Posterior Approach for Open Reduction and Internal Fixation for Scapular Fractures.

BACKGROUND: This technique utilizes a full-thickness flap to provide a posterior approach to the scapula for open reduction and internal fracture fixation. The present video article outlines the Judet approach along with an incision modification tip for the surgeon's consideration.

DESCRIPTION: Prior to making the incision, perform preoperative planning, patient and C-arm positioning, and identification of the primary fragments of the fracture that necessitate fixation on imaging. The Judet incision is made, and the full-thickness flap is retracted laterally (also described as a "boomerang-shaped" incision, allowing for the flap to be reflected medially). Next, detach and reflect the deltoid off the scapular spine superolaterally to reveal the internervous plane between the infraspinatus and teres minor. Utilize this interval to access the fracture sites while making sure to reflect the infraspinatus cranially, carefully minding the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve. A longitudinal arthrotomy may then be created parallel to the posterior border of the glenoid, with careful attention paid toward protecting the labrum from iatrogenic injury. The arthrotomy will allow for intra-articular evaluation of the reduction if needed. Primary fractures are then reduced. Reduction is confirmed with use of fluoroscopy, and fixation is applied to maintain the reduction.

ALTERNATIVES: Most scapular fractures do well with nonoperative treatment, and this has been well documented in the literature. Open reduction and internal fixation has been shown to offer good-to-excellent clinical outcomes with minimal risk of complications in patients with traumatic scapular fractures that necessitate operative treatment1 . In certain fractures of the glenoid fossa, operative treatment is necessary to restore normal anatomy, provide stability to the glenohumeral joint, and facilitate functional rehabilitation. Operative treatment is typically reserved for injuries with intra-articular involvement that results in joint incongruity or joint instability2,3 . When operative treatment is indicated, an open posterior approach is utilized for some fractures. The posterior Judet approach is the best-known operative technique for such fractures, while other modifications of the Judet technique have also been described in the literature3-5 .

RATIONALE: Reports state that scapular body or neck and glenoid fossa fractures account for up to 80% of scapular fractures6 . Open reduction and internal fixation of the scapula is an invasive procedure, requiring large incisions and manipulation of soft tissues to expose the various possible fracture sites on the scapula. Thus, numerus surgical techniques have been described that allow surgeons to best tailor treatment to their patients on a case-by-case basis. However, the Judet approach is the workhorse approach for the operative treatment of scapular fractures and is a technique that should be mastered7 . The Judet approach allows access to the posterior scapula and provides excellent exposure for fractures that require posterior fixation. The alternative boomerang-shaped incision represents a mirrored version of the Judet incision, with the skin flap reflected medially. The benefit of this modified approach is that it increases the degree of lateral surgical exposure of the scapula and provides easier access to the glenohumeral joint.

EXPECTED OUTCOMES: With this technique for open reduction and internal fixation of scapular fractures, patients can expect comparable outcomes to those described in the literature for the standard Judet technique. These outcomes have been reported as clinical scores and defined as good-to-excellent in a few retrospective case series1,2 . Given the variability in scapular fracture morphology, a trauma surgeon should have a strong repertoire of approaches to address these fractures on a case-by-case basis. The Judet approach is one of these necessary approaches and has been shown in the literature to have acceptable outcomes1-3,7 .

IMPORTANT TIPS: Placing the vertical limb of the boomerang incision too medial can limit lateral exposure of the scapula and make glenohumeral joint access difficult. To avoid this, be sure that the vertical limb of the incision remains in line with the posterior axillary fold.Wound-healing complications can occur following such an extensive surgical approach. A thorough and secure wound closure with repair of the deltoid back to the scapular spine may avoid these problems.Difficulty with intra-articular visualization may occur. Placing a threaded pin into the humeral head or a small distractor across the glenohumeral joint (with a pin in the extra-articular proximal humerus) may improve visualization. Manipulation of the arm can also be beneficial in this regard.Lateral positioning offers easier imaging and allows for exposure to the coracoid or clavicle if these structures are also injured and require operative fixation.Drawing a boomerang-shaped incision with the horizontal limb paralleling the scapular spine and vertical limb along the posterior axillary fold of the arm allows the skin flap to be reflected medially, increasing the degree of lateral surgical exposure of the scapula.After identifying the internervous plane between the infraspinatus and teres minor, take care to reflect the infraspinatus cranially, protecting the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve.

ACRONYMS AND ABBREVIATIONS: ORIF = open reduction and internal fixationK-wire = Kirschner wire.