Authors:
Jyothiprasanth M. MD.
Senior Consultant Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India
Jithin C R. MD.
Associate Consultant Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India.
Venkatesh Kumar S . MD.*
Consultant Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India.
Aghosh MC. MD.
Consultant Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India.
Sarang P. MD.
Clinical Pharmacologist, Baby Memorial Hospital, Kannur, Kerala, India.
Mohamed Hadi Mansoor. MD.
Clinical Pharmacologist, Baby Memorial Hospital, Kannur, Kerala, India.
Ajinas T P. MD.
Clinical Pharmacologist, Baby Memorial Hospital, Kannur, Kerala, India.
* email: mailvenkatesh91@gmail.com
All the authors declare no conflict of interest.
SUMMARY
Surgical management of scapular fractures with intra-articular extension into the glenoid fossa is a technically demanding procedure which requires careful preoperative plan and precise execution during the surgery to prevent potential complications. Arthroscopic-assisted fracture fixation offers the benefit of reducing complications linked to traditional open surgery and the opportunity to treat concurrent ligament and labral injuries. We present a scenario where a 3-part Ideberg type-3 glenoid fracture in the right scapula was treated with internal fixation using arthroscopic-assisted technique along with Bankart repair. This approach minimizes morbidity, allows optimal visualization and reduction, and provides good functional results.
BACKGROUND
Multifragmentary Intra-articular fractures of the glenoid fossa are rare fractures with associated other bony and soft tissue injuries. Historically, surgery involving the use of open reduction and internal fixation has been advised for displaced intra-articular glenoid fractures [1]. On the other hand, open reduction carries risks such as heightened intraoperative bleeding, harm to soft tissues, higher rate of postoperative infection, joint stiffness, and delayed recovery when compared to arthroscopic surgery.[2] Few studies have reported on arthroscopic assisted fixation of multifragmentary intra-articular glenoid fossa fractures. We present a situation where a 3-part Ideberg type-3 glenoid fracture in the right scapula was treated with arthroscopic-assisted fixation and Bankart repair. This method reduces illness, enables clear view and alignment, and delivers positive functional outcomes.
CASE PRESENTATION
A 40-year-old male arrived at our emergency department with right shoulder pain following a fall onto his right shoulder during an accident two days prior, for which he had received first-aid at a nearby hospital. He had no medical history of diabetes, hypertension, heart diseases, etc. There were no additional issues such as head injury, ear-nose-throat bleeding, vomiting, etc. at the time of the fall. The patient stated that they had no previous injuries or surgical procedures.
Physical examination revealed severe tenderness on palpation of the coracoid process of the right shoulder with no overlying skin or soft tissue injury. 0 – 30 degrees of passive flexion is noted in the shoulder with tolerable tenderness all along the passive flexion. The range of movements of the elbow, wrist and fingers were found to be normal.
INVESTIGATIONS
The right shoulder antero-posterior radiograph demonstrated a 3-part Ideberg type-3 glenoid fossa fracture with the fracture line exiting the scapula superiorly. The MRI reported a displaced fracture of the anterior superior aspect of the bony glenoid involving the articular surface with a tear noted in the glenoid labrum. The supraspinatus tendon, infraspinatus tendon, subscapularis tendon and teres minor tendon appear normal. The long head of biceps and its attachment appears normal
SURGICAL PROCEDURE
The right Shoulder prepared and draped in lateral position. The standard anterior and posterior arthroscopic portals were made. Following that Neviaser portal was made. A diagnostic arthroscopy is done to determine all the bony and ligament/ tendon injuries of the shoulder. A severely displaced 3-part fragments were noted with a transverse fracture of glenoid fossa exiting superiorly and anterior labral tear extending from 12 o' clock to 6 o' clock were noted. The callus between the fracture sites were removed and the fracture site freshened using shaver.
A K-wire is passed into the displaced intra-articular fragment under arthroscopic and fluoroscopy guidance through the neviaser portal. The K-wires will be 5 mm below the cortical edge of the glenoid surface and parallel to one another. Using the K-wire as the joystick the displaced fracture was reduced without any intra-articular steps and provisionally placed in position using a probe. K-wire was then advanced into the glenoid bone and the fracture was provisionally stabilized. The reduction was found to be satisfactory through posterior viewing portal and C-arm. Two CC screws were placed over the reduced glenoid fracture from the antero-superior aspect of the glenoid to the postero-inferior aspect of the glenoid under the arthroscopic and fluoroscopic guidance. The labral tear identified and fixed with 1 suture anchor (Sironix all suture anchor - 1.5mm). Wound closed and sterile dressing done.
OUTCOME AND FOLLOW-UP
The post-operative shoulder x-ray demonstrated satisfactory joint space and articular surface alignment. There was no bleeding or discharge from the surgical site throughout the postoperative period. The postoperative period was uneventful without any stiffness or infection. Active shoulder ROM exercise started after 3rd week after surgery and the patient gained full ROM without any shoulder instability by 8th post-operative week.
DISCUSSION
Multifragmentary fractures of the glenoid are extremely uncommon and typically require surgical intervention to realign and stabilize the dislocated joint fragments. Typically, open surgical arthrotomy is performed for complex displaced fractures[3]. Nevertheless, there has been a recent attempt to use arthroscopic assistance in reducing fractures and internally fixing them with screws or k-wires in order to minimize soft tissue damage, promote quick recovery, and achieve early functional outcomes[4]. In our case study, we effectively performed surgery on an Ideberg type-3 fracture using arthroscopic assistance for fracture reduction with a probe and joystick method, and then fixed internally with Cannulated Cancellous screws. Surgery was necessary due to significant displacement of the three articular fragments. Yet, in the traditional approach, open surgery would have required both anterior and posterior arthrotomy along with significant soft tissue damage.
There are only a small number of case studies available discussing the arthroscopic management of Ideberg type III patterns, where there is a transverse fracture dividing the upper portion of the glenoid fossa [5, 6]. Nevertheless, only two case studies have been documented regarding multifragmentary glenoid fractures treated through arthroscopic surgery[7, 8].
Glenoid fractures within the joint continue to pose challenges. While traditionally performed in an open manner, the morbidity associated with this procedure has resulted in a greater utilization of arthroscopy due to its distinct benefits[9]. Type III Ideberg fractures are less common and pose a more challenging situation. Nevertheless, we think that the advantages of arthroscopy for this type of fracture are even greater as compared to the more invasive open surgical method used for anterior glenoid rim fractures.
Gigante et al [8] reported a comparable fracture pattern of the glenoid fossa that was treated arthroscopically. Two percutaneous K-wires were used for internal fixation and were taken out after 6 weeks. In their case report, Wafaisade A et al [7] explain a method for fully arthroscopic fixation of a three-fragment, y-shaped glenoid fracture by initially using k-wires for temporary fixation and then applying a CC screw for permanent fixation. In the same way, we utilized k-wires for temporary stabilization and for the joystick technique to align the fracture in our situation, along with using a probe to maintain the reduction in position.
Tao MA et al [5] explain that when screws are strategically placed, there is a high chance of damaging the suprascapular nerve because it runs through the suprascapular notch and provides motor fibers to the supraspinatus muscle. In our situation, both the temporary K-wires and CC screws are inserted with fluoroscopic guidance from the front upper part of the glenoid to the back lower part outside the joint. The arthroscopic procedure revealed the positioning of both the K-wires and screw outside the joint. During the post-operative evaluation, there was no indication of damage to the suprascapular nerve as there was no weakness or involvement of the supraspinatus or infraspinatus.
LEARNING POINTS
Arthroscopic-assisted procedure anatomic reduction and stable screw fixation can be performed for intra-articular y shaped fracture patterns of glenoid fossa.
Modifications of the arthroscopic techniques and detailed pre-operative plan tailored for the specific for simple/ complex glenoid fractures can be planned accordingly sparing the need for open surgery and its associated complications.
REFERENCES
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