Scapular Fracture 

Updated: Oct 21, 2015
Author: Joseph C Schmidt, MD; Chief Editor: Trevor John Mills, MD, MPH 

Overview

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.

Scapular fractures can be divided by location[1] :

  • Body (spine) fractures
  • Acromion fractures
  • Neck fractures
  • Glenoid fractures

Scapula fractures have been found to be associated with the following[1] :

  • Pneumothorax
  • Pulmonary contusions
  • Clavicle fractures
  • Rib fractures

Fractures of the acromion are generally caused by a significant blunt force to the shoulder that is directed anteriorly. Fractures of the glenoid neck often occur as the result of falling on an outstretched arm, as well as blunt force, and may be associated with humerus fractures or shoulder dislocation.[1]

Glenoid fractures may occur from a direct lateral blow to the shoulder or a force transmitted from the humerus, such as falling on the elbow. Glenoid fossa fractures constitute about 50% of scapular fractures, and glenoid rim fractures about 7% of all scapular fractures.[1]

Up to 90% of scapular fractures are nondisplaced. Most scapular fractures will heal within 6 weeks, but it may take months before full functional recovery is achieved.[1]

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 depicted in the image below, such as from a motor vehicle accident or a fall.

Scapular anatomy. Muscle origin and insertion. Scapular anatomy. Muscle origin and insertion.

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. Classification of these fractures is depicted below.

Classification of glenoid cavity fractures: IA - A Classification of glenoid cavity fractures: IA - Anterior rim fracture; IB - Posterior rim fracture; II - Fracture line through the glenoid fossa exiting at the lateral border of the scapula; III - Fracture line through the glenoid fossa exiting at the superior border of the scapula; IV - Fracture line through the glenoid fossa exiting at the medial border of the scapula; VA - Combination of types II and IV; VB - Combination of types III and IV; VC - Combination of types II, III, and IV; VI - Comminuted fracture

The AO Foundation and Orthopaedic Trauma Association also developed a comprehensive system for in-depth classification of scapular fractures for clinical research and surgical decision making.[2, 3]

Epidemiology

Scapular fractures occur infrequently and account for approximately 1% of all fractures and 3% to 5% of shoulder girdle injuries.[4, 5]

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. One 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.[6] Another study confirmed an association between scapular fractures and concomitant injuries but noted that most of the association could be explained by differences in injury severity scores.[7]

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.

Scapular fractures are more common among men than among women because of their increased incidence of significant blunt trauma. Scapular fractures predominate in persons aged 25-40 years because of the increased occurrence of significant blunt trauma in this population.

 

Presentation

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.

 

DDx

 

Workup

Laboratory 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.[8, 9]

 

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 c 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.

Fractures of the scapular neck can be divided into stable fractures, fractures with rotational instability, and fully unstable fractures. Accurate diagnosis can be helped by 3D CT reconstructions. Undisplaced or minimally displaced fractures may be treated nonoperatively.[10]  Displaced neck fractures, as in the image below, require urgent orthopedic consultation for traction or surgical reduction.[11]

Classification of glenoid neck fractures. Type I i 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

Medication Summary

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

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

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.

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.

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.

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.

Analgesics

Class Summary

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.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for the treatment of mild to moderate pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for the relief of moderate-to-severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for the relief of moderate to severe pain; DOC for aspirin-hypersensitive patients.

Oxycodone and aspirin (Percodan)

Drug combination indicated for relief of moderate to severe pain.

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.

 

Follow-up

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 eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Shoulder Dislocation and Broken Collarbone.