdominal blunt tween patients with and without scapula fractures. The
injuries and cervical spine injuries have been observed in severity of extremity injuries in patients with scapula
these patients, potentially leading to increased risk of fractures was significantly lower than in those without
complications and fatal outcome. Veysi et al. [49] carried scapula fractures.
out a retrospective review of 1164 multiple injured pa- During initial management, all life-threatening injuries
tients, defined as an Injury Severity Score (ISS) > 16, with should be rapidly identified and controlled, aiming to re-
chest and musculoskeletal injuries. In this group, 79 store physiologic stability, avoid complications, and pre-
(6.8%) patients sustained a scapula fracture. They ob- vent further damage to the vital organs [50, 51]. In the
served a significantly higher overall ISS in the group of stable patient, operative treatment is advisable to ana-
patients with scapula fractures, with a significantly tomically restore the glenoid cavity and adequately re-
higher incidence of rib fractures. These patients also construct both the scapular neck and body to allow a
showed more severe chest injuries, although this finding pain-free motion of the shoulder. Again, we prefer to
did not raise statistically significance. The incidence and use limited and/or minimally invasive approaches for
severity of head and abdominal injuries, and the rate of acute fractures (Fig. 7), leaving more extensile ap-
admission, the length of intensive care unit stay, and the proaches for delayed cases [28, 31, 32].
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 11 of 18

Fig. 7 a: Preoperative AP and lateral scapular radiographic views of the left shoulder of a 42-years-old male polytraumatized patient done in the
Intensive Care Unit (ICU), showing a comminuted displaced complex scapula fracture; b: Anteroposterior (AP) radiograph of the thorax done in
the ICU, demonstrating a drain tube in the left hemithorax due to a traumatic haemopneumothorax; c: Preoperative CT axial cuts of the left
shoulder and hemithorax, demonstrating the comminuted displaced complex scapula fracture, involving fragmentation of the glenoid fossa
(orange arrowheads) and the scapular body (blue arrowheads). Note the multiple contiguous displaced rib fractures (black arrowheads),
extending from the 3rd to the 9th left rib; d: Preoperative 3-D CT reconstructions showing comminuted displaced complex scapula fracture,
involving fragmentation of the glenoid fossa and the scapular body. Observe the angled fracture of the spine of the scapular; e: Immediate
postoperative true AP, AP, and lateral scapular views of the left shoulder demonstrating the fixation of the most proximal fractures of the scapula.
Note the anatomic reduction of the glenoid fossa fracture. Patient was operated on in two steps, apart 5 days from each other; f: Intraoperative
images of the 2nd operative procedure performed for the management of some rib fractures and the inferior angle of the scapular body.
Observe the sequential reduction and fixation of the 6th left rib with a 2.0-mm straight non-locked plate; g: Intraoperative fluoroscopic images
demonstrating the final fixation of the 6th, 7th, and 9th rib fractures, and the inferior angle of the scapular body; h, Postoperative AP, oblique,
and lateral radiographs of the thorax, demonstrating the adequate reduction of both the complex left scapular and the multiple left rib fractures.
Postoperative in-hospital and after discharge management protocols are the same as previously described for glenoid cavity fractures
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 12 of 18

Fractures of the acromion resistance during shoulder movement. Anecdotally, al-

Acromion fractures are rare, accounting for 8 to 16% of though it is believed that the use of an abduction sling
all scapular fractures [9, 52, 53]. The classic injury mech- can be more effective to reduce the lever arm of the del-
anism is a direct impact over the lateral surface of the toid muscle and prevent secondary displacement,
shoulder, usually occurring as a result of high-energy nothing has been reported in the literature [18]. Symp-
trauma. Although uncommon, acromion fractures can tomatic nonunion is one of the most frequently occur-
occur after acromioplasty, when the bone removed for ring complications following conservative treatment and
the acromioplasty thins out the acromion to the point has been associated with persistent pain, rotator cuff
that it fractures secondary to forces applied to it by the tears secondary to subacromial impingement, sublux-
upper extremity [54]. Iatrogenic acromion fractures are ation of the humeral head, shoulder weakness, and re-
more common after arthroscopic surgery than after duced function of the shoulder [59]. It has been
open acromioplasty [55]. Moreover, acromion fractures suggested that nonsurgical treatment of an undisplaced
may also occur as a postoperative complication following or minimally displaced acromion fracture associated to
reverse shoulder arthroplasty due to changes in shoulder SSSC disruption presents a higher risk of failure due to
length and biomechanics [18]. Associated fractures in instability of the shoulder girdle and secondary displace-
other regions of the scapula, as well as clavicle and rib ment of the fracture [37].
fractures, pulmonary contusion, and brachial plexus in- There are no absolute indications for surgical treat-
jury may also be part of the acromion fracture scenario. ment of acromion fractures. However, Gorczyca et al.
Diagnosis is sometimes difficult and a high-level of [60] reported that, although conservative treatment of
suspicion should be raised in the patient complaining of displaced fractures of the acromion may result in sat-
severe shoulder pain after a direct trauma to the lateral isfactory function, measurement of shoulder strength
aspect of the shoulder. Although the best radiograph for after non-operative treatment of the displaced frac-
detection is an axillary view, these fractures can be diffi- tures of the acromion has yet to be reported. Indeed,
cult to see with conventional radiography. Therefore, a several complications have been associated with non-
CT scanning or sometimes a Magnetic Resonance Image operative management of displaced acromion frac-
(MRI) may be necessary to better visualize the fracture tures, including pain, decreased range of motion,
[54]. The main differential diagnosis is the os acromiale, rotator cuff tears secondary to subacromial impact,
which is present in approximately 3% of the population subluxation of the humeral head, shoulder weakness,
[56, 57]. and symptomatic nonunion [61–64]. Hardegger et al.
As previously mentioned, our preferred classification [9] recommended osteosynthesis for acromion frac-
for acromion fractures is the Kuhn et al. [19] system, tures with significant displacement to prevent painful
which takes into account the existence of displacement nonunion and to protect the rotator cuff from suba-
and reduction of the subacromial space. Unfortunately, cromial impingement. We believe that conservative
there is no consensus regarding the treatment of acro- treatment of displaced acromion fractures could result
mion fractures. The singular, complex, and thin anatomy in weakness of the deltoid muscle, therefore strongly
of the acromion, as well as its multiple ligamentous and impairing the shoulder girdle function. Therefore, we
muscular attachments make the treatment challenging. indicate surgery for all displaced Kuhn et al. type-II
Conservative treatment is indicated for undisplaced, and type-III acromion fractures.
stable fractures (Kuhn et al. type-I) and must be thor- Several fixation options have been described for the
oughly monitored due to the risk of progressive fracture treatment of acromion fractures, including K-wires only
displacement, especially in the type-IB. However, factors or as part of a tension band technique, screws only,
such as the length of immobilization, initiation of active plates and screws especially designed for acromion frac-
motion and the type of orthosis are not consistently ad- tures, or unconventional customized plates with or with-
dressed in the literature. Kuhn et al. [19] recommended out arthroscopy aid [58, 60, 62, 65]. Kim et al. [63]
a simple sling for two weeks in cases of Type-IA fracture compared early with delayed fixation of acromion frac-
and for 4 to 12 weeks in the type-IB fracture. On the tures in a retrospective series of 34 patients and found a
other hand, Hess et al. [18] recommended the use of a significantly better Constant Score on the early fixation
sling for 6 weeks with passive mobilization starting after group. Hess et al. [18] drafted a helpful treatment algo-
3 weeks and sling removal and active motion after 6 rithm based on the Kuhn et al. [19] classification. The
weeks. Ringelberg [58] demonstrated that the average treatment strategy is focused on both initial fracture dis-
force generated by the middle third of the deltoid to placement and patient physical demand. Patients pre-
maintain the arm at 45 degrees of abduction is higher senting displaced fractures who are physically active,
than 400 N. The author concluded that there is a consid- employed, and living independently are typically
ered deltoid traction over the acromion, even with no assigned to the high demand group, regardless of their
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 13 of 18

Fig. 8 Proposed treatment algorithm for acromion fractures by Hess et al. [18] The classification is based on the original system described by
Kuhn et al. [19]

age. Figure 8 depicts the Hess et al. [18] algorithm, glenoid neck, or scapula body fractures are associated
which also represents our rationale for treatment. with an acromion fracture, the Brodsky [31] approach
Our standard approach for displaced acromion frac- with proximal curved extension is a helpful alternative.
tures is the posterior straight skin incision with exten- Our fixation strategy usually combines stronger plates
sion to the scapular spine. If posterior glenoid fossa, with minifragment implants. We normally prefer to

Fig. 9 a and b: Radiographs of the shoulder showing a Kuhn et al. [18] type-II multifragmentary fracture of the acromion extending to the most
lateral part of the scapular spine. c, d, and e: Observe the amount of comminution on the CT scan. There is no obvious reduction of the
subacromial space. f, g, and h: Fracture fixation was performed with a superiorly placed non-locked one-third tubular plate. i, j, and k: Observe
the functional range of motion of the operated shoulder after fracture healing at 24 months postoperatively
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 14 of 18

associate 3.5- and/or 2.8-mm conventional or locking fluoroscopic beam directed at the coracoid tip demon-
plates with a minifragment 2.4-mm plate, depending on strates the entire profile of the superior coracoid pillar
the fracture pattern. Distal radius plates may be uncon- (‘superior pillar view’) and the cephalad and medial an-
ventionally used, particularly when there is an extension gulations (30 to 40° each) of the fluoroscopic beam dem-
of the fracture into the scapular spine. If an oblique frac- onstrates the entire ‘inferior coracoid pillar’. van Trikt
ture line is present in the absence of comminution, lag et al. [77] described the coracoid tunnel view based on
screws can be placed, usually outside the plate. Add- simple landmarks of the scapular bone. They found the
itional sutures can be placed to increase fixation stabil- optimal passageway of a screw through the coracoid base
ity. However, careful soft tissues dissection must be into the neck of the scapula as the coracoid tunnel.
performed to prevent devitalization around the fracture Starting with the anteroposterior fluoroscopic view, the
site. Also, in the very skinny patient, it is preferable to glenoid fossa, coracoid, acromion, scapular notch, super-
use minifragment implants to avoid hardware protru- ior scapular border, medial border, inferior border, and
sion, soft tissue discomfort, and wound complications. scapula spine are identified. Then, the fluoroscopic beam
Figure 9 shows an acromion fracture fixation. is moved in a cephalad direction until an oval shaped
tunnel (the coracoid tunnel) is projected between the
Fractures of the coracoid process coracoid tip, glenoid fossa, scapular notch, and superior
The coracoid process is part of the superior shoulder scapular border. Finally, the beam is re-adjusted until
suspensory complex and contributes to the anterosuper- the glenoid fossa is parallel to the drilling direction,
ior stability of the glenohumeral joint [36, 37, 66]. A making sure that the superior border of the scapula is
fracture of the coracoid process is a rare injury, with kept into roughly one line.
McGinnis and Denton [67] describing the prevalence of Coracoid fractures can be addressed with an anterior
coracoid fractures between 3 and 13% of all scapula frac- deltopectoral Henry approach, although some nondis-
tures. Data from two systematic reviews of scapular frac- placed Ogawa et al. [17] type-1 fractures can be fixed
tures in 2006 and 2008 reported the prevalence of percutaneously [75, 76]. The arm is internally rotated
apophyseal (acromion, coracoid, and scapular spine) and adducted to protect the brachial plexus. The entire
fractures to be up to 8.2% [22, 53]. Fractures of the cor- limb should be prepped and draped to allow for intraop-
acoid process are typically caused by high-energy trauma erative elbow flexion, which can relieve the traction
and are often seen in combination with other injuries force caused by the biceps tendon [73]. After fracture re-
[16, 17, 68]. The vast majority of case reports and series duction, a 2.0-mm K-wire is used to temporarily main-
of coracoid fractures is associated with concurrent tain the reduction. A correct and accurate screw
shoulder injuries, most commonly located at the acro- placement is essential to achieve adequate stability and
mioclavicular joint [69]. prevent fixation failure [75–79]. As mentioned before,
Isolated coracoid fractures that are either nondisplaced the sharp, hooked, and thin coracoid tip precludes the
or minimally displaced can be successfully treated with screw placement starting from this landmark. Therefore,
nonsurgical management [70–72]. Even displaced iso- the screw must be placed down the coracoid body
lated coracoid tip and fractures located between the cor- through the coracoid base and into the neck of the scap-
acoclavicular and coracoacromial ligaments can be ula, which is the coracoid tunnel [77]. In the vast major-
successfully treated with nonsurgical management [73, ity of cases, the drill must be positioned perpendicular
74]. Indications for surgical treatment include more than to the coracoid process and parallel to the longest axis
10 mm of displacement, multiple disruptions of the of the glenoid cavity and the screw must be placed paral-
SSSC, and symptomatic nonunions [73, 74]. Coracoid lel to the glenoid fossa. Care must be taken so the screw
process fractures may also be displaced by the traction does not violate or penetrate the osseous borders of the
of the short head of the biceps tendon, thereby requiring coracoid tunnel. We usually perform the fixation with a
surgical treatment depending on the amount of 3.5-mm cortical screw or less commonly with a partially
displacement. threaded 3.5-mm cannulated screw. Although rare, in
For coracoid process fracture fixation, the patient is certain fracture patterns with very large coracoid base, a
placed in the beach chair position on a radiolucent table. second screw may be necessary and/or a minifragment
The C-arm can be positioned either on the opposite side plate may additionally be used to increase construct sta-
or behind the shoulder to allow for at least 2 orthogonal bility. Figure 10 depicts the safe placement of the corac-
views. Bathia [75, 76] suggest the image intensifier to be oid process screw through the coracoid tunnel.
positioned in the anteroposterior plane, so fluoroscopic Figure 11 shows a case of coracoid process fracture as-
versions of two specialized radiographic coracoid pillar sociated with acromioclavicular dislocation.
views can be done to visualize two coracoid pillars. The Ogawa et al. [17] retrospectively reviewed 67 patients
cephalad and lateral angulations (30 to 40° each) of the with isolated coracoid fractures. Forty-five patients were
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 15 of 18

Fig. 10 a, b, c, and d: Photographs of a scapular specimens showing the placement of K-wire parallel to the glenoid fossa, guiding the screw
placement into the coracoid process. Observe that the screw must be positioned parallel to the longest axis of the glenoid. e, f, and g:
Fluoroscopy images showing the coracoid fixation

Fig. 11 Radiographs (a and b) and 3D-CT reconstruction (c, d, and e) showing the fractures of the coracoid process and scapular spine
associated with acromioclavicular dislocation. f and g: Postoperative radiographs showing the coracoid process fracture fixation with two 3.5 mm
cortical screws and the acromioclavicular fixation with a static tension band
Pires et al. Patient Safety in Surgery (2021) 15:6 Page 16 of 18

available for a follow-up at a mean of 37 months (12 to Acknowledgements

117 months). No notable difference was observed in the We would like to thank Dr. Egidio Oliveira Santana Junior M.D., Dr. Antônio
Eneas Rangel de Carvalho Junior M.D., Dr. Rafael Fuchs Lazarini M.D., and Dr.
outcomes between patients with type-1 and 2 fractures Matheus Benica Campos DellOrto M.D. for their assistance during some of
according to their classification between those undergo- the surgical procedures.
ing conservative and surgical treatment. Hill et al. [73]
Authors’ contributions
analyzed the outcomes of 22 patients with isolated cor- REP, VG, and PJL had substantial contributions to the conception of the
acoid process fractures treated with surgical fixation. A work, acquisition of data, literature review, and drafting the article. REP, VG,
total of 17 patients underwent open reduction and in- PJL, and FS preformed the surgical procedures. All authors revised the draft
critically for important intellectual content. All authors read and approved
ternal fixation with one to three lag screws, whereas five the final manuscript.
patients underwent surgical fixation with a combination
of screws and minifragment plates. At a mean follow-up Funding
of 23.5 months, the median Disabilities of the Arm, No funding was involved to support this study.

Shoulder and Hand (DASH) score was 12.3 (range, 0 to Ethics approval and consent to participate
74; mean, 10.1) and 16 (84%) returned to previous work Ethical approval was obtained by the Department Assembly at Federal
or employment. In our opinion, due to the rarity of this University of Minas Gerais. The manuscript contains no individual personal
data. No consent for publication was necessary.
fracture type and the inconsistencies in results from
existing studies in terms of surgical indications, the deci- Competing interests
sion regarding the modality of treatment should be thor- The authors declare that they have no competing interests related with this
article.
oughly shared with the patient for a correct and
individualized management based on the fracture pat- Author details
1
tern, associated shoulder injuries, patient activity level, Departamento do Aparelho Locomotor, Universidade Federal de Minas
Gerais, Av. Prof. Alfredo Balena, 190, Santa Efigênia, Belo Horizonte, MG, Brazil.
and patient’s expectation. 2
Serviço de Ortopedia e Traumatologia, Instituto Orizonti, Belo Horizonte,
MG, Brazil. 3Serviço de Ortopedia e Traumatologia Professor Nova Monteiro,
Rio de Janeiro, RJ, Brazil. 4Clínica São Vicente, Rede D’Or São Luiz, Rio de
Conclusion Janeiro, RJ, Brazil. 5Serviço de Ortopedia e Traumatologia, Hospital Santa
Teresa, Petrópolis, RJ, Brazil.
Treatment of scapular fractures remains challenging. Al-
though the vast majority of scapula fractures may be Received: 2 December 2020 Accepted: 15 December 2020
safely managed with conservative treatment, caution
should be taken to not miss the opportunity to correctly References
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