Rahikiran Yallapragada, Kuntal Patel, Pardhasaradhi Davuluri, Andy Sloan, Hans Marynissen
Burnley General Hospital, East Lancashire Hospitals NHS Trust, Casterton Avenue, Burnley, BB10 2PQ, United Kingdom
House-12, Ross Avenue, CARMARTHEN. SA31 1HX
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We are reporting an interesting case of glenoid fracture in a 46-year-old male which was fixed with the help of arthroscopy. At present, anterior or posterior glenoid rim fractures and some greater tuberosity fractures are widely treated arthroscopically. We report the arthroscopically assisted fixation of a transverse articular glenoid fracture. Arthroscopic reduction and percutaneous fixation of glenoid fractures not only allows anatomic reduction with minimal surgical trauma but provides a valid diagnostic and treatment alternative for associated capsular, ligamentous, labral or tendon injuries as well as joint irrigation. The principle portals are discussed. We suggest fixation with cannulated screws for better stability of fracture fragments and advise K-wires for fractures that are comminuted and not amenable to cannulated screw fixation. However, arthroscopic fixation of shoulder fractures is associated with a learning curve depending on surgeon’s experience in shoulder arthroscopy.
Keywords: Arthroscopy, fracture glenoid, glenoid, intraarticular, percutaneous fixation, shoulder arthroscopy
How to cite this article:
Yallapragada R, Patel K, Davuluri P, Sloan A, Marynissen H. Arthroscopy-assisted percutaneous fixation of glenoid fossa fracture. Int J Shoulder Surg 2007;1:96-9
How to cite this URL:
Yallapragada R, Patel K, Davuluri P, Sloan A, Marynissen H. Arthroscopy-assisted percutaneous fixation of glenoid fossa fracture. Int J Shoulder Surg [serial online] 2007 [cited 2013 Apr 19];1:96-9. Available from: http://www.internationalshoulderjournal.org/text.asp?2007/1/3/96/34515
Glenoid Fossa Fractures typically present with transverse fracture through the glenoid articular surface and are very uncommon comprising about 10% of scapular fractures, of which less than 10% of glenoid cavity fractures are significantly displaced. Arthroscopic reduction and percutaneous fixation yields excellent results with no complications that are associated with traditional open surgery. We are presenting a typical case of glenoid fracture which was successfully fixed arthroscopically.
Case Report Top
A 46-year-old right dominant-handed male slipped over cellar steps and fell backwards on his left shoulder. He presented with pain and difficulty in moving his left shoulder. No other significant medical history was noted. Examination revealed a superficial graze, bruising and tenderness over the posterior and lateral aspect of the shoulder, but no obvious deformity was noted. Mild swelling of the shoulder joint along with limited range of movements was observed. No neurovascular deficit in the left upper limb and no other injuries were noted. X-rays revealed a scapular fracture type Va Ideberg with significant intraarticular disruption. CT scans were not requested, as X-rays showed a large fragment of glenoid with obvious displacement and no significant comminution.
As surgical reduction was indicated, the patient underwent arthroscopically-assisted percutaneous fixation of the glenoid fracture under general anaesthesia. Patient was positioned in the lateral decubitus position with axial traction of 10 lbs. A standard postero-lateral portal was used. Glenoid labrum was intact anteriorly but there was a radial tear at the posterior labrum at the 9 o’clock position. Subscapularis was intact. Middle and inferior glenohumeral ligaments were intact anteriorly. There was an intraarticular fracture at the mid-equator of the glenoid with the main fracture line extending from 3 to 9 o’clock position and a second fracture line extending to the 7 o’clock position [Figure – 1]. The inferior glenoid was tilted and there was a 7 mm step off in the articular surface. The hemarthrosis was drained and an anterior portal was established under direct vision using an inside-out technique. The fracture fragments were reduced using 2 punch leavers and an anatomical reduction was achieved [Figure – 2]. The reduction was stabilised with a 2 mm K-wire. An attempt was made at placement of cannulated screw from antero-superiorly to postero-inferiorly. Unfortunately, the guide wire of the cannulated screws could not be positioned accurately and therefore, the reduction was further secured by a second 2 mm K-wire from antero-superior to postero-inferior in a somewhat divergent way. Arthroscopic observation confirmed that the wires did not violate the articular surface. The reduction was probed and found to be stable with no significant articular step off. The adequacy of the reduction was confirmed both arthroscopically as well as with image intensifier. Washout of debris carried out with normal saline. Portals were closed using 4/0 vicryl. The K-wires were bent and cut outside the skin.
Check X-rays on the second post-operative day revealed loss of position. Revision arthroscopic surgery was performed, this time using the beach chair position. Around 5 mm step-off was noted posteriorly and a gap of around 5 mm was noted in the horizontal plane posteriorly. Fracture was reduced using two punch levers and two 3.5 mm cannulated screws passed from antero-superior to postero-inferior direction over the guide wire of cannulated screws, from the anterior portal. Satisfactory anatomical reduction and inter-fragmentary compression was achieved [Figure – 3]. A sling was given to immobilise the left shoulder for four weeks. Gentle external and internal rotation movements were allowed. A continuous interscalene block using ropivacaine was used to control the post-operative pain for three days. Standard scapula tonifications and isometric exercises were started. Physiotherapy was started at four weeks, starting with gentle active-assisted movements of shoulder with less than 60 degrees of flexion and abduction for two weeks. Subsequently the shoulder was mobilised as discomfort allowed. After three months he regained around 90 % range of painless movement as compared with his right shoulder.
Fractures of the glenoid cavity are rare and can result in chronic instability or degenerative joint disease. Scapula fractures account for only 1% of all fractures and 3% of injuries to the shoulder girdle. Of these, 10% involve the glenoid cavity, while 25% involve the glenoid neck.  Many authors have concluded that operative indications include intraarticular fractures with greater than 5 mm of articular step-off or instability.  Anatomic restoration of the joint surface is the goal in management of displaced intra-articular fractures. In the light of recent advances in the arthroscopic surgery the surgical fixation of these fractures moved from extensive open reduction to minimally invasive surgery. At present, anterior or posterior glenoid rim fractures and some greater tuberosity fractures are widely treated arthroscopically. Arthroscopic reduction and percutaneous fixation of glenoid fractures not only allows for anatomic reduction with minimal surgical trauma but also provides a valid diagnostic and treatment alternative for associated capsular, ligamentous, labral or tendon injuries as well as for joint irrigation.
Arthroscopy has been used for removing the fibrous tissue at the nonunion site and freshen bone surfaces in treating greater tuberosity nonunion  as well as for bone grafting of a juxta-articular glenoid cyst following a fracture of the glenoid.  Successful treatment of anterior glenoid rim fractures involving greater than 15%-25% of the articular surface and associated with shoulder instability has been well-established in the literature using arthroscopic surgery.  The surgical technique includes a lateral decubitus position of the patient which may aid in the reduction of the fracture by providing ligamentotaxis around the joint.  Beach chair position can be used in fractures with complex configuration, as it aids appropriate placement of cannulated screws.  The fracture should be provisionally fixed with K-wires under direct visualization through arthroscopy.  Inter-fragmentary compression should be achieved with a cannulated lag screw placed over the guide wire.  In Ideberg type II, IV and V fractures, posterior plating may be required for fracture neutralization. ,
Current indications for surgical reduction of Ideberg type I fractures include a fracture displacement of > 10 mm, involving >25% of the anterior rim or >33% of posterior rim and/or persistent instability. , The recommended treatment is screw fixation with/without capsulolabral repair. However, when comminution precludes screw fixation, the fragment can be excised followed by a bone grafting procedure to augment the glenoid rim. , Various treatment options have been described in literature for Ideberg type II to type V fractures of the scapula. These range from functional treatment, percutaneous surgical fixation and open reduction and internal fixation.  Fracture with greater than 5 mm displacement and/or humeral head subluxation is an indication for surgical fixation.  Surgical approach depends on the fracture type. Anterior approach is chosen for anterior rim fractures (Type Ia), as well as some glenoid fossa fractures (Types III, IV and Vb) whereas posterior approach is appropriate for posterior glenoid rim fractures (Type Ib), most fractures of the glenoid fossa (Types II, III, IV and V) and glenoid neck fractures.  However, arthroscopic fixation considered as a preferred method of surgery, depending on the fracture pattern and expertise of the surgeon. 
Complications associated with arthroscopic fixation of gelnoid fracture include compartment syndrome due to fluid extravasation  and anterior interosseous nerve syndrome due to mechanical trauma, compressive hematoma or direct anaesthesia neurotoxicity.  Injury to the neurovascular structures due to incorrect placement of portals is another possible complication, which can be avoided by using properly placed appropriate portals. The following table outlines the commonly used portals and the structures at risk.
The central-anterior portal is deemed to be safe as long as the surgeon wouldn’t move below the tip of the coracoid process.
There are a variety of surgical options for fixing the glenoid fractures of which cannulated screws fixed arthroscopically provide better fixation whilst avoiding the complications of arthrotomy such as soft tissue dissection, blood loss, long postoperative recovery periods and poor cosmetic outcomes. K-wires can provide temporary or permanent fixation and can be used to “joystick” fracture fragments into position, but in our experience they may be better reserved for fixing the fractures not amenable to cannulated screws. In spite of few relative contraindications to arthroscopic repair of associated injuries such as humeral avulsions of the glenohumeral ligaments and capsular ruptures which may need high level of arthroscopic skills,  many associated injuries can be detected and repaired arthroscopically with minimal surgical dissection. There are few studies detailing the results of open operative management of glenoid fractures but there were less than ten reports of arthroscopy-assisted procedures since the first report published in 1999. Carro et al. ,  described percutaneous external fixation of a displaced intraarticular glenoid fracture under arthroscopic guidance. However, results of this technique have not been shown by any other studies. Suture anchors are commonly used to fix the fragment if the fragment is small and not amenable to screw fixation. Sugaya et al. ,  described arthroscopic stabilization using suture anchors for a consecutive series of 8 patients, with an average of 27% bone loss (fragment size) against the lower part of the circular glenoid portion. They have used three-dimensional computed tomography (3D-CT) to assess the fracture with the humeral head eliminated, preoperatively and postoperatively. Gigante et al ,  described the surgical technique adopted to treat a multiple, Y-shaped articular glenoid fracture using arthroscopy assisted percutaneous fixation.
Adjunct use of arthroscopy in fixing the intraarticular fractures has been well-established in the recent past. However, the technique is still evolving for fixation of transverse glenoid fractures and fractures with complex fracture patterns. In conclusion arthroscopic technique alleviates the need for the open approach and certainly seems promising as an alternative surgical method.
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