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© 1998 The Journal of Bone and Joint Surgery, Inc.
Non-Union of the Scapular Body. A Case Report* , PHILADELPHIA, PENNSYLVANIAInvestigation performed at the Shoulder and Elbow Service, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia
Numerous authors have reported on the relative rarity of scapular fractures, the high association between such fractures and other injuries, and the infrequent necessity of operative treatment1,6-8,10,13,14. Non-operative treatment is routinely recommended for most, if not all, fractures of the scapular body10,11,15. Non-union of such a fracture is a relatively rare complication. Although there have been reports of non-unions involving the base of the coracoid process, the scapular spine, and the acromion1,11,12,15, we were unable to find a reported case of symptomatic non-union of the scapular body. We report the case of a patient who had pain and scapular dysfunction due to a non-union of the body of the scapula, which was successfully treated with open reduction and internal fixation with local bone-grafting.
A forty-five-year-old right-hand-dominant man who worked as a cement mason sustained a burst fracture of the second lumbar vertebra when a pallet of bricks fell on him on December 12, 1993 (Fig. 1). The fracture was treated with posterior instrumentation from the twelfth thoracic to the third lumbar vertebra; however, because the fracture was treated at another institution, no information was available regarding whether or not a spinal arthrodesis was performed at any level. Postoperatively, the patient was immobilized in a body cast for three months. It was not noted how much of the scapula and thorax was covered by the cast. After removal of the body cast, the patient noticed prominence of the left scapula, pain in the scapular region, and restricted motion of the left shoulder. The patient was then referred to our Shoulder and Elbow Service.
Physical examination in July 1994 revealed a healed laceration over the inferior aspect of the left scapula. There was a visible and palpable defect involving the inferior third of the body of the scapula. Active glenohumeral motion was limited to 110 degrees of elevation in the plane of the scapula, 20 degrees of external rotation with the arm at the side, and internal rotation to the posterior superior iliac spine. Passive motion was restricted to the same degree. Attempted active flexion was accompanied by marked medial winging of the scapula, with associated scapulothoracic crepitus and pain. There was no visible scapulothoracic rotation. Radiographs revealed a comminuted transverse fracture of the scapular body. The inferior fragment appeared to be trapped between the superior fragment and the ribs. Computerized tomography revealed a non-united comminuted fracture of the inferior third of the scapula with displacement of the inferior fragment between the superior fragment and the ribs (Fig. 2). Electromyography revealed a moderate suprascapular neuropathy and the absence of insertional or spontaneous activity of the serratus anterior, which was thought to indicate that the electromyographic needle had missed the muscle or that the muscle was non-functional because of its attachment to the inferior, non-united fragment. The initial diagnoses included adhesive capsulitis, non-union of the scapular body, and suprascapular neuropathy.
After a trial of non-operative treatment, the patient had an arthroscopic capsular release and closed manipulation on September 26, 1994. After ten weeks of physical therapy, the passive range of motion had improved to 150 degrees of flexion, 45 degrees of external rotation, and internal rotation to the twelfth thoracic vertebra. Active elevation in the plane of the scapula, however, continued to be limited to 110 degrees and was still associated with painful scapular winging and scapulothoracic crepitus. On December 12, 1994, the patient had open reduction and internal fixation of the scapular non-union. With the patient in the left lateral decubitus position, the scapula was approached through a curvilinear incision, which started at the posterior corner of the acromion and extended to the inferior angle of the scapula. The superior border of the latissimus dorsi was reflected anteroinferiorly to expose the underlying scapula. The inferior margin of the superior fragment was easily palpable at this time. The inferior fragment was not united with the superior part of the scapula and was interposed between the ribs and the inferior aspect of the superior fragment. Next, the inferior border of the origin of the teres minor was reflected from the lateral border of the superior fragment. The origin of the teres major was trapped between the superior and inferior fragments at the site of the non-union. Dense fibrous tissue and small comminuted fragments of the scapula that had not united to either major fragment were excised from between the two major fragments. The origin of the teres major was then reflected off the inferior fragment, which was mobilized from under the superior fragment. After excision of the small comminuted fragments, the two major fragments remained. A small osteotome and a rongeur were used to remove a small rectangular piece of bone from the central portion of the medial and lateral borders of the superior fragment to create two slots. A burr was used to fashion the medial and lateral borders of the inferior fragment into projections that would fit into the two slots in the superior fragment. This type of tongue-and-groove configuration provided an element of stability to the fragments (Fig. 3). Small pelvic reconstruction plates were then placed along the lateral and medial borders of the scapula, overlying and reinforcing the two tongue-and-groove junctions (Fig. 4). Local bone from the small excised fragments was placed as a graft in areas of osseous deficiency.
Postoperatively, the upper extremity was placed in a sling. Active elevation was forbidden for six weeks; however, pendulum exercises were begun within the first postoperative week. Passive flexion to 90 degrees and passive external rotation with the arm at the side were performed with the patient supine beginning three weeks postoperatively. The patient was seen approximately four weeks postoperatively because of increasing pain and swelling over the scapula. Computerized tomography revealed no change in the alignment of the fracture. Exercises with an overhead pulley and active elevation were initiated six weeks postoperatively. Strengthening exercises for the rotator cuff, the deltoid, and the scapular rotators were added eight weeks postoperatively. The symptoms gradually resolved. However, with increasing activity, the patient began to have pain over the lateral border of the scapula as well as tenderness over the lateral plate. Another computerized tomography scan was made in June 1995 (six months postoperatively) in an attempt to verify union of the fracture. There was no sign of loosening of the hardware or displacement of the fracture (Fig. 5). The hardware was removed on September 21, 1995. The scapula was well healed at the time of the operation, and the postoperative course was uneventful. At the two-year follow-up examination, in December 1996, the patient was pain-free and the active range of motion had improved to 170 degrees of elevation in the plane of the scapula, 65 degrees of external rotation, and internal rotation to the tenth thoracic vertebra. Scapulothoracic rotation was symmetrical.
Non-operative treatment of scapular fractures is usually successful. McGahan et al. reported satisfactory results after the non-operative treatment of 137 fractures. McGinnis and Denton also advocated non-operative treatment and reported a good or excellent result for nineteen (73 per cent) of twenty-six patients. Non-union of the scapula is uncommon. Imatani, Hardegger et al., and Thompson et al. did not report any instances of non-union in their series. Ada and Miller reported one instance of a painful non-union of the scapular spine in a series of 113 patients. We were unable to find any instances of symptomatic non-union of the scapular body in our review of more than 600 scapular fractures that were reported in the literature1-5,8-12,14,15. The symptomatic non-union of the scapular body in our patient was due to several factors. The inferior fracture fragment was interposed between the ribs and the superior fracture fragment, and the teres major was interposed between the two fragments. Furthermore, the serratus anterior, one of the major scapular rotators, could not function normally because of its insertion on the inferior, unattached fracture fragment. Loss of function of the serratus anterior resulted in medial winging of the superior fragment and poor scapular rotation. Our patient was diagnosed with adhesive capsulitis as well as non-union of the scapular body. Arthroscopic capsular release, closed manipulation, and physical therapy led to the successful restoration of a passive range of motion. However, active elevation did not return after capsular release alone, presumably because of the loss of function of the serratus anterior as well as the interposition of the inferior fragment between the ribs and the superior fragment. We hypothesized that osteosynthesis at the site of the non-union of the scapular body would restore function of the serratus anterior, reduce or eliminate winging of the superior fragment, improve elevation and scapular rotation, and eliminate the crepitus associated with interposition of the inferior fragment between the ribs and the superior fragment. Successful union of the fracture resulted in a dramatic improvement in function and relief of pain. Most fractures of the scapular body are amenable to non-operative treatment. However, unusual fracture patterns, such as the one in our patient, are likely to have a poor outcome without reduction and stabilization. On the basis of our experience with this patient, we now routinely consider the diagnosis of non-union when a patient has persistent pain following a displaced fracture of the scapular body. In addition, if the findings on plain radiographs are inconclusive, computerized tomography scans may help to establish the diagnosis.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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