Open Reduction and Internal Fixation of Scapula Fractures in a Geriatric Series.

The purpose of this small descriptive series was to report patient and injury characteristics, as well as, surgical and functional outcomes in patients aged 70 years or older, with operative scapular fracture. A retrospective review of 214 scapula fractures identified 6 consecutive geriatric patients aged 70 years or older and formed the basis for this study. Outcomes reported include surgical complications; disabilities of the arm, shoulder, and hand (DASH); range of motion (ROM); and strength assessment at the 6-month postoperative interval and final follow-up. All patients were community ambulators and 5 of the 6 patients routinely performed recreational activities that required shoulder strength and/or motion. Outcomes were attained on all patients at greater than 1 year with a mean of 23.2 months. There were no surgical complications and all fractures united. The mean ROM expressed as a percentage of contralateral ROM ranged from 82% to 100% at both 6-month and final follow-up. The mean strength expressed as a percentage of contralateral strength ranged from 63% to 82% at the 6-month follow-up and 94% to 100% at the final follow-up. The mean DASH score was 12.3 at final follow-up. Our conclusion is that operative treatment for displaced scapula fractures appears to be safe and can yield good functional results in patients aged 70 years and older.

"The Skiver Screw": A Useful Fixation Technique for Iliac Wing Fractures.

The contour of the ilium is curved and the iliac fossa is thin, making adequate fixation for fractures involving the iliac wing challenging to achieve at times. The purpose of this article is to describe a previously unreported technique for enhancing fixation in iliac fractures using simple cortical screws.

"A to p" screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures.

OBJECTIVES: To compare radiographic and clinical midterm outcomes of posterior malleolar fractures treated with posterior buttress plating versus anterior to posterior lag screw fixation. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between January 2002 and December 2010, patients with posterior malleolar fractures were identified by Current Procedural Terminology code and their charts reviewed for eligibility. INTERVENTION: Posterior malleolar fixation using either anterior to posterior (AP) lag screws or posterior buttress plating. MAIN OUTCOME MEASUREMENTS: Demographic data, length of follow-up, range of motion, and postoperative Short Musculoskeletal Function Assessment (SMFA) scores were the main outcome measurements. Immediate postoperative radiographs for residual gap/step-off and final follow-up radiographs for the degree of arthritis that developed were evaluated. RESULTS: Thirty-seven patients were eligible for the study, and 27 chose to participate. Sixteen patients underwent posterior buttress plating, and 11 underwent AP screw fixation with mean follow-up times of 54.9 and 32 months, respectively. Demographic data were similar between groups. The posterolateral plating group demonstrated superior postoperative SMFA scores compared with the AP screw group with statistically significant differences in the SMFA bother index (26.7 vs. 9.2, P = 0.03) and trends toward improvement in the mobility (28.3 vs. 12.9, P = 0.08) and functional indices (20.2 vs. 9.4, P = 0.08). There were no significant differences in the range of motion or the development of ankle arthritis over time. CONCLUSIONS: Patients with trimalleolar ankle fractures in whom the posterior malleolus was treated with posterolateral buttress plating had superior clinical outcomes at follow-up compared with those treated with AP screws. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Triple and quadruple disruptions of the superior shoulder suspensory complex.

OBJECTIVES: The purpose of this study is to report on a series of patients who sustained triple and quadruple disruptions to the superior shoulder suspensory complex (SSSC), their associated injuries, and functional outcomes of open reduction and internal fixation. DESIGN: Prospective observational study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Patients who sustained more than 2 lesions to the SSSC that underwent surgery. OUTCOME MEASUREMENTS: Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion, and shoulder strength measurements. RESULTS: Fifteen patients with greater than 2 disruptions (12 triple and 3 quadruple) were identified. There were 14 scapula neck fractures, 8 clavicle fractures, 6 acromioclavicular separations, 10 coracoid, and 10 acromion fractures. Rib fractures were present in 87% (13 of 15) patients. Thirteen patients (87%) sustained nerve injuries with 13 lesions distal to the brachial plexus, 5 at the level of the brachial plexus, 3 nerve root, and 2 spinal cord injuries. At final follow-up (14 of 15 patients, mean follow-up = 30.7 months), DASH scores averaged 14.9 and mean range of motion when expressed as the percentage of injured shoulder over the contralateral shoulder was 95% forward flexion, 92% abduction, and 78% external rotation. Mean strength measured by a hand-held dynamometer and expressed as the percentage of injured over contralateral was 67% forward flexion, 61% abduction, and 65% external rotation. CONCLUSIONS: Patients with triple and quadruple disruptions of the SSSC had a high rate of associated injuries including a majority with spinal and peripheral nerve lesions. Treatment with open reduction internal fixation of the scapula was associated with satisfactory functional outcomes despite decreases in shoulder strength measurements. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical management of coracoid fractures: technical tricks and clinical experience.

The coracoid process plays a pivotal role in the foundation of the coracoacromial arch and in cases of displaced fractures; surgical management may be warranted to avoid functional compromise or impingement. A direct approach through Langer's lines allows for easy exposure and direct visualization for an anatomic reduction of simple fractures through the shaft or base of the coracoid. An anterior approach for fractures that extend into the superior glenoid fossa allows for direct exposure to obtain an anatomic articular reduction and indirect reduction of the coracoid fracture. In cases where a complex glenoid or scapula neck/body fracture is being addressed simultaneously either a posterior Judet approach can be used with an indirect reduction method or a separate anterior approach must be combined to address it if not in continuity with the superior scapular segment. Implant selection, primarily interfragmentary screws or a buttress plate, should be based on the size of the fragment, the degree of comminution, and the degree of articular involvement to ensure adequate stabilization. The purpose of this manuscript was to describe a stepwise approach to the surgical management of displaced coracoid fractures, describe surgical tips and techniques, and to present the clinical outcomes in 22 patients after surgical treatment with this approach.

Surgical management of isolated acromion fractures: technical tricks and clinical experience.

SUMMARY: Acromion fractures of the scapula are rare and most often occur with concomitant fractures of the ipsilateral glenoid, neck and body of the scapula as sequelae of high-energy injuries. Indications for operative management include symptomatic nonunion, displaced fractures, or acromion fractures associated with other lesions of the superior shoulder suspensory complex. Less displaced acromion fractures resulting in decreased subacromial space may also warrant surgery. Although surgical indications have been reported, the literature regarding surgical approaches and fixation techniques for management of these factures is limited. Acromion fractures can generally be addressed with a direct posterior approach using either tension band or low-profile plating in combination with cortical lag screws to obtain a stable construct. This technique is both effective in achieving fracture union and safe to the patient. When associated with a more complex fracture of the glenoid and/or scapula body, the surgical approach and fixation strategy should be dictated by the optimal approach to other displaced elements of a scapula fracture. The purpose of this study was to describe a step-wise approach to the surgical management of isolated acromion fractures, describe surgical tips and techniques, and to present the early clinical outcomes in 13 patients after surgical treatment with this approach.