Acetabular Fractures: A Problem-Oriented Approach.

The main goals of acetabular fracture management are to restore the congruity and stability of the hip joint. These goals are the same for all patients who have an acetabular fracture, regardless of the morphology or etiology of the fracture. Nevertheless, certain acetabular fracture types and several patient factors pose management challenges for surgeons. Therefore, surgeons who manage acetabular fractures must understand the distinctive features of acetabular fractures as well as the soft-tissue and patient-related factors that play a critical role in patient outcomes. Particular challenges in the management of acetabular fractures include acetabular fracture types that involve the posterior wall, acetabular fractures with soft-tissue concerns, acetabular fractures in patients with multiple injuries, and acetabular fractures in the geriatric population. Although the well-known protocols that were established by Judet and Letournel continue to be important guidelines for the management of acetabular fractures, the injury characteristics of acetabular fractures, the demographics of the patients in whom acetabular fractures occur, and the treatment options for acetabular fractures have evolved. Therefore, surgeons must be aware of new and more recently published information on acetabular fractures.

Current management of posterior wall fractures of the acetabulum.

The general goals for treating an acetabular fracture are to restore congruity and stability of the hip joint. These goals are no different from those for the subset of fractures of the posterior wall. Nevertheless, posterior wall fractures present unique problems compared with other types of acetabular fractures. Successful treatment of these fractures depends on a multitude of factors. The physician must understand their distinctive radiologic features, in conjunction with patient factors, to determine the appropriate treatment. By knowing the important points of posterior surgical approaches to the hip, particularly the posterior wall, specific techniques can be used for fracture reduction and fixation in these often challenging fractures. In addition, it is important to develop a complete grasp of potential complications and their treatment. The evaluation and treatment protocols initially developed by Letournel and Judet continue to be important; however, the surgeon also should be aware of new information published and presented in the past decade.

The effect of body mass index on posttraumatic transfusion after pelvic trauma.

The impact of body mass index (BMI) on posttraumatic blood transfusion after pelvic trauma is not well known. We conducted a retrospective review of trauma registry data over a 5-year period. Patients were stratified by BMI as normal: less than 25 kg/m(2), overweight: 25 to 29.9 kg/m(2), obese: 30 to 39.9 kg/m(2), and morbidly obese: 40 kg/m(2) or greater. Fractures were identified as "likely to receive transfusion" based on literature. Multivariable logistic regression modeling evaluated the relationship between BMI and initial posttraumatic transfusion. A second regression model was created to test the effect of BMI after adjusting for fractures "less likely to receive transfusion." Sixty-six of 244 patients (27.3%) received transfusion (mean: 1.1 ± 2.3 units). Morbid obesity was associated with transfusion (less than 55.6 vs 24.8%; P < 0.05) and units of total blood transfused (2.2 ± 2.9 vs 1.0 ± 2.2 mL; P < 0.05). The average age of patients who received a blood transfusion was significantly older compared with patients who did not receive a transfusion (45.4 ± 18.8 vs 36.1 ± 16.1 years; P < 0.05). After adjusting for potential confounders, morbid obesity was a significant risk factor for transfusion (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.4 to 12.0). Adjusting by age and fracture patterns "less likely to receive transfusion," morbid obesity remained a risk factor for transfusion (OR, 4.5; 95% CI, 1.5 to 12.9). Morbid obesity represented a significant risk factor for posttraumatic transfusion in isolated pelvic trauma, even for fracture patterns "less likely to receive transfusion."

Unstable pertrochanteric femoral fractures.

BACKGROUND: Fractures in the trochanteric region of the femur are classified as AO/OTA 31-A, as they are extracapsular (). This report analyzes the relatively rare 31-A3 fracture, which has also been referred to as an "intertrochanteric femur fracture with subtrochanteric extension," "reverse obliquity intertrochanteric femur fracture," "unstable intertrochanteric femur fracture," or a "subtrochanteric femur fracture." The A3 fracture is characterized by having a fracture line exiting the lateral femoral cortex distal to the vastus ridge. Possible fixation constructs include compression hip screws, intramedullary hip screws, trochanteric intramedullary nails, cephalomedullary antegrade intramedullary nails, and 95° plates. Most reports investigating 31-A fractures do not describe the 31-A3 fracture. For this analysis, only reports clearly indicating that the fracture treated was a 31-A3 were included. It should be understood that this approach therefore excludes reports on generic "subtrochanteric fractures" or "intertrochanteric fractures," some of which may have been 31-A3 fractures. OBJECTIVE: To determine the effect of fixation technique for the AO/OTA 31-A3 fracture on rates of union, infection, risk of reoperation, and functional outcomes.

Hot topics in biomechanically directed fracture fixation.

The evolution of locking plates and modern nail constructs provides the orthopaedic trauma surgeon with a myriad of options with regard to implant selection for common fractures. There is a significant amount of biomechanical literature comparing modern constructs with those conventionally used. A basic understanding of this literature is required to make informed decisions with regard to implant selection in the management of these injuries. This article reviews the most recent biomechanical literature regarding implant selection and application for a variety of commonly treated injuries, including fractures of the clavicle, proximal humerus, distal humerus, intertrochanteric hip region, distal femur, and bicondylar tibial plateau.

External fixation versus ORIF for distal intra-articular tibia fractures.

Tibia plafond fractures have historically demonstrated high complication rates. The purpose of this study was to assess the outcomes of tibia plafond fractures following treatment with definitive external fixation vs delayed open reduction and internal fixation (ORIF). Sixty patients were enrolled in a prospective cohort trial at 1 Level I trauma center. No differences were noted between the 2 treatment groups in terms of age, smoking history, presence of comorbidities, mechanism of injury, incidence of open fractures, or Orthopaedic Trauma Association fracture classification. Complete 12-month follow-up was available for 18 patients in the definitive external fixation group and 27 patients in the ORIF group. No difference was noted in articular reduction between the groups at 6 and 12 months postoperatively. Delayed union or non-union occurred in 4 (22.2%) of 18 patients in the external fixation group and 1 (3.7%) of 27 patients in the ORIF group (P=.05). Deep infection was equally likely in either group (P=.33). The ORIF group had improved Iowa Ankle Scores at 6 (23.6 ± 12.1 vs 11.1 ± 7.7; P<.05) and 12 months (5.5 ± 2.2 vs 3.1 ± 1.7; P<.05) postopertively and improved Short Form-36 Physical Function scores at 6 months (49.7 ± 30.1 vs 25.5 ± 8.0; P<.05) postoperatively compared with the external fixation group.External fixation and ORIF can attain bony union with adequate articular reduction and similar infection rates. Patients treated with ORIF appeared to have improved union rates and early outcomes with ankle function and Short Form-36 Physical Function scores.

Preoperative skeletal versus cutaneous traction for femoral shaft fractures treated within 24 hours.

OBJECTIVES: To compare the advantages and disadvantages of preoperative cutaneous traction versus skeletal traction in adults with diaphyseal femur fractures amenable to fixation within 24 hours. DESIGN: Randomized prospective trial. SETTING: Level I trauma center in a major metropolitan area. PATIENTS: Sixty-five patients with 66 femur fractures were prospectively enrolled and randomized to a traction group from July 2009 to July 2010. MAIN OUTCOME MEASUREMENTS: Time of application for on call physicians/practitioners, pain relief after application of traction; time of reduction in the operating room theater, and evaluation of pain medication consumption before stabilization. RESULTS: Thirty-seven patients received cutaneous femoral traction, whereas 29 patients received skeletal traction. There was a significant reduction in time of application for the cutaneous traction (24.30 ± 24.74 minutes) compared with skeletal traction (57.10 ± 33.60 minutes) (P ≤ 0.001). There was no statistically significant difference in visual analog scale (VAS) scores when compared with pretraction application pain assessment and posttraction pain assessment between the cutaneous and skeletal traction groups with a decrease in the VAS of (0.56 ± 3.73 and 0.54 ± 2.76), respectively (P = 0.99). There was no difference in pain medication requirements between groups (0.12 ± 0.17 mg/kg for cutaneous versus 0.09 ± 0.14 mg/kg for skeletal, P = 0.39). There was no significant difference in reduction time of the fracture (skin incision or opening reamer to guide wire passage) in the operating room between cutaneous traction versus skeletal traction (P = 0.59). CONCLUSIONS: Use of cutaneous traction for diaphyseal femur fractures when compared with skeletal traction results in a statistically significant reduction in time of application to the on call practitioner with no complications or detrimental change in operative time and no difference in VAS pain scores or narcotic usage.

Bone morphogenetic protein-2 compared to autologous iliac crest bone graft in the treatment of long bone nonunion.

This retrospective study investigated the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) mixed with cancellous allograft on fracture healing compared to iliac crest autograft in the treatment of long bone nonunion. Eighty-nine patients with 93 established long bone nonunions treated between January 2002 and June 2004 at a single academic Level I trauma center were evaluated. Patients with clinical and radiographic evidence of failed fracture union underwent nonunion debridement, revision of fixation, and implantation at the nonunion site of either rhBMP-2 or the standard treatment autologous iliac crest bone graft. Union rate, operative time, estimated intraoperative blood loss, hospital length of stay, and postoperative infections were recorded. Nineteen nonunions received rhBMP-2 on a specialized carrier matrix (an absorbable collagen sponge) mixed with cancellous allograft, and 74 nonunions were treated with autologous iliac crest bone graft. There was no statistical difference in the rate of healing between treatment groups (68.4% vs 85.1%, respectively; P=.09). Incidence of postoperative infection was 16.2% after autologous iliac crest bone graft and 5.3% after rhBMP-2/absorbable collagen sponge (P=.22). Iliac crest autograft was associated with longer operative procedures (257.9±93.0 vs 168.9±86.5 minutes; P=.0007) and greater intraoperative blood loss (554.6±447.8 vs 331.6±357.2 mL; P=.01). These outcomes suggest that rhBMP-2 may provide a suitable alternative to autologous iliac bone graft, with the possible advantages of shorter operative time and reduced intraoperative blood loss, and may be considered as part of the orthopedic surgeon's treatment options.

The surgical treatment of acetabular fractures.

The goals of treating an acetabular fracture are to restore the congruity and stability of the hip joint. Some fracture types may not require surgery for a satisfactory outcome, but a displaced fracture in the weight-bearing area of the acetabulum generally should be treated with open reduction and internal fixation. The surgery is complex and demanding, and the fracture reduction must be anatomic to obtain the best result. There is no doubt, however, that an experienced surgeon can achieve an excellent result. Usually a poor result is related to residual fracture displacement or a perioperative complication. The evaluation and treatment protocols initially developed by Letournel and Judet continue to be important; in addition, the surgeon should be aware of the progress made during the past decade.

Subcellular localization of IRS-1 in IGF-I-mediated chondrogenic proliferation, differentiation and hypertrophy of bone marrow mesenchymal stem cells.

Bone marrow derived mesenchymal stem cells (BM-MSC) can differentiate into chondrocytes. Understanding the mechanisms and growth factors that control the MSC stemness is critical to fully implement their therapeutic use in cartilage diseases. The activated type 1 insulin-like growth factor receptor (IGF-IR), interacting with the insulin receptor substrate-1 (IRS-1), can induce cancer cell proliferation and transformation. In cancer or transformed cells, IRS-1 has been shown to localize in the cytoplasm where it activates the canonical Akt pathway, as well as in the nucleus where it binds to nuclear proteins. We have previously demonstrated that IGF-I has distinct time-dependent effect on primary BM-MSC chondrogenic pellets: initially (2-day culture), IGF-I induces proliferation; subsequently, IGF-I promotes chondrocytic differentiation (7-day culture). In the present study, by using MSC from the BM of IRS-1(- / - ) mice we show that IRS-1 mediates almost 50% of the IGF-I mitogenic response and the MAPK-MEK/ERK signalling accounts for the other 50%. After stimulation with IGF-I, we found that in 2-day old human and mouse derived BM-MSC pellets, IRS-1 (total and phosphorylated) is nuclearly localized and that proliferation prevails over differentiation. The IGF-I mitogenic effect is Akt-independent. In 7-day MSC pellets, IGF-I stimulates the chondrogenic differentiation of MSC into chondrocytes, pre-hypertrophic and hypertrophic chondrocytes and IRS-1 accumulates in the cytoplasm. IGF-I-dependent differentiation is exclusively Akt-dependent. Our data indicate that in the physiologically relevant model of primary cultured MSC, IGF-I induces a temporally regulated nuclear or cytoplasmic localization of IRS-1 that correlate with the transition from proliferation to chondrogenic differentiation.

Long-term functional outcomes after intra-articular distal femur fractures: ORIF versus retrograde intramedullary nailing.

This retrospective study evaluated the long-term clinical, functional, and radiographic outcomes of traditional open reduction internal fixation (ORIF) versus limited open reduction with retrograde intramedullary nailing for supracondylar-intercondylar distal femur fractures (Arbeitsgemeinschaft für Osteosynthesefragen [AO] 33-C type). Twenty-three fractures were followed in 22 patients for a mean follow-up of 80 months. The rate of subsequent bone-grafting procedures (67% vs 9%) and malunion (42% vs 0%) were significantly higher in ORIF compared to the less invasive retrograde intramedullary nailing treatment. A nonsignificant trend was noted for increased infection (25% vs 0%) and nonunion (33% vs 9%) in the ORIF group. The physical function component of the SF-36 was approximately 2 standard deviations below the US population mean, and 50% of patients demonstrated radiographic changes of posttraumatic arthritis. No patient has had a subsequent total knee arthroplasty.

Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981-2006).

BACKGROUND: There is no consensus on the best treatment for periprosthetic supracondylar fracture. MATERIAL AND METHODS: We systematically summarized and compared results of different fixation techniques in the management of acute distal femur fractures above a total knee arthroplasty (TKA). Several databases were searched (Medline, Cochrane library, OTA and AAOS abstract databases) and baseline and outcome parameters were abstracted. RESULTS: We extracted data from 29 case series with a total of 415 fractures. The following outcomes were noted: a nonunion rate of 9%, a fixation failure rate of 4%, an infection rate of 3%, and a revision surgery rate of 13%. Retrograde nailing was associated with relative risk reduction (RRR) of 87% (p = 0.01) for developing a nonunion and 70% (p = 0.03) for requiring revision surgery compared to traditional (non-locking) plating methods. Point estimates also suggested risk reductions for locking plates, although these were not statistically significant (57% for nonunion, p = 0.2; 43% for revision surgery, p = 0.23) compared to traditional plating. RRRs for nonunion and revision surgery were also statistically significantly lower for retrograde nailing and locking plates compared to nonoperative treatment. INTERPRETATION: Modern-day treatment methods are superior to conventional treatment options in the management of distal femur fractures above TKAs. The results should be interpreted with caution, due to the lack of randomized controlled trials and the possible selection bias in case series.

Utilization of the less-invasive stabilization system internal fixator for open fractures of the proximal tibia: a multi-center evaluation.

BACKGROUND: Locked plating has become popular and has clear biomechanical advantages when compared with conventional plating. When combined with minimally invasive surgical techniques, locked plating may cause substantially less iatrogenic tissue damage when compared with conventional plating. These characteristics may make locked plating an attractive option for treating open fractures of the tibial plateau and proximal tibia for which coverage over the plate can be obtained. The purpose of this study was to evaluate the use of the Less-Invasive Stabilization System (LISS) for high-energy open fractures involving either the tibial plateau or proximal tibia. MATERIALS AND METHODS: This study is a retrospective evaluation of a consecutive multicenter series of 52 consecutive patients operated by seven surgeons, who used LISS plating in open proximal tibia or tibial plateau fractures seen at one of four Level I Trauma Centers. All patients were treated using a locked plating system that was implanted using minimally invasive submuscular surgical techniques. The primary outcome measure was the incidence of deep and superficial infection. RESULTS: Fifty-two patients with open fractures have been evaluated, with a mean follow-up of 16.8 (12-36) months. Three patients (5.8%) developed deep infections. Two patients (6.3%) with tibial plateau and one (4.3%) of patients with a tibial shaft fracture developed deep infections. Fifteen patients required flap coverage of their open wounds. The incidence of deep infection as per Gustilo and Anderson classification was Type I and II - 0 (0%); Type IIIA - 2 (7.7%); Type IIIB - 1 (7.1%); and Type IIIC - 0 (0%). CONCLUSIONS: Biomechanically, the LISS functions as an "internal-external fixator" rather than a plate. Traditional plate osteosynthesis has yielded rates of infection between 18% and 35%. Our data indicate that locked plating using minimally invasive techniques yield deep infections rates that are no worse than published series using intramedullary nails or external fixators. Technical difficulties that can be encountered with the LISS system revolve primarily around obtaining and maintaining reduction while performing a minimally invasive procedure. Additional difficulties can include "cold welding" of screws to the plate and malposition of the plate leading to failure in the diaphysis. High-energy open fractures involving the tibia shaft or plateau remain high-risk injuries, but LISS is an acceptable alternative for treatment of these fractures.

Plating of femoral shaft fractures: open reduction and internal fixation versus submuscular fixation.

BACKGROUND: The standard treatment for femoral shaft fractures is intramedullary nailing. However, there are indications for which plating can be performed either openly or in a submuscular manner. METHODS: Between June 1996 and May 2002, two fellowship-trained orthopedic trauma surgeons treated 40 acute diaphyseal femoral fractures in 37 patients with use of plating techniques. Traditional open plating with emphasis on preservation of soft tissue integrity was performed exclusively before February 1999 (n = 19). After that time point, in all but one case (n = 21) submuscular plating techniques were used. No bone grafting was used for either group. A comparison of reduction quality, union rates, secondary interventions, and infection rates between traditional open reduction and internal fixation and submuscular fixation was performed (retrospective cohort study/evidence-based medicine (EBM)-level III). RESULTS: In assessing reduction quality, there were no malreductions in the traditional plating group and six in the submuscular plating group. There was one infection and one nonunion in the open reduction or internal fixation group. One infection was noted in the submuscular group. CONCLUSIONS: A 2.5% incidence of nonunion and a 5% incidence of infection (2 of 40; both in type III open fractures) were seen in this series of 40 femoral shaft fractures treated with plate application. Although the theoretical advantages of submuscular plating are well established, its utilization in the femoral shaft did not have a clear clinical advantage. In addition, its use appears to be more technically challenging, and is associated with a high rate of suboptimal reductions.

Predicting blood loss in isolated pelvic and acetabular high-energy trauma.

OBJECTIVE: To quantify transfusion requirements in patients with isolated acetabular or pelvic fractures and correlate these requirements with fracture classification. DESIGN: Retrospective review of 382 patients with isolated pelvic and/or acetabular fractures. SETTING: Academic Level I Trauma Center. PATIENTS/PARTICIPANTS: Patients were identified from a trauma registry. Appropriate radiographs and complete transfusion data were obtained for 289 (75%) of 382 eligible patients between January 1, 1998 and December 31, 2003. INTERVENTION: Classification of pelvic fracture by Young and Burgess type and acetabular fractures by Letournel type. MAIN OUTCOME MEASUREMENT: Number of units of blood transfused in the first 24 hours after admission to the trauma center. RESULTS: Patients with isolated pelvic fractures with major ligament disruption (APC II or III, LC III, vertical shear, or combined mechanisms) were more likely to receive a blood transfusion (44%) than other fracture types (8.5 %) (P < 0.0005). Transfusion amounts were greatest in APC III (12.6 units) and vertical shear (4.6 units) injuries. Fractures classified as both column, anterior column, anterior column posterior hemi-transverse, or T type were more likely to receive a blood transfusion (56%) than other fracture types (28%) (P = 0.003). Of these fracture types, both column (8.8 units) and anterior column posterior hemi-transverse (6.4 units) received the largest transfusions. CONCLUSIONS: Patients with isolated acetabular fractures are as likely as those with isolated pelvic fractures to receive blood transfusions within the first 24 hours of admission. Higher energy pelvic ring fractures classified as APC II or III, LC III, vertical shear, or combined mechanism require more frequent transfusion than other pelvic fractures. Acetabular fractures involving the anterior column as well as T-type fractures require more frequent blood transfusions than other acetabular fractures.

Shortening after femoral neck fracture fixation: is there a solution?

When using parallel screws for treatment of femoral neck fractures, shortening of the femoral neck might occur. Given the high revision surgery rates associated with parallel screws, we developed a questionnaire to explore (1) surgeons' viewpoints on difficulties in the fixation of femoral neck fractures, (2) their perception of the clinical importance of femoral neck shortening after internal fixation, and (3) their opinions regarding the ideal fixation device. Two hundred three surgeons responded. Eighty-three percent believed shortening of the femoral neck is common after screw fixation of femoral neck fractures; 89% believed shortening limits hip abductor function; and 69% believed shortening limits patients' physical function. When asked for features of the ideal implant for treatment of a femoral neck fracture, allowing compression across the fracture site on insertion and providing angular stability with a fixed-angle device to minimize shortening of the femoral neck were favored by 89% and 79% of the respondents, respectively. A plate with multiple nonparallel lag screws that can be locked into the plate might be a solution. However, the findings of this study are surgeons' opinions, which may or may not be confirmed by scientific evidence.

Recombinant human bone morphogenetic protein-2 in open tibial fractures. A subgroup analysis of data combined from two prospective randomized studies.

BACKGROUND: The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to improve the healing of open tibial shaft fractures has been the focus of two prospective clinical studies. The objective of the current study was to perform a subgroup analysis of the combined data from these studies. METHODS: Two prospective, randomized clinical studies were conducted. A total of 510 patients with open tibial fractures were randomized to receive the control treatment (intramedullary nail fixation and routine soft-tissue management) or the control treatment and an absorbable collagen sponge impregnated with one of two concentrations of rhBMP-2. The rhBMP-2 implant was placed over the fracture at the time of definitive wound closure. For the purpose of this analysis, only the control treatment and the Food and Drug Administration-approved concentration of rhBMP-2 (1.50 mg/mL) were compared. Patients who anticipated receiving planned bone-grafting as part of a staged treatment were excluded from enrollment. RESULTS: Fifty-nine trauma centers in twelve countries participated, and patients were followed for twelve months postoperatively. Two subgroups were analyzed: (1) the 131 patients with a Gustilo-Anderson type-IIIA or IIIB open tibial fracture and (2) the 113 patients treated with reamed intramedullary nailing. The first subgroup demonstrated significant improvements in the rhBMP-2 group, with fewer bone-grafting procedures (p = 0.0005), fewer patients requiring invasive secondary interventions (p = 0.0065), and a lower rate of infection (p = 0.0234), compared with the control group. The second subgroup analysis of fractures treated with reamed intramedullary nailing demonstrated no significant difference between the control and the rhBMP-2 groups. CONCLUSIONS: The addition of rhBMP-2 to the treatment of type-III open tibial fractures can significantly reduce the frequency of bone-grafting procedures and other secondary interventions. This analysis establishes the clinical efficacy of rhBMP-2 combined with an absorbable collagen sponge implant for the treatment of these severe fractures.

Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005).

BACKGROUND: The incidence of distal femur fractures is approximately 37 per 100,000 person-years. Typically, distal femur fractures are caused by a high-energy injury mechanism in young men or a low-energy mechanism in elderly women. Managing these fractures can be a challenging task. Most surgeons agree that distal femur fractures need to be treated operatively to achieve optimal patient outcomes. The articular fracture component is usually treated with open reduction and internal lag screw fixation or external tension wire fixation (Illizarov). However, there is no consensus on the type of implant for the fixation of the metaphyseal-diaphyseal fracture component. OBJECTIVE: The aim of this study is to systematically summarize and compare the results of different fixation techniques (traditional compression plating, antegrade nailing, retrograde nailing, submuscular locked internal fixation, and external fixation) in the operative management of acute nonperiprosthetic distal femur fractures (AO/OTA type 33A and C) and the characteristics of the fractures for each treatment (articular/nonarticular and open/closed). Additionally an attempt was made to evaluate the impact of surgical experience on nonunion rate, fixation failure rate, deep infection rate, and secondary surgical procedure rate. In the context of this article compression plating relates to techniques/implants that require compression of the implant to the femoral shaft-it does not relate to interfragmentary compression.

Treatment of scapula fractures: systematic review of 520 fractures in 22 case series.

BACKGROUND: Fractures of the scapula account for 3% to 5% of all fractures of the shoulder girdle and make up less than 1% of all broken bones. Scapula fractures typically occur after high-energy trauma, and approximately 90% of the patients have associated injuries. OBJECTIVE: (1) To determine the incidences of nonoperative and operative treatment of different scapula fracture types, (2) to systematically stratify the reported results of nonoperatively and operatively treated scapula fractures on the basis of different fracture types and to summarize functional results, and (3) to quantify infection and secondary surgical procedure rates after operative treatment.