Surgical treatment of scapular malunion combined with chest
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Scapular fractures are relatively rare injuries resulting mainly from a high-energy trauma. Most of these fractures historically are treated conservatively and mostly heal in a malunited position with acceptable results. However, certain patients with malunited scapula do suffer from chronic symptoms and a poor functional outcome.

A 17-year-old right-handed male adolescent presented with a very unclear history. He complained of right shoulder pain lasting 4 months with severely impaired function, right chest pain, and some difficulties in breathing. He was unable to feed himself with his dominant hand or perform other important basic daily activities.

On examination, there was a marked asymmetry of the shoulder girdle, with obvious deformations of the right clavicle and scapular region. Shoulder function was severely impaired and painful. Range of motion was reduced to 70° of anteflexion and abduction, both passive and active. The right scapula seemed to be fixed, with almost no scapulothoracic movement. The strength of shoulder muscles was diffusely diminished. He could hardly reach his mouth.

Radiographic and CT scan with 3D reconstruction revealed a fracture of the right scapular body, with severe apex anterior angulation of 75° and its impingement into the deformed proximal posterolateral thoracic wall (duplex fractures of the right ribs 2-5). There was also marked angulation of the mid-third clavicle (60°) and a displaced avulsion fracture of the tip of the coracoid process. Most of the fractures were radiographically healed . His forced vital capacity was 3300 mL (87% of his predicted value).

Taking into account the poor shoulder function due to severe malunion that violated the scapulothoracic joint, operative treatment with correction of deformities was performed. A posterior Judet approach was performed. The scapula was lifted from the chest, with further dissection of the periscapular muscles, from its medial border and inferior angle. Ribs 3-5 were refractured, reduced, and fixed with precontoured 2.9-mm locking plates. The scapula was then osteotomized and the bony callus was partially removed.

Repositioning of the fragments of the scapula was achieved and temporarily maintained with Schantz pins and a small external fixator along the lateral border of the scapula. First, the lateral and then the medial border were fixed with 3.5-mm locking plates. Osteotomy, the reduction and fixation of the clavicle were done through a separate, small, approach using a 3.5-mm locking plate. Muscles were reattached, the wound drained, and the arm was put in a sling.

Immediately after the operation, postoperative rehabilitation comprising passive and assisted range of motion was started, and strengthening exercises were begun 1 month after the surgery. The patient recovered well, with good radiologic bone healing, painless full range of motion, and good functional outcome. His forced vital capacity also improved to 4400 mL (100% of predicted value).