Surgical indications for scapula fractures in the pediatric and adolescent populations include open fractures, fractures with associated neurovascular injuries requiring operative intervention, large glenoid rim fractures with associated proximal humerus subluxation/dislocation, Type II glenoid neck fractures, coracoid process fractures with greater than 2 cm of displacement, and glenoid cavity fractures with displacement greater than 5 mm (An et al. 1988; Ada and Miller 1991; Kavanagh et al. 1993; Nettrour et al. 1972). Floating shoulder injuries involving the glenoid neck and midshaft of the clavicle can be managed by ORIF of the clavicle, as the glenoid neck will reduce via ligamentotaxis provided by the intact coracoclavicular ligament (Bahk et al. 2009). Likewise, floating shoulder injuries involving fractures of the glenoid neck, midshaft of the clavicle, and scapular spine can be treated by ORIF of the clavicle and scapular spine due to ligamentotaxis provided by the intact coracoclavicular and/or coracoacromial ligaments (Bahk et al. 2009). The remainder of injuries should be managed nonoperatively with immobilization.

A standard deltopectoral approach is utilized to gain anterior access to the glenoid and coracoid. An incision is made along the deltopectoral groove beginning at the coracoid proximally and extending 10–15 cm distally. Sharp dissection is performed through the skin, and the cephalic vein is identified in the deltopectoral groove. The deltoid is then retracted laterally and the pectoralis major medially; the cephalic vein can be taken in either direction. The short head of the biceps and the coracobrachialis are then identified and retracted in a medial direction. Access to the anterior aspect of the shoulder joint is now easily gained. In order to obtain adequate exposure of the glenoid, the subscapularis must be taken down and a retractor placed in the glenohumeral joint to retract the humeral head.

The majority of coracoid fractures are fixed via an incision over the coracoid in Langer’s lines. The deltopectoral approach may be extended proximally to achieve coracoid exposure if there is an associated superior glenoid fracture that also requires exposure. Dissection should continue down the slope of the coracoid to the base so that the fracture can be best visualized. If a coracoid base fracture involves part of the superior glenoid fossa, a posterior approach with indirect reduction of the superior glenoid may be used (Anavian et al. 2009). Fractures of the lesser tubercle of the humerus may be exposed via an anterolateral approach or standard deltopectoral approach.

A posterior approach to the glenoid requires a vertical incision overlying the posterior glenoid and full thickness flaps to be raised. The deltoid is split longitudinally in line with its fibers in order to visualize the infraspinatus and teres minor. These muscles can be partially or completely detached, or the interval between them can be utilized, depending on the amount of exposure necessary. The capsule is now visualized and can be incised to access the glenoid. Alternatively, a transverse incision can be made along the length of the scapular spine and extended to the posterior corner of the acromion. Next, the deltoid is detached from its origin on the scapular spine, and the plane between the deltoid and infraspinatus is identified and established. The teres minor is then identified, and the plane between the teres minor and infraspinatus is established. Retracting the infraspinatus superiorly and the teres minor inferiorly will expose the posterior aspect of the glenoid and scapular neck. A longitudinal incision of the glenohumeral joint capsule along the edge of the scapula will then provide access to the joint.

The posterior approach is performed to visualize displaced glenoid neck fractures, and a plate is then placed along the posterior aspect of the glenoid and extending down along the lateral angle of the scapula. Surgical treatment of Type Ib, Type II, and Type IV glenoid cavity fractures are also performed via a posterior approach. The infraspinatus attachment can remain intact during fixation of Type Ib fractures; however, detachment is required for Type II and IV fractures. Fixation of Type Ib fragments typically requires two interfragmentary screws, whereas Type II and IV fractures usually require plate and screw fixation.

ORIF of Type Ia and III glenoid cavity fractures or coracoid fractures displaced greater than 2 cm is performed via the anterior deltopectoral approach. Fixation of Type Ia and large coracoid process fractures is achieved utilizing interfragmentary screws if the fragment is large enough, whereas Type III fractures typically require plate and screw fixation. Suture anchors can alternatively be used to stabilize Type Ia fragments, and small coracoid process fractures can be reattached with the conjoint tendon by utilizing heavy nonabsorbable suture placed in a Bunnell fashion through the tendon and passed through a drill hole in the intact coracoid process. Additionally, arthroscopic fixation of Type Ia fractures can be performed via suture anchor fixation to the intact labral attachment of the fragment (Sugaya et al. 2005).

There is currently no data evaluating outcomes of pediatric and adolescent patients treated with ORIF of scapula fractures. Adult studies have reported that the results of operative fixation of glenoid cavity fractures depend on near-anatomic restoration of joint alignment, with good to excellent results expected for 80–90 % of patients who have residual incongruity less than 2 mm (Mayo et al. 1998; Kavanagh et al. 1993).

Damage to neurovascular structures can occur if forceful retraction is used, thus care must be taken during ORIF when retracting structures about the shoulder. For example, the musculocutaneous nerve and lateral cord are at risk during excessive medial retraction about the glenohumeral joint and coracoid.

Near-anatomic reduction of the articular surface is critical during ORIF of glenoid cavity fractures as residual displacement greater than 2 mm leads to poorer outcomes (Mayo et al. 1998; Kavanagh et al. 1993). Additionally, persistent glenohumeral subluxation/dislocation can develop if large glenoid cavity fragments are not properly reduced.

Nonoperative management of scapular body fractures can be complicated by nonunion and symptomatic malunion (Ferraz et al. 2002; Martin and Weiland 1994; Michael et al. 2001). Nonunions can be treated with good to excellent results by performing ORIF. Moreover, significant displacement associated with glenoid neck fractures has been shown to be a poor prognostic indicator. Therefore, fixation of fractures with angulation greater than 40° or more than 1 cm of displacement will generate improved outcomes (Nordqvist and Petersson 1992; Edwards et al. 2000; Labler et al. 2004). Finally, large glenoid rim fractures should be treated surgically to prevent subluxation/dislocation of the glenohumeral joint.

Pain in the shoulder region localized to the acromioclavicular joint area is the most common complaint of patients who have sustained acromioclavicular dislocations. Patients may also complain of numbness and tingling due to edema or concomitant cervical spine and/or brachial plexus injury. Sometimes, however, patients only complain of a “bump” in the region.

Physical examination should begin with observation of the shoulder with the patient in an upright position, allowing the weight of the arm to make any deformity more evident. While observing, note any swelling, ecchymosis, and/or abrasions. Palpation of the acromioclavicular joint will cause significant discomfort and thus should be performed at the conclusion of the examination. Surrounding areas including the proximal humerus, midshaft and medial clavicle, sternoclavicular joint, and cervical spine should be palpated first. Potential concomitant brachial plexus or cervical spine injury should be evaluated for with a thorough neurologic examination. Most displaced distal clavicles are malpositioned superiorly and demonstrate both visual and palpable deformity. However, the clavicle may displace posteriorly, become entrapped in the trapezius muscle, and exhibit a palpable prominence with tenderness being present medial and posterior to the acromion. These Type IV injuries may be difficult to diagnose unless explicitly evaluated for.

When an acromioclavicular injury is suspected, the joint should be evaluated for stability once the acute pain has subsided, approximately 5–7 days post-injury. Horizontal and vertical stability should be assessed before considering a potential closed reduction. Closed reduction is performed by using one hand to stabilize the clavicle while generating upward force under the ipsilateral elbow with the other hand. Once reduction in the coronal plane has been achieved, the midshaft of the clavicle can be gripped and translated in an anterior and posterior direction to assess horizontal stability (Simovitch et al. 2009).

Plain radiographs are the preferred initial imaging modality and should include a true AP view, axillary lateral view, and a Zanca view of the shoulder to visualize the acromioclavicular joint. The Zanca view requires the patient to be positioned upright so that the injured arm can hang by the weight of gravity, while the x-ray beam is aimed 10°–15° cephalad (Zanca 1971). Stress views can also be obtained to differentiate between Types II and III injuries by asking the patient to hold a weight in their hand. A CT scan may be necessary to diagnose posterior fracture-dislocations (Type IV) as they are often difficult to identify on plain radiographs.

Akin to any injury about the shoulder region, the entire shoulder girdle must be examined for an associated injury. If enough force was present at the time of impact, anterior sternoclavicular dislocations as well as additional scapula, humerus, or clavicle fractures may occur concurrently. Furthermore, brachial plexus or cervical spine injuries may also be present, particularly if the injury occurred during a collision sport such as football.

Acromioclavicular injuries in adults are classified using a scheme developed by Tossy et al. and Allman, which was subsequently modified by Rockwood (Tossy et al. 1963; Allman 1967; Williams et al. 1989). Type I injuries demonstrate normal radiographs and exhibit the sole finding of tenderness to palpation over the acromioclavicular joint caused by a sprain of the acromioclavicular ligaments. In Type II injuries, the acromioclavicular ligaments are disrupted along with a sprain of the coracoclavicular ligaments. Radiographs demonstrate a widened AC joint with slight vertical displacement exhibited by a mild increase in the coracoclavicular space. Type III injuries involve disruption of the acromioclavicular and coracoclavicular ligaments, and radiographs show displacement of the clavicle superiorly relative to the acromion by 25–100 % the width of the clavicle. Type IV injuries have disruption of the acromioclavicular and coracoclavicular ligaments as well as the deltopectoral fascia, permitting posterior displacement of the clavicle into or through the trapezius muscle. In Type V injuries, there is disruption of the acromioclavicular and coracoclavicular ligaments and deltopectoral fascia, with concomitant injury to the deltoid and trapezius muscle attachments to the clavicle. Thus, the clavicle is typically displaced greater than 100 % and lies in the subcutaneous tissue. Type VI injuries involve disruption of the acromioclavicular ligaments and deltopectoral fascia; however, the coracoclavicular ligaments remain intact. This injury occurs via a high-energy mechanism that causes the shoulder to be hyperabducted and externally rotated, resulting in a subacromial or subcoracoid position of the clavicle and a decrease in the coracoclavicular distance seen on radiographs (Tossy et al. 1963; Allman 1967; Williams et al. 1989).

Due to the low incidence of true acromioclavicular injuries in skeletally immature patients compared to fractures of the distal clavicle, this classification has been modified for the pediatric and adolescent populations (Dameron and Rockwood 1984). Generally, the clavicle itself displaces out of the periosteal sleeve, leaving the coracoclavicular and acromioclavicular ligaments attached to the periosteum. The clavicle injuries that result are then analogous to the six types described for adults.

Currently, no outcome scores exist to explicitly evaluate the results of acromioclavicular injuries, or any injury about the shoulder, in children and adolescents. Several adult shoulder and upper extremity outcome measures are available, however, to assess these injuries in older adolescents. Reported outcomes from acromioclavicular injuries have typically been based on subjective measures, the development of acromioclavicular osteoarthritis, and range of motion.