Scapular Fractures

Scapular fractures are caused by different mechanisms, of which blunt trauma is probably the most common.¹,³,⁸,¹¹⁵,¹¹⁶,¹⁶⁹
This direct force may cause fractures in all anatomic areas of the
scapula. Other mechanisms are indirect injuries: (i) traction by
muscles or ligaments may induce avulsion fractures of the acromion or
coracoid, which in rare cases are caused by a seizure or an electrical
shock¹¹⁰,¹⁶⁶; and (ii) impaction of the humeral head into the glenoid fossa which may induce glenoid and some scapular neck fractures.

As in general with high-energy trauma, traffic accidents
are the main cause of scapular fractures (occupants of motor vehicles
in about 50% of cases¹,⁸,¹¹⁵ and pedestrians in 20%³,¹¹⁵).
Other causes are motorcycle accidents, fall from heights, crush
injuries, or sporting activities (horseback riding, skiing, and contact
sports).

Usually, high energy is required to fracture a scapula,
hence scapular fractures are commonly associated with concomitant
injuries. Research shows that 61% to 98% of scapula fractures have
associated injuries.¹,³,¹⁷,²¹,⁷⁹,⁹⁷,¹¹⁵,¹¹⁶,¹⁶⁵,¹⁶⁹
These associated injuries may be multiple and may need priority in
treatment. As a result, diagnosis and treatment of scapular injuries
may be delayed or suboptimal.

A wide variety of regional and remote injuries have been
reported that may be life-threatening, such as pneumothorax (9% to 38%),³,⁴⁵,¹¹⁸,¹⁶⁹ pulmonary contusion (8% to 54%),⁴⁵,¹¹⁶,¹⁶⁹ arterial injury (11%),⁴⁵,¹⁶⁹ closed head injuries (20% to 42%),⁷⁹,¹¹⁵ and splenic or liver lacerations 3% to 5%.¹¹⁶ Brachial plexus injury is present in 5% to 13%³,⁴⁵,⁷⁹,¹¹⁵,¹⁶⁹
and is often the most important prognostic factor with regard to the
final clinical outcome, whether fracture treatment be conservative or
otherwise. The reported mortality rate of patients with scapular
fractures from the concomitant injuries varies between 2% and 15%.¹¹⁵,¹⁶⁹,¹⁹¹

In a recent review article on the operative treatment of scapular fractures, Lantry⁹⁷
analyzed the associated injuries of 160 cases in 11 different studies.
Rib fractures were the most common associated injury, followed by head
and chest injuries. Fractures in remote anatomic areas were found in
nearly 20% of patients. To determine the significance of scapular
fractures in blunt trauma, Stephens¹⁶¹
compared two matched groups of patients with and without scapular
fractures. Except for a significantly higher incidence of thoracic
injuries in the group with scapular fractures, he found no difference
in mortality or incidence of neurovascular injuries. Veysi¹⁷⁹
reported in 2003 that patients with scapula fractures have more severe
underlying chest injuries and overall injury severity scores (ISS).
However, these findings, which were confirmed by other authors,¹⁶¹,¹⁸³
did not correlate with a higher rate of intensive therapy unit
admission, length of hospital stay, or mortality. There is no clear
correlation between the number and severity of associated injuries and
the type of scapular fracture. Nevertheless, Tadros¹⁶⁵
found in a prospective study that the ISS and abbreviated injury score
for chest injuries are higher and posterior structure injuries are more
frequent in patients with fractures involving multiple scapular regions.

In summary, scapular fractures should alert the surgeon
to the presence of other, sometimes very severe injuries. Severe chest
injury should also raise suspicion of a possible scapular fracture.¹⁰⁸

A patient with a scapular fracture typically presents
with the arm adducted along the body and will protect the injured
shoulder from all movements.

Physical examination may reveal swelling, ecchymosis,
crepitus, and local tenderness. The ecchymosis is in general less than
expected probably because the scapula is protected by a thick layer of
soft tissue. Active range of motion is restricted in all directions.
Abduction in particular is very painful.

Neviaser¹²⁶ described
in 1956 that the rotator cuff function is weak and very painful
secondary to inhibition from intramuscular hemorrhage. This has been
described as a “pseudorupture” of the rotator cuff and usually resolves
within a few weeks. When a scapular fracture is diagnosed, it is
important to perform a careful neurovascular examination to rule out
arterial injury and/or brachial plexopathy.

After initial assessment, according to Advanced Trauma
Life Support (ATLS) principles, specific radiographic evaluation of the
injured shoulder is indicated as soon as the patient is in a stable
condition. Associated injuries requiring urgent treatment may force the
treating surgeon, particularly in polytrauma patients, to evaluate the
chest only by a routine supine chest radiograph. This is the earliest
opportunity to identify a scapular fracture. Harris⁶⁸
pointed out in a retrospective analysis of 100 patients with major
blunt chest trauma that the scapular fracture was diagnosed on the
initial chest radiograph in only 57 of 100 patients and, although
present, was not recognized in 43%. Particularly extensive associated
chest injuries may overshadow the scapula with a delay in diagnosis as
a result.¹⁶⁴

Scapular fractures are notoriously difficult to
visualize radiographically. Except for the chest radiograph, a true
anteroposterior (AP) view, perpendicular to the plane of the scapula, a
lateral, and an axillary view are recommended. A true axillary
projection of the glenohumeral joint and scapula is ideally performed
with the arm in 70 to 90 degrees of abduction, which might be very
painful for the patient in the acute situation. Alternatives for this
view are the Velpeau axillary lateral view¹² (see Fig. 39-6) or the trauma axillary lateral view,¹⁷⁰
which can be taken while the patient is supine. In case of a complex
shoulder injury with a double disruption of the superior shoulder
suspensory complex (SSSC) (Fig. 37-1), a weight-bearing AP projection of the shoulder is recommended by Goss.⁶⁰

Most scapular fractures will be diagnosed by the
three-view scapula trauma series, but special views may be necessary
for selected fracture types. The Stryker notch view is useful for
coracoid fractures (see Fig. 39-8) while the apical oblique view⁴⁸ and the West Point lateral view¹⁴⁷ are useful for glenoid rim fractures. In cases of scapular fractures with multiple fracture

lines and particularly significant displacement, a computed tomography
(CT) scan is recommended, although the additional value is not clear in
every fracture type.¹¹³
It is, however, useful to assess the size, location, and degree of
displacement of fragments in coracoid, acromion, and glenoid fractures.
In glenoid fractures, it is also helpful to evaluate the position of
the humeral head in relation to the glenoid fossa or fracture fragment (Fig. 37-2).
Finally, a three-dimensional CT scan can be very helpful in
understanding complex fracture patterns and in preoperative planning.

Scapular fractures are generally classified by anatomic
area (body and spine, glenoid cavity, glenoid [scapular] neck,
acromion, and coracoid).

Fractures of the body and spine are the most common
(approximately 50%), followed by the scapular neck (approximately 25%),
glenoid cavity (approximately 10%), acromion (approximately 8%), and
coracoid process (approximately 7%).¹,⁷⁹,¹¹⁵,¹²⁷,¹⁸⁴

There are several other classification systems reported in the literature. Zdravkovic and Damholt¹⁹¹
divided scapular fractures into three types: type 1, fractures of the
body; type 2, fractures of the apophysis (including acromion and
coracoid); and type 3, fractures of the superior lateral angle,
including the glenoid neck and glenoid. Zdravkovic and Damholt¹⁹¹ considered type 3 fractures, which represented only 6% of their series to be the most difficult to treat.

Thompson and colleagues¹⁶⁹ presented a classification system which also divided scapular fractures into three different classes:

Class 1: acromion, coracoid, and minor fractures of the body

Class 2: glenoid and scapular neck fractures

Class 3: major scapular body fractures

In their opinion, classes 2 and 3 were much more likely to have associated injuries.

Wilber and Evans¹⁸⁴
divided scapular fractures into two groups. Group 1 included patients
with fractures of the scapular body, scapular neck, and spine; group 2
included patients with fractures of the acromion, coracoid process, and
glenoid. They reported poor functional outcome caused by loss of
glenohumeral motion and residual pain in patients of group 2.

Finally, the Orthopaedic Trauma Association’s (OTA)
classification, which was originally published in 1996, has been
revised for scapular fractures.¹⁰⁷
In this new format, the differences between the OTA and AO
classification have now been eliminated by a unified alpha-numeric code
(Fig. 37-3).

A thorough knowledge of the bony contours of the scapula and its related musculotendinous and neurovascular structures is

required for adequate treatment of patients with scapular fractures,
particularly if operative treatment is considered. The scapula is a
large, flat, triangular bone that connects the clavicle to the humerus.
At least 18 different muscles originate from and insert into this
highly mobile bone (Fig. 37-11).

Special attention should be given to neurovascular
structures at risk when surgery (both anteriorly and posteriorly) is
undertaken.

Glenoid fractures make up 10% of all scapular fractures. Only 10% of glenoid fractures are significantly displaced,⁶⁰
meriting surgical consideration. The majority (90%) are minimally
displaced or undisplaced and should be treated nonoperatively.
Fractures of the glenoid are commonly found in the middle aged, between
40 and 60 years, with a male prevalence,⁷⁸ and result most often from high-energy direct trauma.¹,⁵⁷,⁷⁹,¹¹²,¹¹⁵,¹⁵⁰
They occur when the humeral head is driven with a substantial force
against the glenoid fossa. This may be caused by a direct force on the
shoulder or an axial force through the humerus. The direction of this
axial force will predict the fracture pattern. The most common fracture
type is the anterior chip fragment fracture (type Ia), which is often
associated with an anterior shoulder dislocation.⁷⁸

Many authors have reported good early functional outcome
in patients treated nonoperatively with intra-articular fractures
without associated instability.²⁰,⁷⁷,¹⁴⁴,¹⁵¹ Since the late 1980s, operative treatment of glenoid fractures has gained more attention.⁴,⁸,⁷⁴,⁸⁴,⁸⁹,⁹⁸,¹⁵⁶
There is a current trend towards arthroscopic techniques of glenoid
fracture treatment, particularly in Ideberg type I fractures.⁹,²²,²⁴,⁵¹,¹³⁸,¹⁶³,¹⁶⁷

A fracture of the neck of the scapula is the second most common scapular fracture.³,⁷⁹,¹¹⁵,¹¹⁶
The suggested mechanisms of trauma are a direct blow to the shoulder, a
fall on the point of the shoulder, or a fall on the outstretched arm.
The fracture line most often extends from the suprascapular notch area
across the neck of the scapula to its lateral border inferior to the
glenoid (surgical neck fracture) or, rarely, lateral from the origin of
the coracoid to its lateral border inferior to the glenoid (anatomic
neck) (see Fig. 37-5).

Scapular neck fractures, by definition extra-articular
fractures, are sometimes accompanied by a fracture line through the
coracoid process or may remain as an intact unit. If the scapular neck
fracture is not associated with an ipsilateral shoulder lesion (of the
SSSC), displacement is possible but rare.³¹,⁵⁸,¹⁷⁶ According to the concept of the SSSC, isolated fractures of the scapular neck are considered stable fractures.⁶¹

The treatment of these fractures has historically been nonoperative, mostly with a favorable outcome.⁷⁹,⁸³,¹⁰³,¹¹⁵,¹¹⁶,¹⁷⁷ Recommended methods of closed treatment include closed reduction and olecranon pin traction for 3 weeks followed by a sling,³² closed reduction and a shoulder spica cast for 6 to 8 weeks,⁷ and even the use of a traction suspension system for reduction of a displaced neck fracture.¹⁷⁷
Some authors doubt the usefulness of closed reduction in these
fractures, advocating the use of a sling and suggest mobilizing the
affected arm as soon as possible.¹¹⁷ Lindholm and Leven¹⁰³
studied a series of scapular neck and body fractures and concluded that
if untreated, all fractures healed in the position displayed at the
time of the original injury.

These studies, however, do not present data to justify
these recommendations. A more differentiated approach is necessary as
conservative treatment does not uniformly lead to a good result.
Several authors noted fair to poor results after conservative treatment
of severely displaced scapular neck fractures.¹,³,⁴⁹,¹²⁷,¹³⁵,¹⁴⁸
Displacement is defined as at least 1 cm of translation or 40 degrees
of angulation (or a glenopolar angle [GPA]<20 degrees) in the AP
plane of the scapula and separates minor from major injuries according
to Zdravkovic,¹⁹¹ Nordqvist and Petersson,¹²⁷ and Geel.⁵⁰

Ada and Millar 1 reported on 24 patients with displaced
scapular neck fractures. Of the 16 patients treated conservatively, 50%
complained of pain at night, 40% had weakness of abduction, and 20% had
decreased range of motion. Whether translational displacement of at
least 1 cm remains a good criterion for surgical treatment of scapular
neck fractures is controversial.¹⁴⁸,¹⁷⁶
The criterion of angulation greater than or equal to 40 degrees (or a
GPA <20 degrees) is probably less questionable. Several authors
reported less favorable long-term outcome after conservative treatment
of angulated scapular neck fractures, compared with scapular neck
fractures without angular displacement.¹⁵,⁸⁸,¹⁴⁸,¹⁷³
Good to excellent results have been reported on open reduction and
internal fixation of patients with displaced scapular neck fractures.⁹,⁶⁷,⁸⁸,¹⁰⁰
In these series, however, displaced scapular neck fractures are in most
cases associated with ipsilateral clavicle fractures. According to
Zlowodzki,¹⁹⁴ who performed a
systematic review of 520 scapular fractures in 22 case series,
excellent or good results can be achieved with nonoperative treatment
of isolated neck fractures in 77% of the cases and in 88% of the cases
with operative treatment. Universal guidelines for conservative or
operative treatment are difficult to establish empirically because the
available literature does not include randomized or nonrandomized
comparative studies. Treatment should, therefore, be individualized.

Goss⁶¹ described the
SSSC, consisting of the glenoid, coracoid, acromion, distal clavicle,
coracoclavicular ligaments, and acromioclavicular ligaments (Fig. 37-16).
This bone-soft tissue ring maintains the normal, stable relationship
between the upper extremity and the axial skeleton. Single disruptions
of the SSSC, such as an isolated scapular neck fracture, are usually
anatomically stable because the integrity of the complex is preserved,
and nonoperative management yields good functional results. When the
complex is disrupted in two places (double disruption), such as a
scapular neck fracture with an acromioclavicular joint disruption, a
potentially unstable anatomic situation is created. Because the SSSC
includes the glenoid, acromion, and coracoid, many double disruption
injuries involve the scapula. In the presence of a displaced fracture
of the acromion, coracoid process, glenoid, or scapular neck, the
possibility of another lesion of the SSSC (i.e., a double disruption)
should be considered. According to Goss,⁶¹
open reduction is indicated for double disruptions that are accompanied
by significant displacement, which may lead to delayed union, malunion,
or nonunion as well as long-term functional deficits.

The most common described double disruption of the SSSC
is the ipsilateral glenoid surgical neck and midshaft clavicle
fracture. This injury, although the terminology is criticized,⁹¹ is also defined as a floating shoulder.

Ganz and Noesberger⁴⁶
were the first authors who described this injury in 1975. They
suggested a loss of the stabilizing effect of the clavicle in the case
of a combination of these two fractures. In contrast to isolated
scapular fractures, they found more severe displacement of the scapular
fracture when combined with an ipsilateral clavicle fracture. The
weight of the arm and the combined contraction of the biceps, triceps,
and coracobrachialis muscles may cause inferior and rotational
displacement of the distal fragment resulting in a change in the
contour of the affected shoulder, the so-called drooping shoulder (Fig. 37-17). Apart from this possible caudal and rotational displacement, it is also suggested, although criticized by some,¹²⁹,¹⁷⁵ that the glenoid fragment is displaced anteromedially by contraction of the rotator cuff muscles (Fig. 37-18).⁴⁶,⁶⁶,⁷¹
Translational displacement of the scapular neck will result in
shortening of the lever arm of the rotator cuff musculature and
threaten the functional balance of the glenohumeral joint.⁶⁶,¹⁵⁸ This may result in loss of abduction strength,¹,²⁰,⁶⁶ although this is not necessarily synonymous with limitation of range of motion, as demonstrated in a biomechanical analysis.²⁵ Williams and colleagues¹⁸⁵
conducted the only cadaver study on this subject to determine the
stability afforded by specific structures. They concluded that
ipsilateral fractures of the scapular neck and the shaft of the
clavicle do not produce a floating shoulder without additional
disruption of the coracoacromial and acromioclavicular capsular
ligaments. These findings have not yet been confirmed in clinical
studies.

The rarity of the floating shoulder is also illustrated
by the complete lack of well-performed, prospective studies with
comparison of different treatment options. The literature on this
subject is limited to data provided only by case reports and
retrospective studies of small patient series.

Good clinical results are reported for both conservative and operative treatment (Table 37-2).
Traditionally, floating shoulders were treated nonoperatively. However,
over the last 2 decades, there has been increased interest in open
reduction and internal fixation of these fractures.⁴⁰,⁶⁶,⁶⁹,⁷¹,⁹³,⁹⁹,¹⁴¹ Herscovici⁷¹

reported on nine patients: seven had been treated operatively (with
osteosynthesis only of the clavicle) and the remaining two had been
treated nonoperatively. Their good results led them to recommend open
reduction and internal fixation of the clavicle only, in order to
prevent malunion of the scapular neck. The authors presumed that the
glenoid neck fracture would usually reduce and be stabilized
indirectly. Rikli¹⁴¹
retrospectively analyzed 12 cases, 11 with osteosynthesis of the
clavicle alone, whereas one had both the clavicle and the glenoid neck
fractures fixed. The findings of Leung and Lam⁹⁹
are based on the treatment results in 15 cases in whom simultaneous
fixation of the displaced scapular and clavicle fractures had been
performed. All but one patient had a good, or excellent, functional
result, according to the scoring system of Rowe.¹⁵¹
All fractures healed at an average of 8 weeks postoperatively. Good
results in seven operatively treated patients, by fixation of both the
scapular neck and clavicle fractures, or disrupted acromioclavicular
joint, have also been described in a retrospective study by Egol et al.⁴⁰ Finally, in a study of Labler et al.,⁹³
six patients were treated with internal fixation of only the clavicle
and three with fixation of both clavicle and scapular fractures.

Routine operative treatment of a floating shoulder without regard to displacement has recently been questioned. Edwards³⁹
reported excellent results in 17 and good results in 3 patients in whom
all ipsilateral fractures of the scapula and clavicle had been treated
nonoperatively by a shoulder immobilizer, until the associated injuries
allowed mobilization of the shoulder. They recommend conservative
treatment, especially in patients with less than 5-mm displacement. In
a retrospective study, van Noort et al.¹⁷³
reported fair to good results in 28 patients treated conservatively
(mean constant score: 76), with a well-aligned glenoid. The authors
concluded that these rare shoulder lesions are not unstable by
definition and that conservative treatment leads to a good functional
outcome in the absence of caudal displacement of the glenoid. Caudal
displacement was defined as an inferior angulation of the glenoid of at
least 20 degrees.¹⁷⁴ Ramos et al.¹³⁹
in 1997 reviewed 13 patients with ipsilateral fracture of the clavicle
and scapular neck treated conservatively. The average follow-up was 7.5
years. Using Herscovici’s scoring method,⁷¹ they reported 84.6% excellent, 7.7% good, and 7.7% fair results.

Based on both clinical and biomechanical studies, it
remains unclear under which criteria a floating shoulder should be
treated operatively. Current experience indicates that an undisplaced,
or minimally displaced, ipsilateral clavicle and scapular neck fracture
can be treated conservatively, with a good functional outcome. The
amount of displacement that is acceptable at the fracture sites of the
glenoid neck and clavicle is controversial.

Approximately 50% of scapular fractures involve the scapular body and spine.⁶¹ This fracture type is correlated with the highest incidence of associated injuries.¹⁹,¹⁶⁹ They are generally caused by indirect forces or by direct trauma. Wyrsch and coworkers¹⁹⁰
reported a scapular body fracture in a professional boxer who sustained
the injury during an attempted punch. More rare causes are seizures,
electrical shock treatments,¹¹,⁷⁰,¹¹⁰,¹⁶⁶ or stress fractures.¹³⁶ Scapular body fractures heal readily and do not merit operative intervention,¹¹⁵,¹¹⁶,¹⁸⁴
regardless of the number of fracture fragments. The fact that these
fractures heal well without significant clinical symptoms is probably
directly related to the protection of a thick layer of muscles
surrounding the scapula. Several series of conservatively treated
patients with scapular body fractures have been reported with union of
the fracture and a good functional outcome.³,⁷⁹,¹⁰³,¹¹⁵ Zlowodzki¹⁹⁴
reported in a systematic review of 520 scapular fractures in 22 case
series, that 99% of all scapular body fractures had been treated
nonoperatively. Excellent or good results were achieved with
nonoperative treatment in 88% of the cases.

Nonetheless, painful scapulothoracic crepitus caused by
malunion of the scapular body may have adverse mechanical and
functional effects on shoulder movement. Excision of the bony
prominence in these cases is usually curative.⁴⁴,⁴⁵ Other clinical symptoms are pain, limited range of motion, and winging of the scapula by loss of the serratus anterior muscle.⁶⁴ Nordqvist and Petersson¹²⁷
found poor long-term results in some patients with more than 10 mm of
displacement. Nonunions are extremely rare. Two cases have been
reported which were both treated successfully by open reduction, rigid
internal fixation, and bone grafting.⁴³,⁶⁴

The acromion provides one side of the acromioclavicular
joint and serves as the point of attachment for the deltoid muscle and
a number of ligaments. By forming the roof of the glenohumeral joint,
it lends posterosuperior stability. Approximately 8% to 9% of all
scapular fractures involve the acromion.³,¹¹⁵,¹⁸⁴

There are four causes described for an acromial fracture:

A diversity of associated ipsilateral shoulder lesions
with an acromion fracture is described. The brachial plexus is at risk
particularly with an inferiorly displaced acromion fracture.¹¹⁴,¹²³ Other associated lesions, as reported earlier, are rotator cuff lesions.¹⁰⁴,¹⁴⁵
Finally, ipsilateral acromioclavicular joint lesions, coracoid,
clavicle, glenoid, and proximal humeral fractures and shoulder
dislocations have been reported.⁵⁸,⁹²,⁹⁵,¹⁰²,¹¹⁴,¹²²,¹⁹³

Independent of the mechanism of trauma, when a fracture
does occur, it is usually non- or minimally displaced. Nonoperative
treatment in these cases will lead to union of the fracture with a good
to excellent functional outcome.⁶¹
Most acromion fractures are successfully treated simply by
immobilization with a sling or Velpeau dressing until the pain has
subsided, which is usually within 3 weeks.¹,⁸¹,⁹⁰,⁹²,¹⁰²,¹¹⁴,¹²⁰ Some authors have advocated the use of a spica cast with the shoulder in abduction.¹²²,¹⁸⁴ Omission of a sling or another form of immobilization may cause secondary displacement of the fracture.⁵⁹

According to the classification of Kuhn,⁹⁰
the group of nonor minimally displaced fractures are type I fractures
and caused by indirect force (avulsion fracture-type Ia) or a direct
trauma (type Ib). Nonoperative treatment is also advocated by Kuhn⁹⁰
in dislocated acromial fractures in which the subacromial space is not
compromised (type II fracture). However, a poor clinical outcome or a
symptomatic pseudarthrosis of patients with a type II fracture has been
reported.³⁴,⁹⁰
In type III displaced fractures in which the subacromial space is
diminished by the inferior pull of the deltoid on the acromial
fragment, open reduction with internal fixation is advocated by Kuhn⁹⁰ and Ogawa¹³² to prevent secondary impingement. Most authors recommend open reduction and internal fixation for markedly displaced

acromion fractures to reduce the acromioclavicular joint and prevent nonunion, malunion, and secondary impingement.¹²⁴,¹⁵¹
When surgery is performed, a variety of surgical techniques may be
employed, including the use of tension band wiring, sutures, Kirschner
wires, staples, lag screws, and plates.⁸,³⁰,⁶¹,⁶⁶,⁸¹,¹⁸²
Excision of the acromial fragment has been reported but is generally
not recommended for fragments larger than half an inch because it can
result in substantial weakness of the deltoid muscle.⁹⁰,¹²⁰,¹²³,¹³⁰

The most common mechanisms that have been described as a cause of a coracoid fracture are

Coracoid fractures may be isolated, but in many cases are accompanied by ipsilateral shoulder injuries. Ogawa¹³³
reported acromioclavicular dislocations as the most common associated
lesion, seen in 60 of the 67 described patients. Other common
associated lesions are lacerations or abrasions over the posterolateral
or lateral deltoid muscle, (lateral) clavicle fractures, shoulder
dislocations, and rotator cuff tears.

Fractures in adults are most common at the base of the
coracoid, whether or not with extension in the upper border of the
scapula and/or the glenoid.⁴²,⁸⁰,¹³¹,¹⁸⁸ Other reported sites are the middle portion³³,¹³⁷ and the tip.⁷⁵,¹²¹,¹⁹³

Many methods of treatment of coracoid fractures have
been described. There is, however, no consensus in the literature about
the preferred treatment of coracoid fractures. Many authors suggest
that non- or minimally displaced fractures can be successfully treated
by conservative treatment.⁴²,⁵²,¹⁰⁹,¹⁹³
On occasion, however, these injuries may be significantly displaced and
of functional importance, thus making surgical management a
consideration. Fractures of the coracoid tip are avulsion injuries
(Ogawa type 2) that may displace considerably. Despite the chance of
nonunion,¹¹⁷ this type of fracture can be treated conservatively with good functional outcome.²³,⁴²,⁵²,¹⁰⁹,¹³²
On occasion, operative treatment is indicated when the fractured
coracoid tip impedes the reduction of an anterior dislocated humeral
head.⁴²,¹⁸⁹ Other indications for surgery include a painful nonunion after anterior shoulder dislocation.⁴⁷,⁸⁵

Treatment of fractures of the coracoid base (type 1)
follow the same reasoning described for fractures of the coracoid tip.
However, displacement of the fracture is more common which may be due
to accompanying ipsilateral shoulder injuries (double disruptions of
the SSSC). In these circumstances, or in cases with extension of the
fracture into the glenoid fossa (with displacement), open reduction and
internal fixation with screw fixation of the coracoid fracture is
advocated.⁴²,⁶¹,¹³³ Martin-Herrero,¹⁰⁹
however, described satisfactory outcome in conservative treatment in
seven patients despite displacement of the fracture and associated
ipsilateral shoulder injuries in six.

Scapulothoracic dissociation is characterized by a
complete loss of scapulothoracic articulation and lateral displacement
of the scapula, while the skin is usually intact. It is classically
caused by a violent lateral distraction or rotational displacement of
the shoulder girdle when the upper extremity is caught on a fixed
object while the body is moving at high speed.² It is a rare, severe injury of the shoulder girdle with a high mortality rate (10%).²⁹
Some authors describe this injury, which is almost always associated
with severe vascular injuries (prevalence 88% to 100%), as an internal
forequarter amputation.⁹⁶,¹⁵⁴,¹⁸⁷,¹⁹²
As well as lesions of the subclavian and axillary artery, associated
complete or partial disruptions of the brachial plexus (prevalence up
to 94%)²⁹ are frequent and well
described in the literature. Other described associated lesions are
osseous injuries to the shoulder girdle (particularly clavicle
fractures, but also acromioclavicular or sternoclavicular dislocation),
injury to muscles (deltoid, pectoralis minor, rhomboids, levator
scapulae, trapezius, and latissimus dorsi), and massive soft tissue
swelling in the shoulder region. Approximately 50% of the reported
cases are the result of a motorcycle accident.¹⁸

The management of patients with scapulothoracic
dissociation should follow the ATLS principles with cardiopulmonary
stabilization and resuscitation being of paramount importance.
Treatment recommendations have focused on the care of the accompanying
neurovascular injury. In a hemodynamically stable patient,
arteriography is used to determine the vascular integrity, followed by
surgical repair if necessary. However, it should be appreciated that an
extensive collateral network around the shoulder can protect against
limb-threatening ischemia.⁵⁴,¹⁰⁰,¹⁷¹ Sampson et al.¹⁵⁴
presented a series of 11 cases). They questioned the need for vascular
repair in these patients, all of whom had a complete brachial plexus
palsy, no radial pulse, and subclavian or axillary artery occlusion on
arteriography. Of these 11 cases, 6 were revascularized and 5 were not.
All 11 limbs remained viable, although none of the 11 patients regained
any function. Zelle et al.¹⁹²
demonstrated that the extent of the neurologic injury is of paramount
importance in predicting the functional outcome. All of their patients
with a complete brachial plexus avulsion either had an amputation or
had poor shoulder function at the time of follow-up. Partial plexus
injuries, however, have a good prognosis, and most patients achieve
complete recovery or regain functional use of the extremity.⁶⁰
If upper extremity function is not restorable, an immediate above-elbow
amputation seems to result in better functional outcomes, lower
complication rates, better relief of causalgia, and more successful
return to work than a late amputation.¹³,¹⁸,¹⁹² Many patients refuse a secondary amputation despite a flail, anesthetic upper extremity.²⁷,³⁵,⁵⁴,¹⁷¹

The recommended treatment of associated osseous lesions
in patients with scapulothoracic dissociation is unclear and should
therefore be individualized. Nevertheless, Goss⁶¹
advised open reduction and internal fixation of clavicle fractures and
stabilisation of disrupted acromioclavicular or sternoclavicular joints
for three reasons: to avoid delayed or nonunion, to restore as much
stability as possible to the shoulder complex thus reducing long-term
functional problems, and to protect the brachial

plexus, subclavian, and axillary vessels from further injury caused by tensile forces.