eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Scapular: Treatment & Medication
Updated: Sep 2, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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, strategies depicted below.
Fixation of acromion fractures. (A) tension band construct; and (B) plate-screw fixation (most appropriate for proximal fractures).
- Neck fracture
- Manage nondisplaced scapular neck fractures with a sling, ice, analgesics, and early range-of-motion exercises.
- Displaced neck fractures, as in the image below, require urgent orthopedic consultation for traction or surgical reduction.
Classification of glenoid neck fractures. Type I includes all minimally displaced fractures. Type II includes all significantly displaced fractures (translational displacement greater than or equal to 1 cm; angulatory displacement greater than or equal to 40°)
- 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
Nonsteroidal anti-inflammatory agents and opioid analgesics are typically required for scapular fractures.
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.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for the treatment of mild to moderate pain, if no contraindications exist; inhibits inflammatory reactions and pain, probably by decreasing cyclooxygenase activity, which results in prostaglandin synthesis.
Adult
200-400 mg PO q4-6h prn; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: 200-400 mg PO q4-6h prn; not to exceed 3.2 g/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
Used for the relief of mild to moderate pain and inflammation. Administer small doses initially to smaller patients and older persons. Doses of >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing cyclooxygenase activity, which decreases prostaglandin synthesis.
Adult
500 mg followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion may be at risk for acute renal failure; leukopenia occurs rarely and is transient, and condition usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Flurbiprofen (Ansaid)
Has analgesic, antipyretic, and anti-inflammatory effects; may inhibit cyclooxygenase, causing inhibition of prostaglandin biosynthesis that may result in analgesic and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely and is transient, and condition usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
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.
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)
DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or in those with upper GI disease or taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4-6h; not to exceed 5 doses/d
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in persons with chronic alcoholism at various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; many OTC products contain acetaminophen, and combined use of these products may result in cumulative doses exceeding the recommended maximum dose
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab PO q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for the relief of moderate-to-severe pain.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for the relief of moderate to severe pain; DOC for aspirin-hypersensitive patients.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose based on oxycodone content PO; not to exceed 5 mg/dose of oxycodone q4-6h prn
Phenothiazines may decrease analgesic effects; toxicity increases with coadministration of CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; be aware of the total daily dose of acetaminophen that the patient is receiving; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity
Oxycodone and aspirin (Percodan)
Drug combination indicated for relief of moderate to severe pain.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose based on oxycodone content PO; not to exceed 5 mg/dose of oxycodone PO q4-6h prn
Phenothiazines may decrease analgesic effects; conversely, toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants; may also potentiate anticoagulant effects of warfarin
Documented hypersensitivity; liver damage, hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; children <16 y with flu (because of the association of aspirin with Reye syndrome)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis
Morphine sulfate (Duramorph, Astramorph, MS Contin)
DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. IV doses vary and commonly are titrated until desired effect is obtained.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC and reassess hemodynamic effects of dose
Pediatric
Neonates: 0.05-0.2 mg/kg/dose IV/IM/SC q2-4h prn
Children: 0.1-0.2 mg/kg/dose IV/IM/SC q2-4h prn
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where rapidly establishing airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
More on Fracture, Scapular |
| Overview: Fracture, Scapular |
| Differential Diagnoses & Workup: Fracture, Scapular |
 Treatment & Medication: Fracture, Scapular |
| Follow-up: Fracture, Scapular |
| Multimedia: Fracture, Scapular |
| References |
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References
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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].
Baldwin KD, Ohman-Strickland P, Mehta S, Hume E. Scapula fractures: a marker for concomitant injury? A retrospective review of data in the National Trauma Database. J Trauma. Aug 2008;65(2):430-5. [Medline].
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].
Bartonicek J, Tucek M, Fric V. [Radiographic evaluation of scapula fractures]. Rozhl Chir. Feb 2009;88(2):84-8. [Medline].
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.
Tintinelli J, Ruiz E, Krome R. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill; 2000:1784-1787.
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].
Further Reading
Keywords
scapula, scapular fractures, acromion injuries, scapular neck fractures, glenoid rim fractures, glenoid fracture, stellate glenoid fractures, coracoid process fractures, coracoid fracture, shoulder girdle injuries
