This document discusses classifications and treatment approaches for fractures of the scapula. It describes several classification systems for fractures of the scapular body, glenoid cavity, and glenoid fossa. It also outlines various surgical approaches for addressing different types of scapular fractures, including the Judet posterior approach, modified Judet posterior approach, and anterior approaches. Key steps for exposures using these approaches are provided. Outcomes of surgical treatment even with delays are noted to often be favorable.

1. SCAPULA FRACTURE
DR MURUGESH KURANI MAHADEV,
M.B.B.S., M.S. Ortho
Fellow In Arthroscopy And Sports Medicine
Fellow In Shoulder Surgery And Sports Trauma

2. THE FIRST DESCRIPTION OF A CLASSIFICATION SYSTEM FOR
SCAPULAR BODY FRACTURES IS CREDITED TO PETIT IN 1723
Ada and Miller classification system
Goss modification of Ada and Miller classification system
Hardegger classification
AO/OTA classification system/ Revised AO classification
Bartoníček et al. CT based classification
The ideberg et al. Classification is the most accepted system for glenoid cavity
fractures
Goss et al. and Mayo et al. modification of Ideberg classification : glenoid rim
fractures (type I) and glenoid fossa fracture (type II to VI)
Bartonicek classification for glenoid fracture

3. Bartonícek et al. Described an interesting classification system for
fractures of scapula body into three major groups:
• Fractures of the spinal/ medial pillar
• Fractures of the lateral pillar (subtypes: two-part, three-part, and
comminuted fractures)
• Fractures of both pillars (subtypes: fractures involving the medial
third of the spinal pillar and fractures involving the central part of
the spinal pillar)

4. The decision-making on where to start the
fracture reduction (medial or lateral pillar)
depends on the fracture pattern.

5. ARTICULAR DISPLACEMENT
OR GAP >4MM
ARTICULAR INVOLVEMENT
>20-25%
MEDIALISATION OF SCAPULA
>20MM
GLENOPOLAR ANGLE <22*
ANGULATION >45*
Source: The Scapula Institute – St. Paul /
Minnesota (www.scapulainstitute.org).

6. IDEBERG CLASSIFICATION OF GLENOID FRACTURE
(Ideberg r et. al)
TYPE IA: ANTERIOR RIM FRACTURE
TYPE IB: POSTERIOR RIM FRACTURE
TYPE II: FRACTURE LINE THROUGH GLENOID FOSSA EXITING SCAPULA LATERALLY
TYPE III: FRACTURE LINE THROUGH GLENOID FOSSA EXITING SCAPULA SUPERIORLY
TYPE IV: FRACTURE LINE THROUGH GLENOID FOSSA EXITING SCAPULA MEDIALLY
TYPE VA: COMBINATION OF TYPES II AND IV
TYPE VB: COMBINATION OF TYPES III AND IV
TYPE VC: COMBINATION OF TYPES II, III, AND IV
TYPE VI: SEVERE COMMINUTION

8. BARTONICEK CLASSIFICATION FOR
GLENOID FRACTURE
DICTATED MAINLY BY THE DIRECTION OF THE DEFORMING
FORCE AND THE POSITION OF THE ARM AT THE MOMENT OF
THE TRAUMATIC INJURY.
SUPERIOR GLENOID FRACTURE
ANTERIOR GLENOID FRACTURE
INFERIOR GLENOID FRACTUR
POSTERIOR GLENOID FRACTURE
ENTIRE GLENOID/TOTAL GLENOID FRACTURE

9. APPROACHES TO SCAPULA
FRACTURE
JUDET POSTERIOR APPROACH
MODIFIED JUDET POSTERIOR APPROACH
HARDEGGER AND KAVANAGH et.al POSTERIOR APPROACH – AO PREFERRED
BRODSKY VERTICAL POSTERIOR APPROACH
EBRAHEIM’S REVERSE JUDET POSTERIOR APPROACH
GAUGER AND COLE MINIMAL INVASIVE POST APPROACH FOR NECK AND BODY
FRACTURE
LESLIES AND RYAN ANTERIOR APPROACH
ANTERIOR DELTOPECTORAL APPROACH
DIRECT SUPERIOR APPROACH

10. SKIN INCISION FOR JUDET AND
MODIFIED JUDET (BOOMRANG INCISION)

11. JUDET/MODIFIED JUDET
APPROACH
SKIN INCISION:
FROM THE POSTEROLATERAL CORNER OF THE ACROMION,
EXTENDING HORIZONTALLY TO THE SCAPULAR SPINE AND THEN
INFERIORLY ALONG THE MEDIAL BORDER.
A FULL-THICKNESS SUBCUTANEOUS FLAP WAS RAISED OFF THE
POSTERIOR MUSCLE FASCIA OVERLYING THE DELTOID AND
INFRASPINATUS/TERES MINOR MUSCLE.
THE DELTOID WAS IDENTIFIED AND RETRACTED.
DELTOID TAKEDOWN WITH PARTIAL TENOTOMY AND DETACHMENT
WAS EXECUTED IN BOTH (JUDET AND MODIFIED JUDET)
APPROACHES ONLY IF BETTER EXPOSURE WAS REQUIRED.

12. Interval: between the
posterior deltoid fibers
and underlying rotator
cuff.
The infraspinatus origin
elevated out of the
infraspinatus fossa and
reflected laterally
towards the spinoglenoid
notch

13. The plane between the
teres minor and
infraspinatus is developed
and allows exposure of
the ascending branch of
the circumflex scapular
artery, which is ligated

14. FOR BETTER VISUALISATION
IF THE MEDIAL PILLAR OF THE
SCAPULA MUST BE ADDRESSED, PARTIAL
DETACHMENT OF THE INFRASPINATUS
SHOULD BE CAREFULLY PERFORMED

15. Salassa et al., In a cadaveric study, showed that the
modified judet approach without posterior deltoid
takedown allows for safe exposure of the lateral pillar of
the scapula and direct visualization of the critical
neurovascular bundle.

16. KINGS AND BRODSKY APPROACH
A STRAIGHT SIMPLIFIED LONGITUDINAL APPROACH DESCRIBED
BY BRODSKY IS ALSO POSSIBLE, ESPECIALLY FOR FRACTURE
PATTERNS WHEN FIXATION OF THE MEDIAL PILLAR IS NOT
REQUIRED.
ALTERNATIVE FOR FRACTURES OF THE LATERAL PILLAR OF THE
SCAPULA IN ASSOCIATION WITH DISPLACED ACROMION
FRACTURES

17. KINGS AND BRODSKY APPROACH

19. HARDEGGER ET AL AND KAVANAGH ET AL USED A
VERTICAL INCISION FROM THE ACROMION TO THE
INFERIOR SCAPULAR ANGLE

20. INCISION: From scapular spine,
extending horizontally and laterally
to the posterolateral corner of the
acromion, from which the incision
became vertically through the
lateral border of the scapula.
INTERVAL : Between the
infraspinatus and teres minor
The ascending branch of the
circumflex scapular artery was
ligated to prevent bleeding.

21. GAUGER AND COLE DESCRIBED
A MINIMALLY INVASIVE
APPROACH TO SCAPULA NECK
AND BODY FRACTURES

22. INCISION: From the medial acromion, passing the
superior margin of the scapula, to the medial angle of
scapula, at about 8 cm in length.
By separating bluntly and retracting gently the trapezius
muscle, supraspinatus, acromion and acromioclavicular
joint were exposed.
Pull the supraspinatus muscle forward to show superior
glenoid, scapular notch and supraspinatus fossa
Pull the supraspinatus muscle backward to show
superior margin of scapula, posterior margin of distal
clavicle, coracoid process and coracoclavicular ligament

23. ANTERIOR APPROACH FOR ANTERIOR FRACTURE
TYPES CARRYING > 20% OF THE GLENOID FOSSA AND
AVULSED ANTEROINFERIOR GLENOID RIM FRACTURES
OVERHANGING THE SCAPULAR NECK MORE
MARKEDLY THAN OTHER PARTS OF THE GLENOID
FOSSA.
LESLIE AND RYAN APPROACH FOR ANTERIOR
GLENOID CAVITY FRACTURE

24. POSTERIOR APPROACHES FOR POSTERIOR RIM
FRACTURES CARRYING > 25% OF THE GLENOID FOSSA
AND FOR ALL OTHER GLENOID FOSSA FRACTURE
PATTERNS.
FOR ISOLATED POSTERIOR RIM FRACTURES - BRODSKY
STRAIGHT SIMPLIFIED LONGITUDINAL APPROACH.
FOR ALL OTHER TYPES INVOLVING A MAIN FRACTURE
LINE RUNNING ACROSS THE SCAPULA INTO ITS MEDIAL
BORDER, THE SMALL SURGICAL WINDOWS DESCRIBED
BY GAUGER AND COLE IS PREFERRED.

25. THE MEDIAL COMPONENT OF THE FRACTURE
MUST BE REDUCED AND FIXED WITH A
RELATIVELY FLEXIBLE IMPLANT FIRST AS IT
ACTS AS A HINGE TO ALLOW BETTER
MANIPULATION AND REDUCTION FOLLOWED
BY LATERAL COMPONENT FIXATION.

26. DELAYED TREATMENT > 3 WEEKS STILL GIVES
FAVOURABLE RESULTS
PREFERRED IMPLANT : 3.5 mm recon locking plate
Good to excellent results are seen in 85% of cases
over 4 years and 2 months post operatively