AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

The primary function of the scapula is to attach the upper extremity to the thorax and provide a stabilized platform for upper extremity movement. The scapula is attached to the clavicle by the acromioclavicular and coracoclavicular ligaments and articulates with the humerus. The scapula is protected by its surrounding musculature (supraspinatus, infraspinatus, subscapularis) and its ability to move along the wall of the thorax; the body and spine of the scapula are most protected. Fractures to scapular structures typically require significant force. These factors explain the infrequent occurrence of scapular fractures.

Pathophysiology

The primary anatomic features of the scapula provide insight into the mechanisms of injury and offer a convenient classification system. Injuries to the body or the spine of the scapula typically result from a direct blow with significant force, as in a motor vehicle accident or a fall.

Scapular fractures are caused by different mechanisms. Acromion injuries usually result from a direct downward force to the shoulder. Scapular neck fractures most frequently result from an anterior or posterior force applied to the shoulder. Glenoid rim fractures most often result from force transmitted along the humerus after a fall onto a flexed elbow. Stellate glenoid fractures usually follow a direct blow to the lateral shoulder. Finally, coracoid process fractures may result from either a direct blow to the superior aspect of the shoulder or a forceful muscular contraction that causes an avulsion fracture.

Frequency

United States

Scapular fractures occur infrequently. They account for approximately 1% of all fractures and fewer than 5% of shoulder girdle injuries.

Mortality/Morbidity

• Morbidity and mortality result primarily from associated injuries.
• Traditional wisdom holds that scapular fractures serve as markers of increased morbidity and mortality in patients with blunt trauma. A recent retrospective study comparing patients with scapular fractures due to blunt trauma with control subjects matched for age, sex, and mechanism of injury demonstrated an increase in associated thoracic injuries yet revealed no difference in mortality or neurovascular injury.
• A large force is usually required to fracture the scapula, particularly the body or the spine; however, suspect scapular fractures and thoroughly search for associated injuries.

Sex

Scapular fractures are more common among men than among women because of their increased incidence of significant blunt trauma.

Age

Scapular fractures predominate in persons aged 25-40 years because of the increased occurrence of significant blunt trauma in this population.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The mechanisms of injury for various scapular fractures include the following:

• Body or spine fracture (40-75%): Fractures of the body or the spine of the scapula usually result from a severe direct blow, as in a fall or a motor vehicle accident.
• Acromion fracture (8-16%): Acromion fractures typically result from a downward blow to the shoulder. Superiorly displaced fractures may occur as the result of a superior dislocation of the shoulder.
• Neck fracture (5-32%): A direct anterior or posterior blow to the shoulder is the typical mechanism for a scapular neck fracture.
• Glenoid fracture (10-25%): Glenoid rim fractures often result from a fall onto a flexed elbow. A direct lateral blow is the common mechanism for a stellate fracture of the glenoid.
• Coracoid fracture (3-13%): Coracoid process fractures usually result from 1 of 2 mechanisms.
• • A coracoid process fracture is the result of a direct blow to the superior point of the shoulder or humeral head in an anterior shoulder dislocation.
  • An avulsion fracture may result from abrupt contractions of the coracoacromial muscle, short head of the biceps, or coracohumeral muscle.

Physical

Findings at physical examination may include the following:

• Body or spine fracture
• • Most common findings are tenderness, edema, and ecchymosis over the affected area.
  • The upper extremity is held in adduction, and any attempt to abduct the extremity (which results in scapular rotation) increases pain.
• Acromion fracture
• • Tenderness directly over the acromion process is the most common finding.
  • Deltoid contraction and arm abduction exacerbate pain.
  • Perform a careful neurologic examination to determine the presence of an associated brachial plexus injury.
• Neck fracture
• • A patient with a scapular neck fracture resists all movement of the shoulder and holds the extremity in adduction.
  • Maximal tenderness occurs at the lateral humeral head.
• Glenoid fracture
• • Stellate fractures of the glenoid have a presentation similar to that of scapular neck fractures, with severe pain on shoulder movement.
  • Avulsion fractures are occasionally associated with shoulder dislocations.
• Coracoid fracture
• • Patients with coracoid process fractures present with tenderness over the coracoid.
  • Forced adduction of the shoulder or flexion of the elbow exacerbates pain.

Causes

Scapular fractures are usually the result of significant blunt trauma.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Tailor the laboratory evaluation of a patient with scapular fracture to the likelihood of associated injuries.

Imaging Studies

• Radiography
• • An anteroposterior shoulder view, along with a lateral scapular view, demonstrates the vast majority of scapular fractures.
  • A lateral scapular (trans-scapular) view, combined with an anteroposterior shoulder view, provides the necessary 2-plane assessment of the scapula.
  • A lateral axillary view isolates the coracoid process and helps to delineate associated shoulder dislocations.
  • Tangential oblique views aid in the evaluation of small or subtle scapular body fractures.
• Computed tomography: A CT scan may be a helpful adjunct in glenoid and coracoid fracture assessment.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Prehospital care involves transport, with immobilization of the affected extremity.
• Because of the significant forces involved in producing a scapular fracture, consider life-threatening associated injuries.

Emergency Department Care

The following discussion of the ED treatment of scapular fractures assumes that a prudent search for associated injuries revealed negative findings.

• Body or spine fracture
• • Use of ice, analgesics, and sling and swath immobilization suffice for most fractures to the body or spine of the scapula.
  • Early range-of-motion exercises are recommended.
• Acromion fracture
• • Nondisplaced fractures of the acromion usually can be treated with sling immobilization, ice, and analgesics.
    
  • Displaced fractures and those associated with rotator cuff injuries often require surgical intervention.
• Neck fracture
• • Manage nondisplaced scapular neck fractures with a sling, ice, analgesics, and early range-of-motion exercises.
  • Displaced neck fractures require urgent orthopedic consultation for traction or surgical reduction.
• Glenoid fracture
• • Small and minimally displaced glenoid rim fractures usually respond to conservative therapy with a sling, ice, and analgesics, followed by early range-of-motion exercises.
  • Large or significantly displaced fractures, as well as those associated with triceps impairment, often require surgical treatment.
  • All stellate glenoid fractures require early orthopedic consultation.
• Coracoid fracture: Coracoid fractures respond well to conservative therapy with sling immobilization, ice, analgesics, and early mobilization.

Consultations

Follow-up care with an orthopedic surgeon is advised in all cases because of the possibility of long-term complications such as bursitis and posttraumatic arthritis.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Nonsteroidal anti-inflammatory agents and opioid analgesics are typically required for scapular fractures.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

These agents are most commonly used for the relief of mild to moderate pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually the DOC for initial therapy. Other options include naproxen, flurbiprofen, and ketoprofen.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have fractures.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Transfer

• Transfer the patient with a scapular fracture when evaluation or treatment of associated injuries or surgical repair of the fracture is necessary and when neither is available at the initial institution.

Deterrence/Prevention

• Enforcement of traffic safety laws and injury prevention education are the two most productive measures for reducing scapular fractures.

Complications

• After associated injuries are excluded, the most common complication of an isolated scapular fracture is posttraumatic arthritis or bursitis.

Prognosis

• If no significant associated injury exists, the prognosis for complete or near complete recovery is excellent.

Patient Education

• Patient education about the use of sling immobilization, ice, and analgesics is important.
• A critical part of most treatment regimens is early range-of-motion exercises.
• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles, Shoulder Dislocation and Broken Collarbone.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Missed diagnosis
• Failure to consider associated injuries

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Hart RG, Rittenberry TJ, Uehara DT. Handbook of Orthopaedic Emergencies. Lippincott-Raven; 1999:149-55.
• Rosen P, Barkin R. Emergency Medicine: Concepts and Clinical Practice. Mosby Year Book; 2002:584-586.
• Simon R, Koenigcknecht S. Emergency Orthopedics: The Extremities. Appleton and Lange; 1995:207-15.
• Stephens NG, Morgan AS, Corvo P, Bernstein BA. Significance of scapular fracture in the blunt-trauma patient. Ann Emerg Med. Oct 1995;26(4):439-42. [Medline].
• Tintinelli J, Ruiz E, Krome R. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill; 2000:1784-1787.
• McAdams TR, Blevins FT, Martin TP, DeCoster TA. The role of plain films and computed tomography in the evaluation of scapular neck fractures. J Orthop Trauma. Jan 2002;16(1):7-11. [Medline].
• Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. Mar 2006;20(3):230-3. [Medline].
• Veysi VT, Mittal R, Agarwal S, Dosani A, Giannoudis PV. Multiple trauma and scapula fractures: so what?. J Trauma. Dec 2003;55(6):1145-7. [Medline].

Article Last Updated: Aug 15, 2007