Scapular fractures occur frequently when the body is subjected to high-energy injury, and the incidence is low, accounting for 0.4%-1% of the total body fractures. Fractures often involve the scapula, neck, glenoid, coracoid, and acromion and are associated with other injuries ranging from 76% to 100%, such as ipsilateral clavicle, ribs, lung contusion, and craniocranial injury. The treatment of comminuted scapular fractures can be tricky. Improper treatment will likely cause many complications, such as glenohumeral instability, glenohumeral arthritis, scapular chest wall motion disorder, shoulder pain, etc. With the increasing demand of patients for upper limb function, surgical treatment of scapular fractures has attracted people's attention. Surgical treatment of glenoid and acromial fractures, unstable coracoid and acromion fractures, and significantly displaced scapular neck and body fractures is a standard clinical option. Currently, doctors in the Tibet region also use surgical methods for open reduction and internal fixation treatment of the above complex scapular fractures. Tibet is located in a high-altitude area with low pressure and low oxygen environment. Do these environmental characteristics affect the treatment of scapular fractures? We used "scapular fracture" and "plateau region" for literature searches in domestic journals, but there were no relevant reports.

To explore the characteristics of scapular fracture and analyze the therapeutic effect of open reduction and internal fixation of scapular fracture in the Tibet area.

From September 2018 to December 2021, 41 cases of comminuted scapular fracture were treated in the department of Orthopedics, People's Hospital of Tibet Autonomous Region, including 32 males and 9 females, with an average age of 42.1 (21-60) years. Thirteen patients suffered from traffic accidents, 17 patients from heavy crashes, and 11 patients from falling from height. Preoperative imaging examinations including scapular AP view and lateral view were performed to evaluate the ipsilateral shoulder girdle injury comprehensively. CT scan and 3D reconstruction were performed in complex cases. The scapular fractures were classified according to Miller's classification and Ideberg's classification. The indication for operation were as follow: GPT more than 20 degrees; fracture angulation in the scapular body was more than 45 degrees; medial or lateral column displacement was more than 20 millimeters, or 15 millimeters with more than 30 degrees angulation; superior shoulder suspension complex injury with fracture displaced more than 10 millimeters. Early combined surgeries were conducted to treat the scapular fracture and combined clavicle fracture under general anesthesia. The clavicle fracture was treated in the beach chair position, and the scapular fracture was treated in the lateral decubitus position. After an operation, antibiotics were used within 24 hours. The shoulder girdle was protected in a sling for 2 weeks. Only passive motion was allowed in the first 4 weeks. From week 4 to week 8, passive motion and active assisted motion were started. Regular follow-ups were performed to observe fracture healing, and the arm, shoulder, and hand disabilities score (DASH) was utilized to evaluate upper limb function.

The operations were successful in all cases, and complete follow-ups were obtained, with an average follow-up time of 18 months. All incisions healed primarily. Besides, there was no facture nonunion and atrophy of infraspinatus muscle and deltoid muscle after the operation, achieving an ideal overall recovery of shoulder joint function, with an average DASH score of 7.8 (4-21). The mean anterior elevation is 164 degrees, the mean abduction is 110 degrees, and the mean external rotation at side is 54 degrees.

In the Tibet plateau area, the early operation of severe scapular comminution fracture, which achieves anatomical reduction and firm fixation of the fracture, is advantageous for treating combined injuries. Moreover, active functional rehabilitation after the operation benefits the recovery of shoulder joint function.