Case Series Evaluating the Operative and Nonoperative Treatment of Scapular Fractures
TAKE-HOME POINTS
- The majority of patients with scapula fractures are multiply-injured.
- Despite being multiply-injured, most heal with minimal functional shoulder impairment.
- While concomitant injuries do not appear to affect shoulder function scores, tobacco use and alcohol abuse are associated with worse outcomes after scapula fractures.
- Most scapula fractures can be treated successfully without surgery.
- Although patients had higher average function scores after open reduction and internal fixation, further research should be done to define indications for fixation.
DISCUSSION
Patients with scapular fractures often require a complex set of treatment decisions due to high rates of concomitant injuries.2,20-22 A lack of large studies on long-term scapular function, as well as evidence that some patients treated conservatively for scapular fractures experience functional deficit and pain, inspired us to investigate the recovery process after scapular fractures through radiographs and the ASES survey.7 Further, we attempted to identify any factors that may be associated with poor functional results. Our review of long-term outcomes after scapular fractures demonstrates that they not only heal well but also have a good functional outcome in most cases. Over 95% had acceptable ASES scores, with both 14A and 14B/C having similar return of function. While both operatively and nonoperatively treated patients had scores indicating minimal functional impairment, those treated surgically had better scores overall. Surprisingly, concomitant injuries, including chest wall injuries, did not portend a worse shoulder outcome in our patients. The factors that were associated with worse outcome were tobacco use and alcohol abuse.
Beyond these findings, we attempted to comment on surgical indications, which have been highly debated.2,3 For example, the medial displacement at which studies suggest extra-articular fractures merit surgery ranges from >10 mm to >20 mm;8-11 similarly, the indication for surgery based on displacement of intra-articular fractures ranges from >2 mm to >5 mm, depending on the author.12-16 Glenoid articular fractures or neck fractures are other potential indications for operative treatment. In fact, a review of 520 scapular fractures from multiple studies found that 80% of those with glenoid involvement were treated operatively, while only 52% of those with exclusive acromion and/or coracoid involvement, and 1% of those with exclusive scapular body involvement were treated operatively.5 Some reports indicate that 14B/C fractures, especially those that are displaced or complex, show good functional outcomes and low complication rates after fixation.5,23 In this study, articular fractures of the glenoid were treated operatively more often than extra-articular fractures. We attempted to determine the impact of surgical care on functional outcomes according to fracture type, but we were limited by the small number of surgical patients when reviewing the 14A and 14B/C groups. As a whole, surgical patients had better outcomes than non-surgical patients. We believe this difference is clinically relevant and suggests a potential group of patients who may benefit from fixation. Further investigation is needed to better characterize these injuries and to develop specific recommendations.
This study yielded interesting results related to substance abuse. It has previously been shown that tobacco smoking and alcohol abuse have both been associated with poor bone health.24 Studies have suggested that exposure to nicotine and other chemical components in cigarettes can lead to delayed healing, higher rates of nonunion, and decreased mechanical strength of bone.25-29 Additionally, alcohol abuse has been associated with decreased bone mass and poor bone formation.24,30,31 Although we did not measure bone density or quantitate time of healing, this study provides added insight in that the healed fractures of smokers and patients with a history of alcohol abuse showed lower levels of shoulder function, as measured by ASES scores after similar initial injuries and similar follow-up periods. These results suggest that chemical, social, or a combination of these factors affect muscular recovery, other aspects of post-fracture recovery, and/or levels of baseline physical or mental impairment beyond those detailed in previous studies of bone health and substance abuse. For example, return to work was a scored category in the ASES survey that we used to asses the return of shoulder function, and several studies have shown that factors such as education level, coping abilities, and baseline functioning (cognitive, social, and physical) all have a significant impact on rates of return to work, independently of injury type.6,32-35 It is possible, then, that other aspects of the ASES survey are affected by factors that may be more prevalent in populations engaging in substance abuse. From both perspectives, these data highlight the importance of addressing tobacco use and alcohol abuse as a part of caring for all trauma patients, including those with scapular fractures, regardless of their high rates of radiographic healing. They also provide insight for prognosticating and setting patient expectations after scapular fractures.
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