Judet Posterior Approach to the Scapula

What it exposes. The Judet posterior approach is the classic extensile posterior exposure of the scapula, described by Judet for scapular body, neck and glenoid fractures. It brings the infraspinous fossa, the strong lateral (axillary) border, the scapular neck and the posterior glenoid directly into view, allowing anatomic reduction and buttress plating of the lateral column. Why posterior (and not anterior). The posterior scapula, the lateral border, the scapular neck and the posterior glenoid cannot be adequately exposed from an anterior or deltopectoral route. The lateral border is the strongest column and the site for fixation, and it is only directly accessible posteriorly. The Judet is the workhorse extensile exposure for these structures. Indications. - Scapular body fractures meeting operative criteria (marked medialization, angular deformity, functional impairment)

• Scapular neck fractures (anatomical and surgical neck) with displacement or angulation
• Posterior glenoid fractures (Ideberg types) with articular step-off, instability or humeral head subluxation
• Double disruptions of the superior shoulder suspensory complex (the so-called floating shoulder)
• Scapular malunion requiring corrective osteotomy
• Selected scapular tumours requiring excision, open biopsy or reconstruction
• Posterior shoulder instability procedures such as a posterior bone block or capsular reconstruction Contraindications. Medical unfitness for prone positioning (unstable spinal injury, severe cardiorespiratory compromise); active infection or a compromised posterior soft-tissue envelope; minimally displaced fractures that will do well non-operatively; and the polytrauma patient not yet stabilised for a lengthy prone procedure. Alternative and complementary approaches. The anterior (deltopectoral) approach for anterior glenoid rim fractures and coracoid pathology; the mini-open posterior approach for isolated posterior glenoid fractures where full exposure is unnecessary; the superior approach to the supraspinous fossa for high scapular spine and suprascapular nerve pathology; and combined anterior and posterior approaches for complex two-column glenoid injuries. ### Position and landmarks Prone or lateral decubitus on a radiolucent table. Confirm the patient is haemodynamically stable and fit for prone positioning, pad all pressure points (face, eyes, chest, pelvis, knees, dorsum of the feet), keep arm abduction less than 90 degrees and well padded, confirm C-arm access from the opposite side, and document a baseline neurological examination of the upper limb before draping. Prone (on chest rolls or a Wilson frame) gives the most symmetric, stable field for a long posterior fixation but precludes simultaneous anterior work. Lateral decubitus, affected side up with the arm supported over a bolster, is preferred when an anterior procedure may also be required, since it allows easier conversion without repositioning. A bolster under the ipsilateral chest tilts the scapula forward and brings its posterior surface closer to the surgeon. Key bony landmarks are the acromion and its posterior corner (lateral start of the incision), the entire scapular spine (superior limb of the incision), the medial (vertebral) border (vertical limb), the inferior angle (distal extent), and the spinous processes (midline reference). The overlying trapezius is elevated during superficial dissection, the deltoid is reflected laterally off the spine, and infraspinatus and teres minor form the muscular floor that carries the internervous plane.

The muscular floor and its nerve supply

Approach variants

The unifying principle in every variant is the same: identify the internervous plane, stay on bone, and protect the suprascapular nerve at the spinoglenoid notch. ### Operative thresholds The decision to operate is driven by measurements made on the CT, not on plain films alone.

Work down through the layers along the boomerang incision: reflect the trapezius and deltoid off the scapular spine, expose the infraspinous fossa, then develop the infraspinatus to teres minor internervous plane to reach the lateral border and posterior glenoid neck. The suprascapular nerve at the spinoglenoid notch is the structure that governs the whole deep dissection.

The internervous plane The deep internervous plane lies between

infraspinatus (suprascapular nerve) superiorly and teres minor (axillary nerve) inferiorly. This is the true internervous safe interval — it allows exposure of the posterior glenoid neck and lateral border without denervating either muscle. There is no internervous plane in the superficial dissection in the strict sense: the trapezius (spinal accessory nerve) and deltoid (axillary nerve) are each reflected off their bony attachments rather than split, so their nerve supplies are protected provided dissection stays on bone.

Structures at risk, by layer

Extensile options. Extend proximally along the scapular spine toward the acromion and acromioclavicular joint for combined posterosuperior cuff and AC joint pathology (taking the deltoid origin down progressively from the spine and acromion). Extend distally and laterally by curving the vertical limb along the axillary border toward the axilla to expose the inferior glenoid and the long head of triceps origin, connecting distally with the posterior approach to the humeral shaft. The medial limb already exposes the medial border fully, useful for medial-based body fractures and medial scapular tumours. For complex two-column glenoid injuries or a floating shoulder requiring both scapular and clavicular fixation, plan staged positioning — typically the posterior Judet first in prone, then repositioning for any anterior work. Closure. Irrigate copiously and diathermy the circumflex scapular branches; repair the deltoid to the scapular spine with non-absorbable sutures through drill holes; re-attach the trapezius to the spine; close the fascia and subcutaneous layer in layers over a drain for the dead space; and close skin with staples or interrupted sutures. ### Complications

What determines a good result

Restoration of the glenopolar angle and the lateral column is the single most important determinant of a good functional outcome.

• Open reduction and internal fixation of scapular body and neck fractures meeting the operative thresholds above — the principal use of the classic exposure.
• Posterior glenoid fracture fixation (Ideberg types) with articular step-off or humeral head subluxation — the modified or mini-open variant is often sufficient.
• Fixation of double disruptions of the superior shoulder suspensory complex and the floating shoulder pattern.
• Corrective osteotomy for scapular malunion, and excision, biopsy or reconstruction of selected scapular tumours.
• Posterior bone block or capsular reconstruction for posterior shoulder instability.

Guidelines, registries and global practice

Scapular fractures are managed at trauma centres worldwide, and the principles converge across examination systems. Most are high-energy injuries occurring in the polytrauma setting, so assessment and resuscitation follow trauma principles before any operative planning. CT with three-dimensional reconstruction is the standard for operative decision-making, and the Judet posterior approach is the recognised extensile exposure for displaced scapular body, neck and posterior glenoid fractures across all regions. Side-by-side principles (where guidance converges). The AO Foundation regards CT as mandatory for articular and displaced scapular fractures, with the lateral column and glenoid as the key reduction targets and buttress plating of the lateral border restoring offset and the glenopolar angle. BOA / BOAST trauma guidance manages these as part of polytrauma, addressing life-threatening chest and associated injuries first with definitive fixation once the patient is stable. The OTA / AAOS recommends operative fixation for markedly displaced or angulated fractures, double disruptions of the superior shoulder suspensory complex, and unstable glenoid fractures, with anatomic restoration of the glenopolar angle as a primary goal. Population and registry evidence. Scapular fractures represent roughly 0.4 to 1 percent of all fractures and a small fraction of shoulder girdle injuries. The majority arise from high-energy blunt trauma, and a large proportion are associated with rib fractures, pulmonary contusion, clavicle fracture or brachial plexus injury. Long-term outcome is driven by restoration of the glenopolar angle and the lateral column rather than by patient age alone. Global practice variation. In high-resource settings, pre-contoured anatomic scapular plates and routine 3D CT planning are standard. In resource-limited settings the same biomechanical principle — buttressing the lateral column — is achieved with contoured 3.5 mm reconstruction plates, and the modified Judet or mini-open variants are favoured to limit morbidity where implant and theatre time are constrained. Consent (globally applicable). Discuss suprascapular and axillary nerve injury (mostly transient), infection (higher with large flaps and dead space), deltoid dehiscence with loss of abduction power, stiffness, and the possibility of hardware prominence or later glenohumeral arthritis.