Rockwood Children CH19

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SECTION TWO • Upper Extremity

shape of the scapula. Advanced imaging with three-dimensional reconstruction is helpful in planning for ORIF of scapula frac- tures. Positioning Patient positioning will depend on the location of the fracture within the scapula and subsequently the approach being used. If anterior exposure is necessary, the patient is placed in the beach chair position and a standard deltopectoral approach is performed. Posterior exposure is performed by having the patient in the lateral decubitus position in a bean bag, allowing the shoulder and trunk to droop slightly forward. Surgical Approach Anterior access to the glenoid and coracoid is performed through a standard deltopectoral approach. An incision is made along the deltopectoral groove from the coracoid proxi- mally and carried 10 to 15 cm distally. Sharp dissection is car- ried out through the skin and the cephalic vein is identified in the deltopectoral groove. Subsequently, the deltoid is retracted laterally and the pectoralis major medially. The cephalic vein can be taken in either direction. Deep, the short head of the biceps and the coracobrachialis are identified and retracted in a medial direction. Access to the anterior aspect of the shoul- der joint is now easily obtained. Typically, to have adequate exposure of the glenoid, the subscapularis must be taken down and a retractor placed in the glenohumeral joint to retract the humeral head. If a posterior approach to the glenoid is being performed, a vertical incision is made overlying the posterior glenoid and full-thickness skin flaps are raised. Exposure of the glenoid is performed by splitting the deltoid longitudinally in line with its fibers. The infraspinatus and teres minor are now visible. These muscles can be partially or completely detached, or the inter- val between them can be utilized, depending on the amount of exposure necessary. Alternatively, a transverse incision can be performed along the length of the scapula spine, extending to the posterior corner of the acromion. The deltoid is then detached from its origin on the scapular spine and the plane between the deltoid and infraspinatus is identified and developed. Identifica- tion of the teres minor is now performed and the plane between the teres minor and infraspinatus is developed. By retracting the infraspinatus superiorly and the teres minor inferiorly, the pos- terior aspect of the glenoid and scapula neck is now exposed. The glenohumeral joint capsule can be incised longitudinally along the edge of the scapula to gain access to the joint.

❑❑ Retract posterior part of deltoid superolaterally without detaching its origin or insertion—the muscle can be detached if needed for improved visualization ❑❑ Identify and explore interval between the teres minor and infraspinatus by retracting the teres minor inferiorly and infraspinatus superiorly ❑❑ Detach infraspinatous insertion if necessary and incise capsule if fixing a glenoid cavity fracture ❑❑ Reduce fragment utilizing K-wires as joysticks and provisional fixation ❑❑ Fix fragment with either interfragmentary screws or plate/screw construct Anterior Glenoid Cavity Fractures ❑❑ Beach chair position with Mayfield headrest ❑❑ Prep and drape entire upper extremity and hemithorax ❑❑ Standard deltopectoral approach ❑❑ Place stay sutures in subscapularis and detach muscle from humerus ❑❑ Longitudinal incision to enter glenohumeral joint ❑❑ Place Fuduka retractor on humeral head to expose glenoid ❑❑ Reduce fragment utilizing intact labrum or K-wires as joysticks and provisional fixation ❑❑ Fix fragment with either interfragmentary screws or plate/screw construct Displaced Coracoid Process Fractures ❑❑ Beach chair position with Mayfield headrest ❑❑ Prep and drape entire upper extremity and hemithorax ❑❑ Standard deltopectoral approach ❑❑ Identify and protect musculocutaneous nerve ❑❑ Fix large coracoid process fractures with interfragmentary screw fixation ❑❑ Fix small coracoid process fractures using heavy nonabsorbable suture through the conjoint tendon and passed through a drill hole in the intact coracoid process Displaced glenoid neck fractures are approached through the posterior approach with placement of a plate along the poste- rior aspect of the glenoid and extending down along the lat- eral angle of the scapula. Operative treatment of type Ib, type II, and type IV glenoid cavity fractures is also performed via a posterior approach. The infraspinatus can remain attached during fixation of type Ib fractures, whereas detachment is necessary for types II and IV fractures. Fixation of type Ib fragments is typically performed using two interfragmentary screws, whereas types II and IV fractures typically require plate and screw fixation. An anterior deltopectoral approach is used to perform ORIF of type Ia and III glenoid cavity fractures as well as coracoid fractures displaced greater than 2 cm. Fixation is achieved with interfragmentary screws for type Ia and large coracoid process fractures if the fragment is large enough, whereas plate and screw fixation is typically necessary for type III fractures. Alternatively, suture anchors can be used to stabilize type Ia fragments and small coracoid process fractures can be reattached with the con- joint tendon utilizing heavy nonabsorbable suture placed in a Bunnell fashion through the tendon and passed through a drill hole in the intact coracoid process. Arthroscopic fixation of type Ia fractures can also be performed by using suture anchor fixa- tion to the intact labral attachment of the fragment. 142

Technique

✔ ✔ ORIF of Scapula Fractures: KEY SURGICAL STEPS

Posterior Glenoid Cavity Fractures and Glenoid Neck Fractures ❑❑ Lateral decubitus position using bean bag ❑❑ Prep and drape entire upper extremity and hemithorax ❑❑ Posterior approach with arm abducted

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