Comminuted fracture of body of scapula with fracture infra-glenoid neck, fixation with conventional 3.5 reconstructive locking plate and locking compressive T plate, 2 years follow up: A Case Report and Review

Abstract

ABSTRACT
INTRODUCTION
Incident of scapula fracture is 1% of all fractures and 3-5% in fractures of shoulder girdle. Scapula fracture occurs in high energy trauma in young and low energy fractures in elderly patient.95% scapula fractures are managed conservatively and there are high chances of asymptomatic malunion, rotator cuff dysfunction, impingement and scapulothoracic dyskinesia. Conservative management in scapula fracture with floating shoulder, Superior Shoulder Suspensory Complex (SSSC) injury & multiple rib fractures, delay in rehabilitation and compromises the functional result. There are no specific guidelines found regarding the surgical management of scapula fracture associated with clavicle fracture (Floating shoulder) and surgical treatment in these cases remains controversial. However, the open reduction and internal fixation (ORIF) of scapula fractures in such cases, the results are superior compared to conservative management in view of pain, stiffness and functional outcome with minimal complications. Scapula fracture fixation surgery is considered rare and techniqully demanding in South Asian country like India and hence, we are presenting a case of young patient with poly trauma with ipsilateral significantly displaced clavicle midshaft fracture, extra articular comminuted displaced scapular body and infra glenoid fracture with multiple rib fractures. Considering his young age ,job and to reduce his morbidity due to pain and disability, we offered him ORIF of scapula body and glenoid neck with conventional 3.5 reconstructive plate & locking compressive plate (LCP) and ‘anatomically precontoured LCP’ for clavicle midshaft comminuted fracture. Within one month of operation, patient recovered all the function of shoulder with good power and resumed his carpentry work with no complications. Uniqueness of this case is we have used conventional 3.5 reconstructive locking plate as the classical Boomerang plate was not available and we got optimum functional result.
CASE REPORT:
33-year-old patient, carpenter by occupation with history of road traffic accident. Patient was travelling on two-wheeler and dashed by four-wheeler, sustained head injury, right side chest injury, and difficulty in movement of left shoulder with no distal neurodeficit. Patient admitted in ICU and investigated. CT scan chest showed right side 4th,5th,6th rib fracture with minimal hemopneumothorax. X-rays of clavicle showed fracture mid shaft clavicle displaced and fracture scapula body, infra glenoid neck extra articular fracture, lateral wall fracture, medial wall fracture near superior angle. A 3D CT scan of scapula done to evaluate scapula fracture in detail.

As the patient also has displaced clavicle shaft fracture along with 3 ribs fracture at right side with mild hemopneumothorax, decision of fixation of shaft of clavicle and fixation of lateral and medial border of scapula was taken. First clavicle shaft fracture fixation done in a standard manner in supine position and anatomical clavicle LCP fixation performed. Patient was then given lazy lateral position Judet approach was planned. ORIF of scapula body and neck fracture then carried out with LCP. Closure done in layers. Passive range of movement started day 1 post op and active assisted range of movement started as per comfort of patient. Deep breathing exercises and bed sided movement started day one . Aggressive physiotherapy sessions were given for 2 weeks thereafter.
CLINICAL DISCUSSION: Scapula displaced fracture at or below the glenoid neck associated displaced fracture of body along with same side multiple ribs fracture and clavicle displaced fracture all together produces morbidity due to pain, stiffness and functional disability. There are no specific guidelines regarding fixation of theses fractures in same sitting. Surgical treatment for significantly displaced fractures of scapula and clavicle in the form of ORIF on their own merits yielded superior result compare to conservative management with less complications. The duration of recovery and to return to work place in a very short period of time in operative cases compare to conservative management reported in few case studies.
CONCLUSION: In a young poly trauma patient with scapula body fracture displaced, with ipsilateral clavicle fracture displaced and ipsilateral multiple rib fractures associated with hemopneumothorax, fixation of clavicle and fixation of scapula body fracture (floating shoulder)by ORIF with plate and screw, significantly reduces patient’s morbidity due to pain, stiffness & functional disability & gives dramatic functional outcome in a very short period of time compare to conserIpsvative management with less complications.