Surgical exposure for scapular fracture through limited approaches is not recommended. In posterior approach, the axillary nerve, the humeral circumflex artery the suprascapular nerve at the level of scapular neck are at risk.
Preoperative planning
The first important step for successful surgical treatment of scapular fractures is correct analysis of the radiography and proper pre-operative planning. The x-ray of chest should be used as a first screening and taken in all cases of multiple trauma.
The studies of anterior and posterior x-ray, a trans-axillary axial view is minimally required. And a lateral scapular view is essential for the assessment of the displacement of the glenoid in the coronal plane.
A CT scan and reconstruction views will provide the required information in case of suspected fractures of the glenoid in combination with, or without, ipsilateral rib fractures which will surely help to follow the best surgical approach and to determine the size of the fragments and the amount of displacement and to select the most suitable orthopaedic implants like Locking Proximal Radial Head Neck Plate for the surgical treatment. Moreover, the ipsilateral chest, its volume (pneumothorax), and the chest wall with rib fractures need to be recorded.
Approaches and Positioning
Anterior approach
In this approach, anterior glenoid fragments and anterior glenoid rim fractures are approached through a standard Bankart dissection using the delto-pectoral incision. The axillary nerve beneath the under surface of the deltoid and the neurovascular bundle medially are at risk.
Position of the patient
The patient is positioned in a beach chair position with the arm draped free. The patient may be positioned supine with a radiolucent roll under the spine to allow the involved arm to extend. It is very helpful if a complete radiolucent operating table is used to make the intraoperative radiographic imaging easy. In case of a tall or muscular patient the coracoid process or the conjoint tendon of the short head of the biceps muscle and coracobrachialis muscle must be taken down so that there can be satisfactory exposure of the medial extent of the neck of the glenoid.
Posterior approach
Posterior approach is extensile one. It runs from the tip of the acromion along the inferior margin of the scapular spine to the medial scapular border, down which it curves to the inferior angle of the scapula. The posteromedial angle of the deltoid is sharply dissected from the aura spine and acromion base and leaves a small tissue border at the spine to make the reattachment easy. Then the deltoid is carefully folded laterally since the axillary nerve and the circumflex artery are attached to its lateral border. The interface between infraspinatus and teres minor offers an approach to the lateral margin and border of the scapula.
The inferior aspect of the base of the scapular spine, the acromion base, the scapular neck, and the lateral scapula border are seen in this approach. If required, a small arthrotomy may be executed to view the posterior part of the glenoid.
Position of the patient
Due to possible ipsilateral chest wall damages, lateral decubitus positioning is preferable.
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