International Orthopaedics (SICOT) DOI 10.1007/s00264-015-2821-8

REVIEW ARTICLE

Early history of scapular fractures Jan Bartoníček 1 & Michal Kozánek 2,3 & Jesse B. Jupiter 2

Received: 8 May 2015 / Accepted: 15 May 2015 # SICOT aisbl 2015

Abstract The first to use the term Scapula was Vesalius (1514–1564) and thus it has remained ever since. Probably the oldest injured scapula, from 250 million years ago, was described by Chinese authors of a skeletal examination of a fossilised remains of a dinosaur Yangchuanosaurus hepingensis. In humans, the oldest known scapular fractures date back to the prehistoric and early historic times. In ancient times, a fracture of acromion was described in the treatises of Hippocrates. Early modern history of the treatment of scapular fractures is closely interlinked with the history of the French surgery. The first to point out the existence of these fractures were Petit, Du Verney and Desault in the 18th century. The first study devoted solely to scapular fractures was published by Traugott Karl August Vogt in 1799. Thomas Callaway published in 1849 an extensive dissertation on injuries to the shoulder girdle, in which he discussed a number of cases known at that time. The first radiograph of a scapular fracture was published by Petty in 1907. Mayo Robson (1884), Lambotte (1913) and Lane (1914) were pioneers in the surgi-

* Jan Bartoníček [email protected] Michal Kozánek [email protected] Jesse B. Jupiter [email protected] 1

Department of Orthopaedics of the 1st Faculty of Medicine, Charles University and Central Military Hospital Prague, U Vojenské nemocnice 1 200, 169 02 Praha 6, Czech Republic

2

Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA

3

Faculty of Medicine, Comenius University, Bratislava, Slovakia

cal treatment of these fractures, followed in 1923 by the French surgeons Lenormat, Dujarrier and Basset. The first internal fixation of the glenoid fossa, including a radiograph, was published by Fischer in 1939.

Keywords Scapular fracture . History of treatment of scapular fractures . Scapula . History

Background For the first time, we published a study of the history of treatment of scapular fractures in 2010 [1]. However, our findings in the following years have significantly contributed to, and in certain aspects even changed, the facts related particularly to the 19th and the beginning of the 20th centuries as stated in that original study. For this reason we have decided to publish a substantially revised version.

The term scapula According to Hyrtl [2], in the ancient world the term Scapulae (plural of scapula) denoted the back of the body. Scapula was referred to as Os latum scapularum (e.g., by Aristotle and Galen). Celsus mentions that the Romans also used the term Scutulum opertum, or exceptionally Palla (Caelius Aurelianus). The medieval world did not know the term scapula, most often using either Spathula or Scoptula instead. The first to use the term Scapula was Vesalius (1514–1564) and thus it has remained ever since.

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Prehistory Probably the oldest injured scapula, from 250 million years ago, was described by Chinese authors of a skeletal examination of a fossilised remains of a dinosaur, Yangchuanosaurus hepingensis. Based on their analysis, they hypothesized that the injury was caused in a fight with another dinosaur, Mamenchisaurus hochuanensis [3]. In humans, the oldest known scapular fractures date back to the prehistoric and early historic times [4, 5]. In ancient times, a fracture of acromion was described in the treatises of Hippocrates [4].

The French period of 1579–1798 The oldest description of a fractured scapula, caused probably by a war injury, was presented by Ambroise Paré (1510–1590) in 1579 [6]. Paré, the personal physician to four French kings, stated B…in case of fracture, if the parts move and prick the flesh, an incision should be made to remove them with a Bbec de corbinB (special device named Bcrow’s beakB). But if the pieces of bone do not prick the flesh and are still attached to the periosteum, they need not be removed since they will heal. If they are completely free from periosteum, they have to be removed because anyway they will be ultimately forced out, since they do not live anymore and, as stated by Hippocrates, Bthe living will always oust the dead^. When the fracture involves the neck of the scapula the prognosis is almost always fatal, as was also the case of some famous people, for instance the King of Navarre.^ Jean Louis Petit (1674–1760), an extraordinary French surgeon, dealt in detail with scapular fractures in his work BTraité des maladies des osB published in 1723 [7], distinguishing between fractures of the body, neck and processes of the scapula (acromion, coracoid, spine). He subdivided fractures of the scapular body into transverse, oblique and longitudinal ones. He provided the first recorded description of subcutaneous emphysema associated with scapular fractures and discussed the possibility of fracture of the glenoid rim associated with dislocation of the humeral head. Joseph-Guichard Duverney (1648–1730), a French anatomist and surgeon, likely preceded Petit but his works under a similar title BTraité des maladies des os^ were published by his pupils only after his death in 1751 [8]. Duverney used the same classification of the types of scapular fractures as Petit. He was also the first author to describe a fracture of the scapular neck in a 20-year-old woman, revealed by autopsy. In fact, it was the first known case history of a scapular fracture. Posthumous works of another prominent French surgeon Pierre-Joseph Desault (1738–1795), edited by his pupil Marie

Francois Xaver Bichat (1771–1802), were published in 1798 [9]. On the basis of case histories, Desault described fracture of acromion and of the inferior angle of the scapula.

Dissertations, theses and outstanding textbooks of surgery of 19th century The first studies devoted solely to scapular fractures was published by Traugott Karl August Vogt (1762–1807) in 1799 [10] and 1800 [11]. The dissertation containing a precise anatomical description of the scapula, its muscles, blood vessels and nerves, was based on autopsy of two cases of a fracture of the scapular body, one of which was associated with fracture of the clavicle. The drawings documenting these cases are most probably the first known illustrations of a scapular fracture (Fig. 1). An excellent description of the clinical examination of scapular fractures was published by a German surgeon, Johann Erdwin Christoph Ebermaier (1769–1825), in 1802 [12]. Giovani Battista Monteggia (1762–1815), in his monumental eight-volume work BIstituzioni chirurgicheB published

Fig. 1 The oldest know illustration of a scapular fracture based on autopsy, published by Vogt in 1799, was associated with a fracture of the clavicle

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in 1814, paid special attention to scapular fractures [13], distinguishing between factures of the body, the acromion and the coracoid process. He also divided fractures of the scapular body into transverse fractures, fractures of the superior angle, inferior angle, or lateral angle (fractures of the scapular neck) and discussed the possibility of fracture of the glenoid fossa. Astley Paton Cooper (1768–1841), in his famous textbook BTreatise on Dislocations and on Fractures of the Joints^ published in 1822, mentioned briefly fracture of the acromion and the surgical neck of the scapula [14]. The description of both types of fractures is illustrated by their drawings (Fig. 2). Adolph Leopold Richter (1798–1876) dealt in detail with scapular fractures in his BHandbuch der Lehre von der Brüchen und Verrenkungen der KnochenB published in 1828 [4]. He presented two basic groups of these fractures, namely, fractures of the scapular body and fractures of the processes. Scapular fractures were further subdivided into longitudinal fractures, fractures of the supraspinatus, fractures of the infraspinatus and fractures of the scapular spine. In the group of fractures of processes he included fractures of the acromion, fractures of the coracoid process, fractures of the neck (surgical neck according to the description) and fractures of the glenoid fossa. Quite interesting is his mention of frequent injuries of the lungs associated with scapular fractures. Robert Adams (1791–1875) in BCyclopedia^ published in 1847–9, described three types of scapular fractures—the fractures of acromion, coracoid process and scapular neck [15]. In 1847, Joseph Francois Malgaigne (1806–1865) published BTraité des fractures et des luxations^ [16] accompanied in 1855 by an atlas of illustrations with a number of beautiful lithographs [17]. Malgaigne recognised fractures of the body of the scapula, fractures of acromion and fractures of the coracoid process. Fractures of the glenoid fossa are not Fig. 2 Fracture of the surgical neck and acromion published by Cooper in 1822

specifically mentioned there, although such a fracture can be seen in one of his drawings (Fig. 3). Thomas Callaway (1822–1869) published in 1849 an extensive dissertation on injuries to the shoulder girdle, in which he discussed a number of cases known at that time [18]. Callaway divided scapular fractures into those of the body, the inferior angle, the neck, the processes and the inferior tip (lowest angle). He described in detail fractures of the surgical and anatomical necks of the scapula, but totally omitted fractures of the glenoid fossa. The German surgeon Ernst Julius Gurtl (1825–1899) published in 1864 his BHandbuch der Lehre von den Knochenbrüchen^ [19], in which he presented an overview of most (in total 42) of the cases of the fractures of the scapula hitherto published in the German, French and English literature. He also mentioned fractures of the glenoid fossa in greater detail. At the same time, he questioned the existence of fracture of the anatomical neck of the scapula, as he found neither description, nor specimen of such a fracture. The book contains illustrations of different types of scapular fractures (Fig. 4). Gurtl’s book actually closes the 50-year period during which scapular fractures were gradually recognized as a separate entity, particularly thanks to works by Desault, Cooper and Malgaigne published not only in Europe, but also in North America. In the second half of the 19th century the issue of scapular fractures was discussed by a number of French authors in their dissertations, namely, Couhard [20] in 1866, Lartigau [21] in 1877 and Cavayé [22] in 1882. Cavayé was also probably the first to study scapular fractures experimentally. Injuries to the scapula in children were described in detail by John Poland (1855–1937) in his monumental textbook published in 1898 [23].

International Orthopaedics (SICOT) Fig. 3 Different types of scapular fractures from the Malgaigne’s atlas of 1855

Interesting case histories of the 19th century Achille-Cléophas Flaubert (1784–1846), the father of the famous writer Gustave Flaubert, described a case of a 57-yearold sailor who sustained anterior dislocation of the shoulder in 1827 [24]. During later reduction, the axillary artery was

damaged with fatal consequences. The autopsy revealed an avulsed anterior glenoid rim. William Gibson (1788–1868), a participant in the battle of Waterloo, described in 1828 a 35-year-old man with anterior dislocation of the head of the humerus. A forced reduction caused aneurysm of the axillary artery [25]. It is interesting

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Fig. 5 Fracture of the glenoid fossa published by Gibson in 1828. Specimen of the left shoulder, detail of fracture of the glenoid fossa: a Fracture of the acromion. b Glenoid fossa. c Anteroinferior fragment of the glenoid fossa. d Avulsed tuberculum maius humeri. e Caput humeri

Fig. 4 Comminuted fracture of the scapular body published by Gurtl in 1864

that assisting in that reduction was John Rhea Barton (who described elsewhere the first intertrochanteric osteotomy, and fractures of the dorsal and palmar rims of the distal radius). The autopsy revealed a fracture of the anteroinferior portion of the glenoid, involving one third of the articular surface, a fracture of the acromion and also of the greater tuberosity of the humerus. The article was accompanied by two drawings. Kirbride [26] described the case of a man hit by a railway locomotive in 1835, who sustained a transverse fracture of the scapula and laceration of gluteal muscles, and who died as a result of the injuries. Among rare injuries were a wound caused by the person’s own axe during the fall from a tree [27], or by an assailant’s sword [28] or a gunshot injury [29]. Of great value for the understanding of the mechanism and anatomy of fractures of the coracoid process were case histories published in 1839 [30], 1858 [31] and 1869 [32]. Spence and Steel [33] were probably the first authors to present a case of glenoid fossa fracture on the basis of clinical description and autopsy in 1863 (see below). A case of an open fracture of the inferior angle of the scapula, in a 16-year-old boy run over by a car, was described by Sissons [34] in 1860. The patient healed in three weeks. In 1895, Holmden [35] reported an open fracture of the neck of the scapula and a simple fracture of the shaft of the humerus. The patient healed without sequelae. A fatal injury to the scapula, caused by fall of a crane, and associated with rupture of the subclavian artery and vein, was

presented in 1891 by Smith [36]. In 1896, Bonnet [37] published a case of a comminuted fracture of the scapula with devastation of soft tissues and fracture of the humerus, caused also by a crane, in which interthoraco-scapular (forequarter) amputation did not prevent the patient’s death. A transpinous fracture of the scapular neck and the resulting gangrene of the upper limb, caused by rupture of the axillary artery, in a train shunter were described by Ziegler [38] in 1899. In this case amputation of the arm saved the patient’s life.

Fig. 6 Fracture of the scapular body from Callaway’s dissertation of 1849

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Drawings of scapular fractures in the 19th century The first drawings of a scapular fracture, or more specifically the scapular body, were presented by Vogt in 1799 [10] and 1800 [11]. Probably the oldest drawing of a fracture of the glenoid fossa may be found in a study published by Gibson [25] in 1828 (Fig. 5). Drawings of fracture of the surgical neck of the scapula and fracture of the acromion were published by Cooper [14] in 1822. In 1849, Callaway [18] included drawings of a fracture of the surgical neck and a comminuted fracture of the scapular body in his study (Fig. 6). Malgaigne’s atlas of 1855 [17] is renowned also for its impressive lithographs. A number of illustrations used in the Gurtl’s book of 1863 [19] include a fracture of the glenoid fossa, as described by Spence and Steel [30] (Fig. 7). In 1891, Braun [39] mentioned a secondary autopsy finding of fracture of the superior pole of the glenoid in a patient with a fracture of the humeral head (Fig. 8). Morestin [40], in 1894, published illustrations of a fracture of the surgical neck of the scapula. Of highly instructive value are colour illustrations from the Helferich’s atlas [41] of 1897 (Fig. 9).

Radiology of scapula fractures Probably the first to publish a radiograph of a scapular fracture, more specifically a fracture of the coracoid process, was Petty [42] in 1907. In 1910, he was followed by Struthers with his radiograph of fracture of the glenoid fossa [43]. The first radiological study of scapular fractures included an analysis of 13 cases of different types of the scapular fractures examined between 1909 and 1911 and was published by Grune [44]. In 1911, Plageman [45]

Fig. 7 Original drawing of fracture of the inferior part of the glenoid fossa in the case described by Spence and Steell and published by Gurtl in 1864

Fig. 8 Fracture of the superior pole of the glenoid fossa published by Braun in 1891

described 19 cases of different types of scapular fractures diagnosed radiologically between 1905 and 1910. However, the text included only three drawings and no radiographs. Albin Lambotte (1866–1955) probably had a radiograph of a fractured scapula at his disposal as early as in 1907 [46], but he published the first radiograph of its internal fixation much later, in 1913 [47]. High quality radiographs of different types of fractures were published in 1916 by Hitzrot and Bolling [48].

International Orthopaedics (SICOT) Fig. 9 Fracture of the surgical neck and fracture of the scapular body from Helferich’s atlas of 1897

Outstanding publications of the beginning of 20th century Cotton [49] published a detailed textbook on BDislocation and joint fractures^ in 1910, in which he presented a thorough description of scapular fractures. In 1914, Mencke [50] analysed fractures of the acromion and published radiographs of different types of this fracture. In 1913, Tanton [51] published a study on fractures of the neck of the scapula. He distinguished between three types of fractures of the lateral angle of the scapula—fracture of the glenoid fossa, fracture of the anatomical neck and fracture of

the surgical neck. In addition, he described and illustrated a transpinous neck fracture. Two years later, in 1915, he summarized the contemporary knowledge of fractures of the scapula, including fractures in children, in an extensive chapter in his textbook of surgery, which, although remarkable in its extent, fell into oblivion [52]. An outstanding study was published in 1916 by Hitzrot and Bolling [48]. Even though they called it BFractures of the neck of the scapula^, it actually deals with all types of fractures of the scapula, including fractures of the glenoid fossa. In addition to description of their own eight clinical cases, they also presented results of their experiments. They added a detailed

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history of the treatment of scapular fractures in the second half of the 19th century.

Operative treatment The first to mention operative treatment of an injured scapula was Ambrois Paré in 1579 (see above). Dominique Larrey (1766–1842), a pupil of Desault and personal surgeon to Napoleon, performed an upper limb amputation in a case of open trauma of the shoulder caused by a cannonball in 1814. His operating protocol is precisely described by his assistant [53]. Larrey detected a comminuted fracture of the proximal humerus associated with fractures of the acromion close to its base, and of the scapular neck. These two pieces of bone, i.e., the acromion and the coracoid process-glenoid fossa block, were removed during the amputation. The patient recovered. The first internal fixation of the scapula, for a non-union of the scapular spine, was performed in 1884 by an English surgeon named Arthur William Mayo Robson (1853–1933) [54]. Robson described a case of a young miner who sustained, in January of the same year, a scapular fracture diagnosed as a fracture of the scapular spine. The fracture did not heal and significantly impaired the function of the arm. Therefore, on 6 March 1884, Robson fixed the scapular spine with a silver wire under antiseptic conditions. Both the wound and the nonunion healed without complications and by August of the same year active mobility of the limb was restored. Langlet and Herrmann [55] presented a case of an open fracture of the scapula caused by a blow from a lion in 1911. The fractured inferior pole of the scapula was extirpated. The first internal fixation of a scapular fracture was performed by Albin Lambotte [47] as early as 1910; but he published the case, including preoperative and postoperative radiographs, as late as in 1913. It was an unspecified transpinous fracture of the body, or neck, of the scapula treated with two screws. In 1914, William Arbuthnot Lane (1856–1943) described plate fixation of a displaced vertical fracture, with the fracture line passing through the spine and body of the scapula [56], which was associated with dislocation of the ipsilateral acromioclavicular joint. On 4 July 1923, the French surgeon Lenormat [57] used wire osteosuture of the lateral border for a displaced fracture of the scapula. Three months after the surgery, an infection developed and the hardware had to be removed. In spite of this, the fracture had healed with a good position of fragments. On 4 December of the same year, Lenormat’s colleague Dujarrier [58] fixed a fracture of the scapular neck using Lane Y-plate. One day later, on 5 December 1923, internal fixation of the scapula using such a Y-plate was performed by Basset [59]. In 1932, Dupont and Evrard [60] fixed a fracture of the

lateral border of the scapula using the Sherman plate and presented the first detailed description of the surgical approach along the lateral border of the scapula including two drawings. They were also the first to use the term Bpilier de l’omoplate^ (pillar of scapula) that has been used ever since in the French literature. In the United States, the first to treat a scapular fracture operatively was Darrach [61]. In 1914, he used two silk sutures to fix a delayed fracture of acromion, which subsequently healed. Longabaugh [62], in 1924, fixed an avulsed inferior angle of the scapula using kangaroo tendon. The first internal fixation of a glenoid fracture was described by Reggio [63] in 1938; however, the first pre- and postoperative radiographs of a glenoid fossa fracture were published by Fischer [64] in 1939. In 1943, Harmon and Baker [65] treated a comminuted fracture of the scapula by extirpation of the distal half of the scapula. The posterior approach to the shoulder with retraction of the spinal portion of the deltoid and the infraspinatus was first described by Rowe [66] in 1944.

Fractures of the glenoid fossa Fracture of the glenoid fossa is one of the most severe injuries to the scapula. It is interesting that this type of injury was neglected for a long time, or discussed only marginally. Petit [7] was the first to mention, in 1723, a fracture of the glenoid rim associated with dislocation of the humeral head. The next to discuss fractures of the glenoid fossa was Monteggia [13] in 1814. In 1828, Richter [4] mentioned this fracture only briefly in his textbook. Among the first articles describing and illustrating a fracture of the glenoid fossa were cases published by Flaubert [24] in 1827 and Gibson [25] in 1828 (see above). To our current knowledge, these two case histories are the oldest described fractures of the glenoid fossa, including the accompanying illustrations. In 1855, Malgaigne [17] published a drawing of a scapular injury showing a fracture of the glenoid fossa, but never mentioned this injury in his books, similarly as Desault, Cooper and Adams in the preceding period. In 1858 at a conference of the College of Physicians of Philadelphia, Neil [67] demonstrated a specimen of a scapula with a fracture of the glenoid fossa, with the fracture line running transversely and separating the base of the coracoid process, the scapular spine and the superior border of the scapula from the remainder. Spence and Steel, in 1863, were probably the first authors to present a case of a fracture of the inferior glenoid fossa on the basis of clinical description and autopsy [33]. During autopsy they found avulsion of the distal four fifths of the articular surface of the glenoid fossa and the fracture line extended about 3.5 cm below the infraglenoid tuberosity. The tendon of

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the long head of the biceps with the adjacent portion of the labrum was torn off the upper intact portion of the glenoid fossa. It presented the injury that is known today as SLAP lesion. However, the illustration of this case (Fig. 7) was published by Gurtl, who asked for permission to include it in his book published in 1864 [19]. In 1866, Assaky [68] described a case of a 65-year-old man who sustained an injury to his shoulder as a result of a fall, and a month later died of pneumonia. The autopsy revealed a three-fragment fracture of the glenoid fossa with a Y-shaped fracture line. The superior fragment of the articular surface carried the coracoid process, the superior border of the scapula including a part of the superior angle. The inferior fragment of the articular surface was attached to the lateral border of the scapula. The third fragment broke off from the posterior part of the glenoid fossa. The fracture of the glenoid fossa was associated with the fracture of the acromion. A similar finding was presented by Poland [69] in 1892 to the Hunterian Society, namely, a specimen of the scapula of a 46-year-old man with a stellate fracture of glenoid fossa, with three fracture lines radiating into the scapular body. The first to publish a radiograph of a fracture of the glenoid fossa, including a description of the case and the result of conservative treatment, was Struthers [43] in 1910. In 1916, Hitzrot and Bolling [48] published radiographs of three cases of fracture of the glenoid fossa. One case included a radiograph of the healed fracture and two photographs documenting the functional outcome. The first known internal fixations of fractures of the glenoid fossa were performed as late as before World War II. In 1938, this operation was marginally mentioned by Reggio [63] and the first pre- and post-operative radiographs of fracture of the glenoid fossa were published by Fischer [64] in 1939.

4. 5. 6. 7. 8. 9.

10.

11.

12. 13. 14. 15.

16. 17. 18. 19. 20. 21. 22.

Acknowledgments The study was prepared under the Grant IGA MZ ČR NT/14092: Diagnostics and operative treatment of displaced intraarticular fractures of the scapula. The authors wish to thank Mirka Plecitá and Ludmila Frajerová for assistance in tracing the original documents, and Professor Chris Colton and Ludmila Bébarová for their assistance in preparation of the manuscript. Conflict of interest The authors declare that they have no competing interests.

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