up in Cipto Mangunkusumo Hospital - iKnow

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Case Series

Functional outcome in scapular fracture treatment evaluation with 2-year follow- up in Cipto Mangunkusumo Hospital

Windi Martika

^a^,^*

, Ismail Hadisoebroto Dilogo

^b

, Riky Setyawan

^a

aDepartment of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

bAdult Reconstruction, Hip, and Knee Division, Department of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

a r t i c l e i n f o

Article history:

Received 24 June 2021 Received in revised form 8 October 2021 Accepted 13 October 2021 Available online 27 October 2021

Keywords:

Scapular fracture

Zdravkovic and damholt classiﬁcation Glenopolar angle

DASH score Surgical treatment Conservative treatment

a b s t r a c t

Background:Standard treatment of scapular fractures is still controversial. There was no consensus for the best indication in surgical management and therapeutic choice of the scapular fracture. This study aim is to evaluate both radiological characteristics and functional outcomes between patients with scapular fracture treated with conservative and operative management.

Methods:We did a case series study of 19 patients with scapular fractures between 2012 and 2017. Nine patients were treated with open reduction internalﬁxation and 10 patients were treated conservatively.

We evaluated radiological outcome using degree of Glenopolar Angle (GPA), angulation, and medialization through anteroposterior, lateral, and scapular Y projection, functional outcome using DASH scores, and complications in 2-year follow-up.

Result: The mean patient age was 46.3±18.4 years in the conservative group and 42.7±11.5 years in the operative group. Fracture pattern was classified using Zdravkovic and Damholt (ZD) classification. DASH Score was excellent with 9.5±2.1 points in conservative group and 6.0±2.5 points in operative group with insignificant difference. There was significant difference in GPA and medialization. This is supported by functional outcome of operative group which is higher compared to conservative treatment insignificantly.

Conclusion: Operative treatment resulted high functional outcome and minimal complications compared to the conservative group. Operative treatment was recommended for scapular fractures that are displaced more than 9 mm and/or angulated more than 40.

Level of evidence: II, therapeutic study.

1. Introduction

Scapular fracture occurs due to direct trauma to the upper back area [1]. The incidence of scapular fractures is rare with 1% of all fractures and 3e5% of upper limb fractures [2]. Up to 88% of these fractures occur because of high-energy mechanism, mostly coin- cidentally with rib fracture due to motor vehicle crash [2e4].

Fractures of the scapula can occur in the body, neck, acromion process and coracoid process. Frequently, patient with moderate scapular fracture had other severe injuries. McGahan et al. [5] has reported that scapular fracture occurred at the same time with

other injuries had a thoracic injury in 50% of cases, had rib fractures in 44%e53.6% cases, had clavicle fractures in 26% cases [3,4,6,7].

Fractures of the scapula usually have no displaced fracture fragment. This condition made conservative treatment gave a good result. Generally, early conservative treatment and immobilization can produce predictable healing, return to active daily living, and reduce pain. Treatment with operative treatment is controversial.

Muscular forces and the effect of gravity on the upper limb will result in malalignment of the glenohumeral joint in relation to the body of the scapula. It can lead to pain, weakness and glenohumeral imbalance. Fractures involving intra-articular glenoid fragment will

*Corresponding author. Department of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jalan Diponegoro No.

71, Jakarta Pusat, Jakarta, 10430, Indonesia.

E-mail address:windi.martika@gmail.com(W. Martika).

Contents lists available atScienceDirect

International Journal of Surgery Open

j o u rn a l h o m e p a g e :w w w . e ls e v i e r . c o m / l o c a t e / i j s o

https://doi.org/10.1016/j.ijso.2021.100425

creativecommons.org/licenses/by-nc-nd/4.0/).

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resolve with a joint mismatch, that may cause of glenohumeral arthrosis.

The operative treatment criteria for scapular fracture remains controversial. There are no universal parameters that can be found in the existing literature [8e10]. Cole et al. reported that operative treatment indications include intraarticular gap or step-off equal or more than 4 mm, medialization greater than 20 mm observed in anteroposterior view, angular deformity for equal to or more than 45on scapular Y view, lateral border offset for more than 15 mm with angular deformity more than 30, GPA equal to or less than 22, and displaced double lesions in superior shoulder suspensory complex [9,11e13].

It is important to evaluate the functional outcomes arising from the healing process of fractures. This study was evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) Score between operative and conservative group in scapular fractures. Therefore, this study aims to evaluate the outcome between operative and conservative treatment in scapular fractures using Cole Peter surgery indication.

2. Method

A case series study was conducted in the Trauma Division of Cipto Mangunkusumo Hospital. Patients were collected sequen- tially from all patients with scapular fracture who came to Cipto Mangunkusumo hospital from January 2012 to July 2017 with conservative and operative treatment. The patients were followed up until complete radiographic healing or return to baseline level of functioning (pain-free, normal activities, radiographic fracture consolidation withoutﬁxation failure) for an average of with 2-year follow-up.

Inclusion criteria in this study were patients with scapular fracture treated in Cipto Mangunkusumo Hospital who came to the emergency room or outpatient clinic, and scapular fracture diagnosed by plain radiograph with anteroposterior view, lateral view, and scapular Y view. Some patients were performed Computed Tomography (CT) Scan evaluation. Exclusion criteria were patients that have ipsilateral upper limb fracture. According to ZD scapular fracture classiﬁcation [14], there was 3 fracture classiﬁcation: 1.

Scapular fracture including scapular body, 2. Apophyseal scapular fracture including either coracoid process or acromion, 3. Scapular fracture involved scapular neck or glenoid cavity.

Patients with scapular fracture performed with conservative treatment will be compared with those who underwent operative treatment. Indication for operation in scapular fracture is at least one of these following criteria: (1) medialization of the glenohumeral joint measures more than 20 mm, (2) angular deformity in scapular Y-view X-ray more than 45, (3) 25% glenoid involvement

or intraarticular step-off4 mm, (4) GPA22(Fig. 1). Two or more criteria will make an unstable pattern for injured shoulder. Func- tional outcome were evaluated using DASH score with a minimum 2 years follow-up from ﬁrst diagnosed. Data distribution were tested using Saphiro-Wilk test and analyzed using Mann-Whitney test with signiﬁcance value of p<0.05 using SPSS version 25.0.

This study was carried out in compliance with the PROCESS guidelines [15].

3. Result

We found that 19 patients were eligible for evaluation. Nine patients with 5 males and 4 females were underwent conservative treatment and 10 patients with 7 males and 3 females were underwent open reduction and internalfixation (ORIF) procedure. For all patients, the mean of age was 46.3±18.4 years in conservative group and 42.7±11.5 years in operative group (Table 1). According to ZD classification, non-operative treatment had 6 ZD1, 1 ZD2, and 2 ZD3, and surgical treatment had 3 ZD1, and 7 ZD3 (Table 2). GPA of the conservative treatment was higher significantly compared to operative treatment with 42.3±15.4and 17.5±6.0, respectively (p<0.05). Medialization of the conservative treatment was closer than the operative treatment with 2.3±3.5 and 8.6±9.0, respectively (p<0.05). Angulation of the scapular body was no significant difference between conservative treatment and operative treatment with 19.0±14.2 mm and 23.1±17 mm, respectively (p>0.05).

Medialization was signiﬁcant difference between conservative treatment and operative treatment with 19.0 ± 14.2 and 23.1 ±17.1, respectively (p<0.05) (Table 3) (Fig. 2). We did not evaluate intraarticular gap/step-off because most of patients were not performed CT Scan evaluation.

In this study, we found that functional outcomes from subjects underwent surgical procedure had significant difference compared to conservative treatment supported by fixation technique and faster bony union. From 2-year post-operative follow up, overall patients did not complain any pain or Range of motion (ROM) limitation. DASH score showed significantly better functional score

Fig. 1.Cole Peter indication for operation (a)Medialization of the glenohumeral joint (b) Angular deformity, (c) Fracture translation, (d) Glenopolar angle.

Table 1

Patient demographics in patient with scapular fracture.

Non-operative Operative Signiﬁcancy

N¼9 N¼10

Age (years) 46.3±18.4 42.7±11.5 years 0.49 Gender

Male (%) 5 (55.5) 7 (70.0) e

Female (%) 4 (44.5) 3 (30.0)

*p<0.05 Mann Whitney test.

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in the operative treatment group compared to conservative treatment (p<0.05) (Fig. 3,Fig. 4).

4. Discussion

Scapular fracture is highly related to high energy trauma and most of it accompanied by injury or fracture in other places of the body, including non-skeletal injuries. management of scapular fracture is often being supervised neglect or treated as non-priority injury compared to other life-threatening causes. In some cases, patient needed to be referred and underwent complex surgical treatment [10].

Table 2

Scapular fracture classiﬁcation based on Zdravkovic and Damholt classiﬁcation.

Zdravkovic and Damholt classiﬁcation Non-Operative Operative

ZD Type I (%) 6 (66.7) 3 (30.0)

ZD Type II (%) 1 (11.1) 0 (0)

ZD Type III (%) 2 (22.2) 7 (70.0)

Table 3

Preoperative radiological evaluation and DASH score functional outcome.

Non-Operative Operative Signiﬁcancy

Glenopolar Angle/GPA (degree) 42.3±15.4 17.5±6.0 0.00*

Angulation (degree) 19.0±14.2 23.1±17.1 0.60

Medialization (mm) 2.3±3.5 8.6±9.0 0.04*

Intraarticular gap/Step-off (mm) e e e

post-operative DASH Score (point) 9.5±2.1 6.0±2.5 0.01*

*p<0.05 Mann Whitney test.

Fig. 2.CT-scan shows fracture of the scapula.

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Scapular fractures are classified based on Zdravkovic and Damholt anatomical classification. Type 1 are fractures involving the scapular body. Type 2 are fractures involving coracoid and acromion (apophyseal fractures). Type 3 are fractures involving superior lateral edge of scapula, including glenoid bone and scapular neck. Dienstknetch et al. reported that anatomical location of fractures did not significantly influence surgery outcomes [16].

However, study by Zahid et al. concluded that ORIF procedure in scapular fracture revealed excellent DASH score, pain-free move- ment, and successful clinical and radiological healing in 14 months follow-up [17]. This study has different outcome with the signiﬁ- cant different in DASH Score evaluation at 2-year follow-up between conservative and surgical treatment.

Complications of scapular fracture were related to its fracture fixation and hardware, not only to the injury itself. Despite not having any validation in surgical indication for scapular fixation, surgeon decision and adequate identification of fracture type and classification can help to reduce the fracture without morbidity and return to the normal of upper limb function. Operative fixation

realigned and stabilized the markedly displaced scapular body and neck fractures. Both operative and conservative scapular fracture treatment resulted in high union rates, high return to work rates, and minimal complications [18].

There were controversies regarding indication criteria for operative treatment in scapular fractures. In our study, we use Cole Peter criteria that involves GPA, medialization, angulation, and translation of the fractures. GPA is a measure in rotational malalignment of glenoid from anteroposterior axis. A threshold of GPA 22is indicative for surgery to avoid long-term weakness, pain, and reduced capacity in daily living. A correlation has been found that GPA<20was associated with less favorable long-term outcome.

Nordqvist and Petersson, in their study, recommended early operative treatment in such condition [16]. [[,19].

In intraarticular glenoid fracture, the cutoff gap or step-off is 4 mm. Edward et al. in their study showed that in 21 patients underwent operative procedure, 91% showed anatomic restoration with no loss of reduction or failedﬁxation. In follow-up, 87% were pain-free and 90% may return to preinjury level of activity and/or work [20]. Angular deformity equal to or greater than 45 also showed lower rate of complications and resulted in satisfaction and good functional outcome in patients underwent operative treatment. Similar patterns also found in other Cole criteria including medialization and translation [13].

According to Edwards et al. [21], approximately 25% of the fractures were displaced greater than 5 mm. Also, nonoperative treatment consistently produced some component of weakness, shoulder depression, lateral bump, and crepitation. Therefore, when assessing certain outcome measurements, conservative management of displaced scapular neck and body fractures does not consistently produce early, pain-free, return to preinjury function. In contrast, patients consistently regain preinjury strength, ROM, and function with operative treatment of displaced fractures.

Ada and Miller et al. recorded painless glenohumeral abduction, normal scapulothoracic motion, no resting pain and no night pain Fig. 3.Intra-operative treatment (a) design incision, (b) and (c) expose fracture site.

Fig. 4.Rontgen post-operative (a) scapular Y-view (b) scapular axial view.

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in minimal 15 months follow-up [22]. They recommended operative treatment for scapular fractures displaced more than 9 mm and/or angulated more than 40. Its excellent results showed no complications in patients with operative treatment. Increment of GPA post-operatively was signiﬁcantly revealed better result in DASH score evaluation [23]. Despite operativeﬁxation resulting in no complications and restoration of anatomical function, the study did not recommend surgery for scapula fractures with less than 20 mm displacement. Cooperation and communication are needed.

Further randomized prospective control studies with functional outcome data are required to deﬁne indications for operative ﬁxation.

Several studies also discussed functional outcomes in operative and nonoperative treatment. Gosens et al. in their study included patients that were treated non-operatively. This study used DASH score, SST score, and ROM. They found signiﬁcant difference in DASH score between isolated scapular body fracture and patients with more severe scapular fractures and patients with multiple trauma [24]. In contrast, Jones et al. reported similar ﬁnal ROM evaluation between non-operative and operative procedure.

Although, operative procedure required more physical therapy visits for recovery [8].

This study has adequate number of radiographic images to determine each of fracture pattern found in all subjects. Data evaluation results were known to be statistically signiﬁcant, in having enough time to follow up, evaluating of healing fracture process, and returning the subjects into normal function. The strength of this study was related to study data from advanced trauma center. Patients were treated with similar indication criteria and protocol for operative and non-operative treatment. Soft tissue around fracture site can disturb healing process of the fracture.

In our study, DASH score was not signiﬁcantly different between patients treated operatively and non-operatively. Surgical procedure was performed only in patients that fulﬁlled Cole criteria.

Existing evidence also supported that both operative and conservative procedure did not signiﬁcantly differ in functional outcomes such as DASH score or ROM. In patients with Cole criteria, conservative treatment is associated with higher pain and worse long- term outcome. Scapular healing would not be optimal and subse- quently reduce capability in daily living activities. Conversely, surgical approach in fractures such as isolated scapular body fractures are not necessary and associated with longer recovery time.

Therefore, we recommend using operative procedure only in scapular fractures with included the Cole criteria [14].

5. Conclusion

Operativefixation was realigned and stabilized markedly displaced scapular body and neck fractures. The functional outcomes of operativefixation of scapular fractures following operativefixation resulted in no complications and anatomical function restoration. Both operative and conservative scapular fracture treatment resulted in high union rates, high return to work rates, and minimal complications. Operative treatment resulted high functional outcome and minimal complications compared to the conservative group. Operative treatment was recommended for scapular fractures that are displaced more than 9 mm and/or angulated more than 40.

Ethical approval None.

Sources of funding None.

Author contribution

Windi Martika: study concept or design, data collection, analysis and interpretation, oversight and leadership responsibility for the research activity planning and execution. Ismail Hadisoebroto Dilogo: study concept or design, data collection, oversight and leadership responsibility for the research activity planning and execution. Riky Setyawan: study concept or design, data collection, analysis and interpretation, research execution.

Registration of research studies None.

Guarantor

Prof. Ismail Hadisoebroto Dilogo, MD.

Consent

We have written and signed informed consent obtained from the patients and/or families (in under aged participants) to publish the data and accompanying images.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest None.

Acknowledgement

We thank to all of staffs, residents and patients that were helped this study to be conducted.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijso.2021.100425.

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