Saturday, May 11, 2013

Scapular fractures after reverse total shoulder

Scapular fractures after reverse shoulder arthroplasty: evaluation of risk factors and the reliability of a proposed classification.

Four of the six authors of this paper received payments from the company making a reverse total shoulder (RSA) and the study was funded by this company.

The authors identified 53 patients with scapular fractures after RSA and compared them to 212 control patients. The location of these fractures can be classified as (1) lateral acromion, (2) posterior to the AC joint and (3) scapular spine. They did not consider the first type. These fractures could be difficult to identify on plain films if they are not displaced.  Of note is that the average time from surgery to diagnosis of the fracture was 15 months. The risk of fracture was significantly increased in patients with osteoporosis. Fractures of the scapular spine tended to occur around the fixation screws.

Comment: Recognizing that patients needing reverse shoulder arthroplasty have reduced use of their shoulders prior to surgery with resulting disuse atrophy of the bone. This may be superimposed on osteoporosis, in that many patients are elderly females (over 80% in this report). The reverse total shoulder enables a sudden and dramatic increase in the loads applied to the scapular and also has the potential to weaken it with screw placement. These loads are increased if the deltoid is put under a lot of tension by distal translation of the shoulder. Additional loading may result from the patient's beginning to use the shoulder for assistance in rising from a chair or from use of walker, cane or crutch. 

Our practice is to advise patients of the risk of these fractures and to recommend a very gradual increase in arm use after RSA, especially in the presence of osteoporosis. If the patient presents with scapular pain at any time after this procedure, we find that clinical examination for scapular spine or acromial tenderness is very sensitive, perhaps more sensitive that imaging. These patients are advised to reduce activities while we monitor their progress.

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