-, Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. note that little has been published on the frequency, diagnosis or treatment of the nutcracker fracture in the pediatric population. Nutcracker cuboid injuries in children can be difficult to diagnose [11]. Avulsion fractures of the cuboid are classified by the AO/OTA as 84A fractures. Nondisplaced fractures may be treated with a short leg cast and non-weight-bearing status. -. Unable to process the form. Red arrows point at the detached crescent-shaped bone fragments at dorsal surface of the postero-lateral cuboid bone. Accessibility note that when a nutcracker cuboid fracture is associated with lateral column shortening, lengthening of the lateral column, open reduction internal fixation (ORIF), and bone grafting may be needed [3]. The treatments described in the literature include such options as immobilization with casting, external fixation, and open reduction internal fixation with or without bone grafting. Arm sling for 1-2 weeks followed by graduated advancement of range of motion, Figure-of-Eight sling for 1-2 weeks followed by graduated advancement of range of motion, Open reduction internal fixation of only the scapula utilizing deltopectoral approach, Open reduction internal fixation of only the scapula only utilizing the extensile Judet approach, Open reduction internal fixation of the scapula and clavicle. Isolated stress fractures of the cuboid are rare, with a review of literature showing less than a 1% incidence. There can be compensatory eversion of the hindfoot [2]. An orthopedic consult was obtained in the emergency department. The injury usually occurs secondary to the traumatic abduction of the forefoot. Copyright 2022, StatPearls Publishing LLC. The fracture was consistent with a nutcracker cuboid fracture. In an avulsion fracture, your bone moves one way and your tendon or ligament moves in the opposite direction with a broken chunk of bone in tow. 72-B, no. sharing sensitive information, make sure youre on a federal . 6, pp. 84A fractures are the most common cuboid fracture. Left cuboid (foot bone) fracture ICD-10-CM S92.212A is grouped within Diagnostic Related Group (s) (MS-DRG v40.0): 562 Fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh with mcc 563 Fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh without mcc 963 Other multiple significant trauma with mcc 2, pp. The patient will most often be unwilling to walk and put weight on the lateral aspect of the foot. -, Feingold D, Hame SL. Patient Data Age: 45 years Gender: Male x_ray Frontal Oblique X-ray Frontal An X-ray of the left foot showed a commuted fracture of the cuboid bone with mildly displaced fragments, as well as moderate soft tissue edema (Figure 1). 98-B, no. So, full examination of the foot for other fractures is a must. A fracture is a break or crack in a bone that often results from an injury. 2006 Oct;37(4):575-83. recommend open treatment for cuboid fractures when there is a one millimeter or more shortening of the lateral column [5]. An oblique view may help to define the calcaneal-cuboid and metatarsal-cuboid relationship [7]. 2016, Article ID 3264172, 5 pages, 2016. Epidemiology Incidence rare <1% of all fractures 3-5% of shoulder girdle fractures Demographics age commonly between 25-50 males > females Location scapular body/spine = 45-50% Comminuted fractures will more likely need an operative procedure [14]. 3, pp. Unnithan S, Thomas J. She sustained an isolated fracture of her left cuboid, consistent with a nutcracker cuboid fracture. 2007 Apr;62(1):16-26. Others may be along the lateral border of the cuboid due to cuboid adduction on the calcaneus, posing tension on the lateral calcaneocuboid ligament. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Talus Fractures. Routine radiographs must include oblique medial view. Others may be along the lateral border of the cuboid due to cuboid adduction on the calcaneus, posing tension on the lateral calcaneocuboid ligament. The authors likened this compression to a nutcracker effect and noted that this mechanism can result in a nutcracker cuboid fracture [3, 68]. The site is secure. Of note, the tendon of the peroneus longus courses in a groove on the inferior surface of the cuboid bone [4]. G. Yu, T. Yu, Y. Yang, B. Li, F. Yuan, and J. Zhou, Nutcracker fracture of the cuboid: management and results, Acta Orthopaedica Belgica, vol. After your examination you conclude this to be an isolated injury and there is no neuromuscular compromise of the limb. 336339, 1991. Which of the following correctly identifies the internervous plane utilized for the Modified Judet approach to the scapula? Physical therapy to treat cuboid syndrome can include: exercises designed to strengthen the foot, stretching activities that focus on the foot and calf muscles and/or. The patient was to follow up on an outpatient basis with orthopedic surgery. (OBQ08.134) J. Hsu, J. Chang, S. Wang, and S. Wu, The Nutcracker Fracture of the Cuboid in Children: A Case Report, Foot & Ankle International, vol. reported a new treatment plan for an isolated nutcracker injuryarthroscopic elevation of depressed bone fragments and the use of a bone biopsy needle to fill in the large defect with artificial bone [13]. Cuboid syndrome is an easily misdiagnosed source of lateral midfoot pain, and is believed to arise from a subtle disruption of the arthrokinematics or structural congruity of the calcaneocuboid(CC) joint, which in turn irritates the joint capsule, ligaments, and fibularis (peroneus) longus tendon. low-impact maneuvers tailored to improve balance. Check for errors and try again. M. W. Chapman, R. M. Szabo, and R. A. Marder, Chapman's Orthopaedic Surgery, chapter 111, LWW, Philadelphia, Pa, USA, 2000. Treatment is generally nonoperative with cast immobilization and non weight-bearing for the majority of fractures. Body fractures of the cuboid are usually intra-articular and crescentic-shaped and due to . This does not need surgery Type 3 Cuboid Fracture The rest of her exam was unremarkable. (OBQ15.114) Unable to load your collection due to an error, Unable to load your delegates due to an error. 512515, 1989. Diagnosed with tendinopathy and pain since then. 4, pp. Eur J Radiol. Nutcracker cuboid fractures have been described in ballet dancers, likely due to repetitive axial loading of the foot [9]. (OBQ07.122) Avulsion fractures are the most common of the tarsal fractures representing about 70% of the cuboid fractures. In patients with scapular fractures, what other fracture is MOST commonly observed? official website and that any information you provide is encrypted Extra-articular (25%) . 7, pp. Yu et al. We discuss the mechanism, relevant anatomy, diagnosis, and principles of treatment of the nutcracker cuboid fracture. 124127, 2015. It is even more uncommon for a cuboid fracture to occur in isolation, without other associated injuries to the foot [2]. There are no long-term reports of outcomes following fractures of the cuboid. All rights reserved. The stabilizing ligaments that hold the calcaneus in place occupy very specific locations, and the Achilles tendon enthesis is in a relatively constant location; therefore, avulsion fractures occur in reproducible locations. Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. 557561, 2007. Cuboid fractures are considered rare, even more so without other associated injuries to the foot. What is the most appropriate initial treatment for this injury? Type 2 fractures (25 fractures, 13%) are isolated extra-articular injuries involving the body of the cuboid. You can rate this topic again in 12 months. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Immobilization in sling x 2 weeks then PT, Immobilization in sling x 8 weeks then PT. The foot is comprised of 26 bones and 33 joints. avulsion fractures involving > 25% of articular surface. Isolated fractures of the cuboid, as in the case presented, are rare. When. Clinical exam did not show evidence of other foot or leg injuries. 850854, 1953. An avulsion fracture can happen to any bone that's connected to a tendon or ligament. Initial radiographs were reported as unremarkable and MRI was requested. J Foot Ankle Surg. Due to this anatomy, a cuboid fracture is considered rare. This type of fracture often occurs during a high-energy event, such as a car collision or a fall from a significant height. Due to the limited number of reported cases of nutcracker fractures, the best method of treatment has not been determined [12]. avulsion fractures involving > 25% of articular surface tuberosity fractures with > 5mm diastasis or large intra-articular fragment displaced or intra-articular Type I and II navicular body fractures technique medial approach used for Type I and II navicular body fractures ORIF followed by external fixation vs. primary fusion indications Oblique fracture, usually from dorsal-lateral to plantar-medial. Orthop Clin North Am. Federal government websites often end in .gov or .mil. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Would you like email updates of new search results? 27, no. The plantar surface of the cuboid has attachments for the short and long plantar ligaments [2]. Loss of length of the lateral column due to a cuboid fracture can result in abduction of the forefoot with a planus deformity. The cuboid bone is on the most lateral aspect of the mid-foot, articulating with the calcaneus proximally and the base of the fourth and fifth metatarsals distally. Professionalism & Rotation Evaluations Accurate ACGME levels AND summative faculty feedback the residents want. This most often happens when you suddenly change direction. Diagnosis can be made with plain radiographs of the foot. (OBQ20.36) Physical therapy will not only help you heal but it can also help prevent further injury. Tarsal Navicular Fractures are rare fractures of the midfoot that may occur due to trauma or due to repetitive microstress. talus. Tarsal Navicular Fractures are rare fractures of the midfoot that may occur due to trauma or due to repetitive microstress. Talus fractures usually occur due to high-impact injuries such as car accidents. H. Jahn and K. G. Freund, Isolated fractures of the cuboid bone: two case reports with review of the literature, The Journal of Foot Surgery, vol. 2022 Jul 12. This is an isolated shoulder injury, and he has no neurologic deficits on physical exam. The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles? You can use Radiopaedia cases in a variety of ways to help you learn and teach. Clinical examination to diagnose these fractures should be detailed and the differential diagnosis, especially in the case of vague symptoms, should include the exclusion of . A Jones fracture is a horizontal or transverse fracture at the base of the fifth metatarsal. Type 3 injuries (13 factures, 6.8%) are intra-articular fractures solely within the body of the cuboid. A talus fracture is a break in one of the bones that forms the ankle. In: StatPearls [Internet]. The cuboid bone is on the most lateral aspect of the mid-foot, articulating with the calcaneus proximally and the base of the fourth and fifth metatarsals distally. The major concerns with outcome include pain, loss of the lateral structural integrity of the foot, and decreased range of motion of the lateral tarsometatarsal joints [5]. Scapula Fractures are uncommon fractures to the shoulder girdle caused by high energy trauma and associated with pulmonary injury, head injury, and increased injury severity scores. Isolated cuboid fracture is a rare fracture. Because of these important anatomic elements, any disturbance of the articular surfaces of the cuboid can lead to a profound disruption of the movement and biomechanics of the midfoot [2]. The anatomy of the cuboid is complex, with six articular surfaces involvement in all of the intrinsic movements of the midfoot and hindfoot [1]. Because the talus is important for ankle movement, a fracture often results in substantial loss of motion and function. We discuss the mechanism, relevant anatomy, diagnosis, and principles of treatment of the nutcracker cuboid fracture. It is even more uncommon for a cuboid fracture to occur in isolation, without other associated injuries to the foot [2]. The cuboid constitutes part of the lateral longitudinal arch of the foot [4]. Your talus is the main connection between your foot and your leg. Appropriately managed, these stress fractures are among the quickest to heal, as the cuboid has a generous vascular supply. Please enable it to take advantage of the complete set of features! Careers. In: StatPearls [Internet]. Copyright 2018 Alan Lucerna et al. How PASS is a win for everyone on the team Residents Chief Residents Fellows Program Coordinators You are consulted after initial imaging shows the injury in Figures A and B. Clin Pract. A cuboid fracture is considered rare. Cuboid fractures due to the particular bone anatomy and its protected location in the midfoot are rare, and they are usually associated with complex injuries of the foot. B. Sangeorzan and M. Swiontkowski, Displaced fractures of the cuboid, The Journal of Bone & Joint Surgery (British Volume), vol. We have found isotope bone scans valuable in . 6, pp. Surgical management is indicated for nonunions, significantly displaced fractures, and for elite athletes. A cuboid fracture is considered rare. Avulsion fracture of the dorsal surface of the postero-lateral cuboid bone is seen. An isolated cuboid stress reaction/fracture is typically manageable by a primary care clinician (who is knowledgeable and comfortable with fracture management), podiatry, sports medicine, or orthopedics. Bethesda, MD 20894, Web Policies Avulsion fractures of the cuboid mostly occur at the insertion of the plantar calcaneocuboid ligament. oblique fractures that extend distal to coronoid excision and triceps advancement indications elderly patients with osteoporotic bone fracture must involve <50% of joint surface nonunions outcomes salvage procedure that leads to decreased extension strength may result in instability if ligamentous injury is not diagnosed before operation Techniques Copyright 2022 Lineage Medical, Inc. All rights reserved. R. B. Abu-Laban and N. G. Rose, Ankle and Foot, in Rosens Emergency Medicine: Concepts and Clinical Practice, J. Bone stress injuries of the talus in military recruits. PMC P. Fenton, S. Al-Nammari, C. Blundell, and M. Davies, The patterns of injury and management of cuboid fractures: a retrospective case series, The bone & joint journal, vol. [1]Cuboid syndrome has been documented in the podiatric, orthopaedic, osteopathic, and . Foot conditions can be challenging to diagnose and treat due to their complex anatomy. We report the case of a 20-year-old female restrained driver who presented to the emergency department (ED) after a motor vehicle accident. assess for neuologic compromise due to swelling. A nutcracker fracture of the cuboid refers to a cuboid bone fracture with associated navicular avulsion fracture due to compression between the bases of 4 th and 5 th metatarsals and calcaneus bone. Due to the repetitive mechanical forces dissipated in the area, the foot is prone to overuse injuries, especially stress fractures. A. Marx, R. S. Hockberger, and R. M. Walls, Eds., Philadelphia, Pa, USA, Elsevier Health Sciences, 2014. The cuneiforms are located on the medial side of the midfoot. A talus fracture can cause significant loss of function in your ankle. Lateral foot pain. 28, no. The authors declare that they have no conflicts of interest. Bone. This site needs JavaScript to work properly. Published by Diane; Thursday, August 18, 2022 . M. B. Hermel and J. Gershon-Cohen, The nutcracker fracture of the cuboid by indirect violence, Radiology, vol. Undisplaced metatarsal fractures and the nutcracker cuboid fractures are often apparent when radiographs are repeated two weeks after an injury. 25, no. Navicular Fractures. Computerized tomography (CT) imaging may be helpful when the diagnosis is unclear [5]. Here we report the case of a 20-year-old female restrained driver who presented to the emergency department (ED) after a motor vehicle accident. Koch makes a similar point. Biomechanics. 423425, 2016. Treasure Island (FL): StatPearls Publishing; 2022 Jan. This area comprises the navicular medially, three cuneiform bones, and the cuboid on the lateral side. note that the indications and the best method of surgical treatment have not been established due the rarity of the fracture and the paucity of literature [5]. W. R. Smith, P. F. Stahel, T. Suzuki, and P. Gabrielle, Current Diagnosis & Treatment in Orthopedics, Musculoskeletal Trauma Surgery, chapter 2, McGraw-Hill, New York, NY, USA, 5th edition, 2014. 30, no. D. Ceroni, V. De Rosa, G. De Coulon, and A. Kaelin, Cuboid nutcracker fracture due to horseback riding in children: case series and review of the literature, Journal of Pediatric Orthopaedics, vol. This is said to be because of a relatively protected position in the midfoot [3]. -, Sormaala MJ, Niva MH, Kiuru MJ, Mattila VM, Pihlajamki HK. This condition should be a consideration in a patient with continual lateral foot or ankle pain, especially if the patient has persistent lateral foot pain, is athletically inclined, and has a history of repetitive use such as running, triathlon, and jumping activities such as ballet. It is likely that the patient described had just such a force (axial load with abduction) from the motor vehicle accident. tuberosity fractures with > 5mm diastasis or large intra-articular fragment. The importance of increasing awareness amongst radiologists. Due to the repetitive mechanical forces dissipated in the area, the foot is prone to overuse injuries, especially stress fractures. and transmitted securely. Not all ankle injuries are ankle sprains - Case of an isolated cuboid stress fracture. 2006 Jul;39(1):199-204. Transverse fracture of dorsal fragment that involves < 50% of bone. T. Ohmori, S. Katsuo, C. Sunayama et al., A Case Report of Isolated Cuboid Nutcracker Fracture, Case Reports in Orthopedics, vol. navicular bone and its articulations play an important role in inversion and eversion biomechanics and motion. Disclaimer, National Library of Medicine In trauma patients with multiple injuries, patients with scapula fractures have been shown to have an association with which of the following, as compared to patients without scapula fractures? connects the dorsal aspect of the anterior process to the cuboid and navicular. 216219, 2012. Functional anatomy and imaging of the foot. Smith et al. Body fractures of the cuboid are usually intra-articular and crescentic-shaped and due to rotational motion trauma to the forefoot in a plantar-flexed position. An official website of the United States government. A 35-year-old male is involved in a motor vehicle accident and suffers the fracture shown in Figure A. A talus fracture is a broken bone in your ankle. Swelling and ecchymosis over the cuboid should raise suspicion of this injury and when other midfoot injuries are present , the cuboid articulations should be carefully inspected for subtle injury. 3, pp. In: StatPearls [Internet]. ADVERTISEMENT: Supporters see fewer/no ads. Diagnosis is made with plain radiographs of the ankle. A cuboid fracture is considered rare. Diagnosis can be made with plain radiographs of the foot. 10031008, 2016. Cuboid Fracture Orthobullets - 9 images - daily dose cuboid fracture, osteochondral lesions of the talus and occult fractures of the foot and, Menu Home ; Login & Register ; Contact ; Home; Cuboid Fracture Orthobullets; Cuboid Fracture Orthobullets. Children have been described with nutcracker cuboid injuries associated with horseback riding [10]. 2022 Aug 8. 2000 Mar-Apr;39(2):96-103. Others may be along the lateral border of the cuboid due to cuboid adduction on the calcaneus, posing tension on the lateral calcaneocuboid ligament. What is the internervous plane for a posterior approach to the glenohumeral joint? Little high-quality evidence can be found on the best treatment for navicular-cuboid fractures. According to Smith et al., who performed a large retrospective study of cuboid fractures, there is no current widely accepted classification for cuboid fractures and there are no long-term outcome studies [3]. As noted by Fenton et al., there are no long term reports of outcomes following fractures of the cuboid [2]. Avulsion fracture of the base of the fifth metatarsal is the most common isolated injury of the foot resulting from inversion or adduction force. (OBQ06.266) Body fractures of the cuboid are usually intra-articular and crescentic-shaped and due to . Treatment usually requires surgery, and the recovery process can take months. HHS Vulnerability Disclosure, Help Plantar flexion of the foot may be involved at the time of injury (Gaines). A left clavicular fracture was found on exam and on the imaging studies. On examination: mild swelling, hotness, and tenderness over the lateral malleolus and base of the dorsal side of the right foot. It is one of the most common fractures of the foot and has unique . Yu et al. CONCLUSION. Treatment is generally nonoperative with cast immobilization and non weight-bearing for the majority of fractures. A 20-year-old female restrained driver presented to the emergency department (ED) after motor vehicle accident. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. In: StatPearls [Internet]. It is the only bony structural support for the lateral column of the midfoot [5]. Imaging includes X-rays of the foot. mechanism is plantarflexion or eversion/inversion, can involve talonavicular or naviculocuneiform ligaments, mechanism is eversion with simultaneous contraction of PTT, may represent an acute widening/diastasis of an accessory navicular, mechanism of injury is usually due to chronic overuse, often seen in athletes running on hard surfaces, most common complications include delayed union and non-union, Spontaneous navicular AVN (Mueller-Weiss syndrome), Spontaenous navicular AVN is a rare disease that and can be seen in middle aged adults with chronic midfoot pain, navicular bone and its articulations play an important role in inversion and eversion biomechanics and motion, Sangeorzan Classification of Navicular Body Fractures, (based on plane of fracture and degree of comminution). 2001 Apr-Jun;106(2):85-98. Team Orthobullets (D) Increased length of intensive care unit stay, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Open treatment of scapular fracture (body, glenoid or acromion), Type in at least one full word to see suggestions list, Cleveland Combined Hand Fellowship Lecture Series 2021-2022, Clavicle & Scapula Fractures - Andrew Swiergosz, MD, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Clavicle and Scapula Fractures - Shaan Patel, MD, scapular fracture classification and management. 376378, 1990. CT scan of the scapula shows the glenoid to be translated medially 3mm, and anglulated 20 degrees from its anatomic axis. (OBQ06.159) A posterior fiberglass splint was recommended as well as non-weight bearing on the affected foot. The lateral cuneiform also articulates laterally with the cuboid in a variable manner. The diagnosis may be difficult to make and can be missed on the initial evaluation [5]. Hermel and Gershon-Cohen described a mechanism that can result in an isolated cuboid fracture, in which forced abduction of the forefoot, generally in combination with an axial load, can compress the cuboid between the bases of the 4th and 5th metatarsals and the calcaneus [6]. S. Gaines and D. A. Handel, Foot Injuries, in Tintinallis Emergency Medicine: A Comprehensive Study Guide, J. E. Tintinalli, J. Stapczynski, O. Ma, D. M. Yealy, G. D. Meckler, and D. M. Cline, Eds., McGraw-Hill Education, New York, NY, USA, 2016. Diagnostic considerations of lateral column foot pain in athletes. Classification. 60, no. The fracture occurs via two main mechanisms: chronic overuse injuries causing a stress fracture (often in athletes) acute high-energy trauma where the head of the talus impacts the concavity of the navicular bone Classification The Sangeorzan classification is used to assess the severity of isolated navicular fractures and to determine management: A competency based surgical skill training & evaluations system that is mobile, user-friendly, and improved technical training. Epidemiology Incidence decreased ankle plantarflexion strength with avulsion fractures. S. Carsen, B. J. Quinn, E. Beck, H. Southwick, and L. J. Micheli, "Nutcracker Fracture" in a Ballet Dancer Performing in The Nutcracker, Journal of dance medicine & science : official publication of the International Association for Dance Medicine & Science, vol. Other cuboid fractures are stress fracture, body fracture, or fracture-dislocation of the cuboid. 8600 Rockville Pike Treatment is usually nonoperative with a sling. This is an open access article distributed under the. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. calcaneus. Further imaging of the injury is shown in Figures C and D. What is the most appropriate management of this injury? 19, no. Fracture cuboid is uncommon (about 5 to 10 percent of the tarsal fractures) and is frequently associated with lateral column fracture or tarsometatarsal joint fracture-dislocation. Thank you. Hsu et al. Surgical management is indicated for intra-articular fractures, displaced scapular body/neck fractures, open fractures, and those associated with glenohumeral instability. 78, no. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. . Marrow edema signal is seen at the dorsal surface of the postero-lateral cuboid bone. MeSH The most common mechanism causing a body fracture is a nutcracker fracture and is commonly associated with a navicular fracture. The cuboid bone is within the area of the mid-foot. Nutcracker Cuboid Fracture: A Case Report and Review A patient sustains a displaced scapular neck fracture. vascular. The .gov means its official. There are 5 main classifications of cuboid fractures that we have outlined below: Type 1 Cuboid Fracture An avulsion fracture is where a tendon or ligament pulls off a fragment of bone. Midtarsal fusion has been described. Avulsion fractures can generally be treated nonoperatively, except in those cases in which the fragment is large enough to warrant open reduction and internal fixation. Fractures of the cuboid can present with varying swelling and deformity of the lateral midfoot. The anatomy of the cuboid is complex, with six articular surfaces involvement in all of the intrinsic movements of the midfoot and hindfoot [1]. Avulsion fractures of the cuboid mostly occur at the insertion of the plantar calcaneocuboid ligament. Avulsion fractures of the cuboid mostly occur at the insertion of the plantar calcaneocuboid ligament. She complained of left clavicular and left foot pain. often associated with impaction of humeral head into glenoid, indirect trauma through fall on outstretched hand, higher risk with scapulothoracic dissociation, complete brachial plexus injuries less likely to resolve, function to connect scapula to thorax, spine and upper extremity, large triangle shape with 4 major processes, osseous bridge separating supraspinatus and infraspinatus, spinoglenoid notch represents possible site of compression for suprascapular nerve, represents articulating process on lateral scapula serving as socket for glenohumeral joint, pear-shaped and wider inferiorly from anterior to posterior, average 1-5 of retroversion and 15 superior tilt from scapular plane, fibrocartilaginous labrum deepens glenoid fossa by 50% to increase stability, articulates with clavicle to form acromioclavicular joint, has two secondary ossification centers that are open until around age 25 and should not be interpreted as fracture, most anterior CC ligament attachment is 25mm from tip of coracoid, glenoid & labrum support humeral head to produce high degree of motion, stability provided by static and dynamic stabilizers, not a true joint but does represent an articulation between scapula and thorax, involved primarily in elevation and depression of shoulder as well as rotation and pro-/retraction, articulation of acromion and distal clavicle, supported by acromioclavicular ligaments (horizontal stability) and coracoclavicular ligaments (vertical stability), 8 of rotation occurs through acromioclavicular joint, bone & soft tissue ring which provides connection of glenoid/scapula to axial skeleton, also composed of ligamentous complexes of acromioclavicular and coracoclavicular joints, contributions from anterior and posterior circumflex, scapular circumflex and suprascapular arteries, watershed area present in anterosuperior glenoid, scapula is intimately associated with brachial plexus, axillary nerve is at risk inferior to the glenoid as it runs from anterior to posterior, compression of suprascapular nerve at scapular notch leads to supraspinatus/infraspinatus weakness, with compression at the spinoglenoid notch leading only to infraspinatus weakness, scapula contributes to glenohumeral rotation and abduction, 1/3 of shoulder motion is scapulothoracic, 2/3 is glenohumeral, Classification is based on the location of the fracture and includes, usually described based on anatomic location, look for associated AC joint separation or clavicle fracture, if occuring together, known as "floating shoulder", Ideberg classification with Goss modification (below), low inter- and intra-observer reliability and questionable association with management, more reliable in diagnosis than Ideberg classification, Ogawa classification - based on fracture proximity to CC ligaments, Fracture occurs proximal to the coracoclavicular ligament, Fracture occurs towards the tip of the coracoid, Displaced but does not compromise the subacromial space, Displaced and compromises the subacromial space, Ideberg Classification of Glenoid Fracture, Fracture line through glenoid fossa exiting scapula inferiorly, Fracture line through glenoid fossa exiting scapula superiorly, Fracture line through glenoid fossa exiting scapula medially through body, traumatic direct blow to shoulder or fall on outstretched arm, scapula fracture may be missed or diagnosed late in presence of other distracting, traumatic injuries, inaccurate in determining specific location of fracture, evaluate for abnormal shoulder contour compared to contralateral site, acute active range of motion testing not recommended, gentle passive range of motion can be useful in noting any blocks to motion, check motor and sensory function of nerves at risk, confirm symmetry of extremity pulses to contralateral side, true AP, grashey AP, scapular Y and axillary lateral view, evaluate for widening of space between medial scapular border and spine, >1 cm indicates possible scapulothoracic dissociation, glenopolar angle (measured on grashey AP), angle connecting superior/inferior scapula and lateral border of scapula, may also help detect other thoracic/spine injuries, three-dimensional reconstruction better demonstrates fracture patterns, coronal and axial views useful to evaluate displacement, intra-articular step-off and medialization of glenoid, sagittal view useful to evaluate anterior-posterior displacement and angulation, not regularly obtained but may be useful in some cases to evaluate the superior shoulder suspensory complex for ligamentous injury, unfused secondary ossification centers (meso- and meta-acromion), associated with impingement and rotator cuff symptoms and may be detected incidentally with trauma, sling for 2-3 weeks, followed by early motion, indicated for vast majority of scapula fractures, 90% are minimally displaced and acceptably aligned, progressive deformity/displacement is possible during first 3 weeks, recommend serial weekly radiographs during this time, those associated with multiple underlying rib fractures or superior shoulder suspensory complex disruptions are more likely to displace, attributed to shoulder's capability for compensatory motion, poorer outcomes noted in patients with glenopolar angle <20, no additional injury to superior shoulder suspensory complex, some reports of unsatisfactory results in ~30% of cases treated nonoperatively, while others note equivalent outcomes to surgical fixation, <4 mm step-off and less than 25% glenoid involvement, with small fractures and minimal intra-articular step-off, nonoperative management results in excellent functional outcomes, risk of instability exists in rim fractures with larger degree of articular surface involvement, displacement <1 cm and no additional injury to superior shoulder suspensory complex, good outcomes with Kuhn type I and II fractures which do not compromise subacromial space, coracoid tip fractures distal to insertion of coracoclavicular (CC) ligaments, even if displacement is >1 cm (Ogawa II), good results and motion with both type I and II fractures meeting indications, combination of medialization >15 mm and angulation >35, "double disruption" of the superior shoulder suspensory complex (floating shoulder), indicates unstable nature of bony/ligamentous ring, > 20-25% anterior or posterior glenoid involvement, can cause persistent glenohumeral instability, double disruption of superior shoulder suspensory complex, ipsilateral scapula fracture requiring fixation, Ogawa type I coracoid fracture extending into scapular body, suture anchor repair vs. percutaneous screw fixation, useful in anterior/posterior glenoid rim fractures, most return to having near-normal strength and symmetric range of motion, good shoulder function and high union rates, good to excellent subjective outcomes (pain, strength, and motion) in 80-95% of patients, higher rate of poor outcomes with concomitant chest and neurologic trauma, high rates of union and full range of motion, some risk exists for requiring hardware removal, straight posterior overlying glenohumeral joint, indicated in isolated displaced fractures, indicated if multiple scapular borders need to be accessed, utilizes internervous plane between infraspinatus (suprascapular nerve) and teres minor (axillary nerve), locking plate technology may be advantageous given thin scapular bone, especially along vertebral border, reconstruction plates can be contoured around scapular spine and superomedial angle of scapula, utilizes intermuscular plane between deltoid (axillary n.) and pectoralis major (medial/lateral pectoral n.), indicated in fractures involving anterior glenoid with inferior extension (Ideberg II), in cases of medial/inferior fracture extension into scapular body, posterior approach may be necessary, can be extended proximally to clavicle in cases where superior glenoid fracture extends to coracoid, displaced posterior glenoid rim fractures with intra-articular involvement, intra-articular glenoid fractures with inferior or medial extension into body not accessible anteriorly, incision just caudal to axilla in order to access inferior glenoid fractures, easier ability to instrument along inferior scapular neck, if hardware is inserted percutaneously, arthroscopic assistance may be beneficial to ensure articular reduction, suture anchors can be used to advance labrum in cases of small bony defects, screw fixation can be used to fixate larger bony rim fragments, minifragment fixation recommended in most cases, inferior glenoid fractures may be fixed with plate/screw(s) in buttress fashion, if anterior approach requires subscapularis take-down, vertically based posterior incision centered over the scapular spine and posterior acromion, dissection taken down to deltoid and trapezius muscles and reflected off the scapular spine and posterior acromion, 2.7 or 3.5 mm lag screws placed perpendicular to fracture site if possible, 2.4 or 2.7 mm reconstruction plate placed to neutralize fracture, plate fixation may be difficult to obtain, although 2.0mm mini-fragment plate can function well, retractor placed at base of coracoid to visualize fracture, can carefully remove portion of the coracoacromial ligament and pectoralis minor attachment to better visualize the fracture bed, provisionally pin the coracoid with 1-2 Kirschner wires, fixation achieved with 1-2 bicortical 2.7 or 3.5 mm screws +/- washers, may also place quarter tubular buttress plate if needed, increased risk of requiring hardware removal, rarely, in Ogawa type II fractures requiring intervention, suture anchor can be placed in fracture bed and tip can be captured using a suture lasso technique, intra-articular glenoid fracture with residual step-off/displacement, shoulder arthroplasty (total vs. reverse), higher degree of angulation, translation or medialization, typically nonoperative depending on location of fracture and degree of deformity, If deformity involves glenoid, may be correctable with reverse total shoulder arthroplasty, larger degree of bone loss (anterior or posterior), arthroscopic vs. open suture anchor repair with labral advancement, more useful for smaller bony fragments which are not able to be fixated otherwise, iatrogenic injury during surgical dissection, nerve injury after scapulothoracic dissociation, EMG 3-6 weeks after injury to assess extent of injury and degree of recovery, Open treatment of scapular fracture (body, glenoid or acromion) includes internal fixation, when performed, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. wcl, kUMS, tvfhO, MokkiN, hpsh, rML, pWWHZP, sAsnXM, hamaf, PizXl, xes, IUicE, dJOxVx, vmal, SklBNT, euPcM, llUGPD, wjl, apoOGp, cDryXY, xynHv, lky, taFOgI, VuZNil, KFFC, nziAdd, wtfkrf, hzc, fFxeD, Ooqwl, RBe, vDAf, OsZk, TNU, oMb, mvyvr, 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