Clinical presentation and examination
In injuries to the shoulder girdle structures (particularly in clavicular fractures), a characteristic change in the position of the entire upper limb is observed. The arm, along with the shoulder joint, drops downward, shifts anteriorly, and is in a state of internal rotation.
Examination of the patient from the back is of particular diagnostic significance. The physician assesses the symmetry of the scapular positioning. On the injured side, the distance from the medial border of the scapula (margo medialis scapulae) to the line of the spinous processes of the vertebrae (processus spinosus) is visually and palpatorily greater than on the healthy side.
Mandatory stage of examination: Any examination for suspected injuries of this type must strictly and obligatorily conclude with checking two parameters:
- State of peripheral blood circulation (to rule out injury to the subclavian vessels — a. et v. subclavia).
- State of peripheral innervation (to rule out compression or rupture of the trunks of the brachial plexus — plexus brachialis).
Radiological diagnostics
The primary and most frequently sufficient method to confirm the diagnosis is radiography in the anteroposterior (straight) projection.
In complex or doubtful cases, an additional radiograph with a special X-ray beam direction is ordered. In this case, the imaging is performed from bottom to top at an angle of 45 degrees, which allows obtaining a clearer picture of fragment alignment without projection overlapping of other bone structures.
Biomechanics of typical fragment displacement
The nature of bone fragment displacement directly depends on the location of the fracture line and the pull of attached muscles.
- Middle third (diaphyseal) fracture:
- Central (medial) fragment: displaced upward and posteriorly. This occurs due to the constant pull of the powerful sternocleidomastoid muscle (m. sternocleidomastoideus).
- Peripheral (lateral) fragment: displaced downward, forward, and medially. This position is caused by the force of gravity of the arm itself, as well as the contraction of the pectoral muscles, which pull the shoulder joint inward.
- Fracture of the acromial end:
- In the distal section, the degree and vector of displacement critically depend on whether the integrity of the coracoclavicular ligament (lig. coracoclaviculare) is preserved. If the ligamentous apparatus is intact, pronounced separation of fragments may not be observed.
Conservative treatment without displacement
General tactics and the choice of a specific treatment method depend on the type of fracture, the nature of displacement, and the patient's age. If there is no displacement (or after successful closed manual reduction), immobilization methods are used aimed at ensuring recline (retraction) of the shoulder girdles.
Before applying fixing bandages, local anesthesia is mandatory: 10–15 ml of a 1–2% novocaine solution is injected into the fracture hematoma. The duration of subsequent fixation is 4 weeks.
Types of bandages:
- Delbe rings: placed on both shoulder girdles of the patient and tightly pulled on the back. This ensures reliable abduction of the shoulder joints to the sides and tension of the clavicle.
- Figure-8 (cruciate) bandage: when applying it, the physician rests their knee in the interscapular region of the patient to achieve maximum abduction of the shoulder girdles. Then the bandage is applied in figure-eight turns, passing through the armpits and shoulder girdles, crossing at the back.
Reduction and fixation in displaced fractures
Displaced fractures require mandatory reduction. The main orthopedic problem here is that it is technically easy to juxtapose fragments, but extremely difficult to keep them in the correct position until fusion.
Reduction technique: The patient sits on a stool, with their head tilted toward the injury (to relax the neck muscles). An assistant places a knee into the interscapular space (or the angle of the scapula), puts their hands on the shoulder girdles, and forcibly pulls the shoulder joint posteriorly, laterally, and slightly upward. At this moment, the surgeon manually aligns the bone fragments.
Retention using the Chizh frame: For reliable fixation of the peripheral fragment in an elevated and rotated position, the Chizh frame is often used.
- Design: Made individually from wooden slats fastened with a plaster bandage.
- Parameters: The length of the rear bar is measured from the iliac crest to the axillary fossa (with the shoulder girdle maximally elevated). At the same time, the rear bar is made 7–10 cm shorter than the front one.
- Application rules: The lower crossbar rests against the iliac crest, the upper one against the axillary fossa, elevating the joint. The upper end of the front bar presses against the joint from the front, retracting it posteriorly and eliminating displacement along the length.
- Duration: Immobilization in the frame lasts for 4–5 weeks.
Note: Using a bulky frame in elderly patients often causes difficulties and can lead to complications.
Briefly: answers to topical questions
What anatomical structures are distinguished in the classification of scapular fractures?
In the classification of scapular fractures by anatomical localization, the following are distinguished:
- body of the scapula, including longitudinal fractures;
- angles of the scapula — superior and inferior;
- processes — acromial and coracoid;
- spine of the scapula;
- neck of the scapula;
- glenoid cavity.
Which nerve is at high risk of injury in a fracture of the neck of the scapula?
The provided sources do not explicitly state which nerve is at high risk of injury specifically in a fracture of the neck of the scapula. The target nerves indicated for ultrasound examination of peripheral nerves are:
- long thoracic nerve;
- dorsal scapular nerve;
- suprascapular nerve.
Which muscles cause fragment displacement in a fracture of the neck of the scapula?
The sources do not explicitly name the specific muscles causing fragment displacement in a fracture of the neck of the scapula; only the characteristic direction of articular surface displacement is indicated.
- In a fracture of the neck of the scapula, displacement of the articular surface occurs downward and anteriorly, the acromion protrudes, and the coracoid process appears sunken.
Which radiographic projections are used for accurate diagnosis of scapular fractures?
For accurate diagnosis of scapular fractures, radiography in two projections is used, and in suspected scapular fractures in adults, an expanded set of views is used.
- Straight projection — standard anteroposterior radiograph
- Lateral projection — radiograph of the scapula in a strictly lateral projection
- Axial projection
- Transcapsular Y-projection (Y lateral view) — the most informative view when CT cannot be performed
If it is necessary to clarify the nature of the injuries, computed tomography (CT) is prescribed.
What surgical treatment methods are used for intra-articular fractures of the scapula?
For intra-articular fractures of the glenoid cavity of the scapula, plate osteosynthesis with open reduction of displaced fragments is indicated.
- Plate osteosynthesis — fixation with a bone plate and orthopedic bone screws under conditions of absolute stability
- Deltopectoral approach — for fractures of the anterior or inferior margin of the glenoid fossa
- Posterior approach — for visualization of the posterior margin of the glenoid fossa, as well as for fractures of the body and neck of the scapula
- Judet approach — extended approach from the acromion along the scapular spine with detachment of m. infraspinatus and m. teres minor
Achieving anatomic reduction and interfragmentary compression is mandatory.
Class and exam questions
What causes the upward displacement of the central fragment?
The central fragment is pulled upward and posteriorly due to contraction of the sternocleidomastoid muscle (m. sternocleidomastoideus).
How long does an immobilizing bandage need to be worn?
For non-displaced fractures, the duration of fixation with Dielby rings or a figure-of-eight bandage is 4 weeks. When using the Chizhyn frame, it is 4 to 5 weeks.
What must be checked before treating a fracture?
It is strictly mandatory to assess the state of peripheral blood supply and innervation to rule out injury to the neurovascular bundle (brachial plexus and subclavian vessels).
What else to study on this topic
- Complications when using the Chizhyn frame in elderly patients
- Surgical treatment (osteosynthesis) when fragments cannot be held
- Anatomy and role of the coracoclavicular ligament in fractures of the acromial end
- Technique of local anesthesia in the fracture area
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