Scapula Fracture

30-year-old male presents to the ED with pain over the right shoulder after being assaulted by a bat. The right arm is held in adduction and has a limited range of motion due to pain. An x-ray of the right shoulder was obtained and is shown above (Figure 1. Case courtesy of Dr. Ian Bickle, Radiopaedia.org, rID: 74640).  

 

Nondisplaced scapular neck and spine fracture (labeled in red in Figure 2).

Figure 2. Case courtesy of Dr. Ian Bickle, Radiopaedia.org, rID: 74640. Annotations by author

The scapula is relatively mobile and surrounded by large muscles that can absorb a significant amount of force. Therefore, in the presence of a scapular fracture, suspect other traumatic injuries such as the following [1,2].

  1. Upper torso: rib fractures, clavicular fractures, sternal fractures
  2. Cardiopulmonary: myocardial contusion, aortic dissection, pulmonary contusion, pneumothorax
  3. Spinal: thoracic spine > cervical spine > lumbar spin

By obtaining a shoulder trauma x-ray series

  1. True anteroposterior view
  2. Superior-inferior axillary view – looking inferiorly at the shoulder with the arm abducted (Figure 3)
    shoulder series

    Figure 3. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 7505. Annotations by author

  3. Scapular Y view (Image 4)
    Shoulder Series

    Image 4. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 48080. Annotations by author

  • Pearl: CT can be used to further characterize the fracture if there is a concern for intra-articular extension, significant displacement, or high suspicion for concurrent injuries (Image 5).
    Shoulder CT

    Figure 5. Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 28072

This patient can be placed in a sling and follow up with orthopedics and/or sports medicine in 1-2 weeks. Most isolated scapular fractures are minimally displaced and require a sling for 2 weeks, followed by early shoulder mobility.

  • Pearl: Indications for operative management include the following [2]
    • Open fractures or neurovascular compromise
    • Glenoid: displaced intra-articular fracture
    • Scapular neck: fracture with significant angulation
    • Scapular spine: comminuted fracture
    • Acromion: fracture with subacromial space impingement
    • Coracoid process: fracture with > 1cm displacement or third-degree acromioclavicular separation

 

Resources & References:

Consider brushing up on the radiologic approach to the traumatic shoulder and other can’t miss shoulder injuries.

  1. Cole PA, Freeman G, Dubin JR. Scapula fractures. Curr Rev Musculoskelet Med. 2013;6(1):79-87. PMID: 23341034.
  2. Egol K, Koval, KJ, Zuckerman JD. Handbook of Fractures. Lippincott Williams & Wilkins. 2010 ISBN: 160547760.
  3.  
BuMin Kong, MD

BuMin Kong, MD

Resident
Department of Emergency Medicine
Loma Linda University Medical Center
BuMin Kong, MD

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Mark Hopkins, MD

Mark Hopkins, MD

Loma Linda University Health
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Alexander J. Tomesch, MD

Alexander J. Tomesch, MD

Primary Care Sports Medicine Fellow
Department of Orthopedic and Sports Medicine
University of Arizona - Tucson
Alexander J. Tomesch, MD

@DocTomesch

Emergency Medicine/Sports Medicine physician, Father, Husband, Sports Enthusiast, Craft Beer Lover, COVID HATER!
Alexander J. Tomesch, MD

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