At a glance......
- 1 Mechanism of Scapula Fracture
- 2 Types of Scapula Fracture
- 3 Scapula Fracture Causes
- 4 Symptoms of Scapula Fracture
- 5 Diagnosis of Scapula Fracture
- 6 Fracture Treatment
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How Do I Treat an Injured Scapula/Scapula fracture is rare and historically have been treated effectively with nonsurgical methods. The indications for surgical intervention are still unclear but are becoming better defined. The operative approaches are refined and include either a standard anterior deltopectoral approach or a posterior approach. The latter involves detachment of the deltoid from the spine of the scapula and development of the interval between the infraspinatus and teres minor muscles. Accurate reduction of the articular surface is crucial, and internal fixation should be varied in relation to the size and location of the fracture fragments. The stability of the fixation should allow for early or slightly delayed motion in order to allow soft tissue, musculotendinous, and capsule healing.
Fractures of the scapula are rare, comprising 1% of all skeletal injuries and 3%–5% of injuries of the shoulder girdle [rx]. As a rule they are sustained as a result of high-velocity trauma, although rarely they can occur due to low impact injuries [rx]. We report the case of a patient who sustained a low-velocity indirect fracture of his scapula following a simple mechanical fall, in which the diagnosis was initially missed.
Mechanism of Scapula Fracture
The mechanism of scapular fractures is always a high-energy trauma. Concomitant injuries occur in up to 90% of the patients with the majority being thoracic injuries followed by injuries of the ipsilateral extremity [rx–rx]. Thus, complex shoulder injuries often involve fractures of the ipsilateral clavicle, the acromion or the coracoid process as well as ligamentous and osseoligamentous structures as the acromioclavicular joint, the coracoclavicular ligaments and the coracoacromial ligament. However, the classification of scapula fractures described by Euler and Ruedi [rx], as well as the Ideberg classification of glenoid fractures, do not systematically include concomitant injuries of the shoulder girdle. Goss and co-workers introduced the concept of the Superior Shoulder Suspensory Complex (SSSC) and expanded the definition of a floating shoulder to a double disruption of this bone and soft tissue ring [rx, rx]. In contrast to previous definitions of a floating shoulder being a combined fracture of the scapular neck and the ipsilateral clavicle [rx, rx–rx], only a double-disruption of the SSSC causes an unstable anatomical situation and therefore a true floating shoulder [rx]. Biomechanical cadaver studies performed by Williams and colleagues emphasized that a fracture of the scapular neck and the ipsilateral clavicle can only produce an unstable, floating shoulder when combined with a disruption of the coracoacromial and acromioclavicular capsular ligaments [rx]. However, this assertion of stability has recently been doubted [rx] indicating that there are still controversial criteria of stability and little agreement on classifications and indications.
Types of Scapula Fracture
Coracoid process fractures
|I||Fracture proximal to the coracoclavicular ligament|
|II||Fracture distal to the coracoclavicular ligament|
|I||Non- or minimally-displaced|
|II||Displaced but not affecting the subacromial space|
|III||Displacement compromising the subacromial space|
The Ideberg classification is a system of categorizing scapula fractures involving the glenoid fossa.
|Ia||Anterior rim fracture|
|Ib||Posterior rim fracture|
|II||Fracture through glenoid exiting scapula laterally|
|III||Fracture through glenoid exiting scapula superiorly|
|IV||Fracture through glenoid exiting scapula medially|
|Va||Combination of types II and IV|
|Vb||Combination of types III and IV|
|Vc||Combination of types II, III and IV|
Fractures of the scapula are relatively uncommon and may be classified according to the following anatomic locations.1,2
- The body and spine
- The acromion
- The neck
- The glenoid rim and supraglenoid tuberosity
Scapula fractures may also be classified by fracture stability and joint involvement.3 Such a classification system defines scapula fractures in three categories:
Associated injuries include
- Rib fractures
- Hips lateral lung injuries
- Injuries to the shoulder girdle complex
- Neurovascular injuries
- Suprascapular nerve injuries
- Vertebral compression fractures
Scapula Fracture Causes
- Fractures of the scapula typically result from a high-energy blunt-force mechanism [rx–rx]. Direct force may cause fractures in all regions of the scapula, while indirect force via impaction of the humeral head into the glenoid fossa can cause both glenoid and scapular neck fractures. Motor vehicle collisions account for the majority of scapular fractures with 50% occurring in occupants of motor vehicles and 20% in pedestrians struck by motor vehicles [rx, rx].
- Usually, it takes a large amount of energy to fracture the scapula; the force may be indirect but is more often direct.[rx] The scapula is fractured as the result of significant blunt trauma, as occurs in vehicle collisions.[rx]
- About three-quarters of cases are caused by high-speed car and motorcycle collisions.[rx] Falls and blows to the shoulder area can also cause the injury.[rx]Crushing injuries (as may occur in railroad or forestry accidents) and sports injuries (as may occur in horseback riding, mountain biking, boxing or skiing) can also fracture the scapula.[rx]
- Scapular the fracture – can result from electrical shocks and from seizures: muscles pulling in different directions contract powerfully at the same time.[rx]
- Sudden forceful fall down
- Road traffic accident
- Falls – Falling onto an outstretched hand is one of the most common causes of a broken clavicle.
- Sports injuries – Many Scapular fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
- Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
- Have osteoporosis – a disease that weakens your bones
- Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
- Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
- Wave an inadequate – intake of calcium or vitamin D
- Football or soccer – especially on artificial turf
Symptoms of Scapula Fracture
The most common symptoms of a scapula fracture include:
- Extreme pain when you move the arm
- Swelling around the back of the shoulder
- Scrapes around the affected area.
- As with other types of fractures, the scapular fracture may be associated with pain localized to the area of the fracture, tenderness, swelling, and crepitus (the crunching sound of bone ends grinding together).[rx]
- Since scapular fractures impair the motion of the shoulder, a person with a scapular fracture has a reduced ability to move the shoulder joint.[rx] Signs and symptoms may be masked by other injuries that accompany the scapular fracture.[rx]
Diagnosis of Scapula Fracture
- In a scapula fracture – there is usually an obvious deformity, or “bump,” at the fracture site. Gentle pressure over the break will bring about pain. Although it is rare for a bone fragment to break through the skin, it may push the skin into a “tent” formation.
- During the physical examination – a dropped shoulder on the affected side, swelling, and hematoma at the middle third of the clavicle are usually observed. Often the fracture elements are palpable. Assessment of possible skin compromise and neurovascular status is important. In addition to the physical assessment, radiological assessment is part of the diagnostic workup.
- The basic method to check for a clavicle fracture – is by an X-ray of the clavicle to determine the fracture type and extent of the injury. In former times, X-rays were taken of both clavicle bones for comparison purposes. Due to the curved shape in a tilted plane X-rays are typically oriented with ~15° upwards facing tilt from the front.[rx]
Differential Diagnosis/ Associated Injuries
- Scapholunate ligament tear
- Median nerve injury
- TFCC (triangular fibrocartilage complex) injury, up to 50% when ulnar styloid fx also present
- Carpal ligament injury – Scapholunate Instability(most common), lunotriquetral ligament
- Tendon injury, attritional EPL rupture, usually treated with EIP tendon transfer
- Compartment syndrome
- DRUJ (Distal Radial Ulnar Joint) Instability
- Galeazzi Fracture: highly associated with distal 1/3 radial shaft fractures[rx]
- Radiographic imaging is important in diagnosis, classification, treatment and follow-up assessment of these fractures. The routine minimal evaluation for distal radius fractures must include two views-a postero-anterior (PA) view and lateral view.[rx]
- The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette
- CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, distal radial articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
- CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.
Magnetic Resonance Imaging
- Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous and soft tissue abnormalities associated with these fractures.
- MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.
Treatment available can be broadly
- Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your shoulder area, then get medical care immediately. Fractured scapula causes significant pain in the front part of your shoulder, closer to the base of your neck. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up.
- Apply ice to your fractured clavicle – After you get home from the hospital (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured scapular in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your clavicle for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
- Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your arm and shoulder in all different directions. Don’t aggravate the scapular so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light calisthenics and then progress to holding light weights (five-pound weights to start). Your clavicle needs to move a little bit during the later phases of the injury to stimulate complete recovery.
- Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
- A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
- Get a supportive arm sling – Due to their anatomical position, fractured scapular can’t be cast like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. A figure-eight splint wraps around both shoulders and the base of your neck in order to support the injured shoulder and keep it positioned up and back. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body.
- Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder and upper chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and shoulder movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility.
Rest your shoulder
Eat nutritiously during your recovery
All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins are proven to help heal broken bones of all types, including scapular. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your scapular. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
- Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.
- Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury. After a clavicle fracture, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.
- You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.
- To elevate breathing problem or remove the lung congestion.
Medication can be prescribed to ease the pain.
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.[rx]
- Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
- Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
- Muscle Relaxants – These medications provide relief from associated muscle spasms.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic or nerve-related pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, naproxen
- Calcium & vitamin D3 – to improve bones health and healing fracture.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
- Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
- Dietary supplement – to remove general weakness & improved health.
- Cough Medication – Specially Cough expectorant syrup to elevate breathing problem or remove the lung congestion.
|Patient number||Mechanism||Fracture type||Operative indication||Blood loss, mL||Op time, minutes||Surgical approach||Length of stay|
|1||Snowmobile collision||Articular and body||8 mm intra-articular step 3 cm M/L displacement||200||290||Minimally invasive posterior||1 day post-op 6 days total|
|2||Fall from height||Articular and body||2.7 cm M/L displacement 6 mm intra-articular gap||250||170||Posterior interval||2 days post-op 2 days total|
|3||MVC||Periprosthetic fracture (articular)||4 mm intra-articular step off||650a||413a||Extensile posterior||5 days post-op 13 Days total|
|4||Skiing||Articular||4 mm intra-articular step off||200||166||Straight posterior||3 days post-op 3 days total|
|5||MVC||Acromion||Symptomatic nonunion||50||132||Straight posterior||1 days post-op 1 days total|
|6||Iatrogenic during total shoulder replacement||Articular||1 cm intra-articular step and gap||300||205||Staged: 1. Straight posterior 2. Deltopectoral||2 days post-op 7 days total|
Abbreviations: MVC, motor vehicle collision; M/L, medial–lateral; Op, operative; ORIF, open reduction and internal fixation.
ORIF of tibial plateau was also performed and contributed to blood loss and op time.
There are risks associated with any type of surgery. These include:
- Nonunion (1-5%)
- Infection (~4.8%)
- Adhesive capsulitis
- 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
- Problems with wound healing
- Blood clots
- Damage to blood vessels or nerves
- Reaction to anesthesia
- Hardware prominence
- Malunion with cosmetic deformity
- Restriction of ROM
- The difficulty with bone healing
- Lung injury
- Hardware irritation
- Fracture comminution (Z deformity)
- Fracture displacement
- Increased fatigue with overhead activities
- Thoracic outlet syndrome
- Dissatisfaction with appearance
- The difficulty with shoulder straps, backpacks and the like
- ~30% of patient request plate removal
- Superior plates associated with increased irritation
- Superior plates associated with increased risk of subclavian artery or vein penetration.