Working Diagnosis:
Comminuted scapular neck fracture with a large glenoid fragment

Treatment:
The patient was admitted to observation unit for evaluation by the orthopedics team. Throughout his stay, he received a total of 14mg Morphine, 1L D5NS, and supplemental potassium. Orthopedic surgery recommended sling to the left arm, non-weight bearing with the arm, pain control, and follow up in 1-2 weeks.

Outcome:
Patient followed up one month later in ortho clinic with improvement of symptoms. Repeat x-ray of the left shoulder showed a stable fracture. Case Photo #6 Case Photo #7 No further intervention was determined to be necessary unless symptoms return or worsened.

Author's Comments:
Scapular fractures are not commonly reported sports-related injuries. There have been case studies that show a higher incidence with contact field sports, such as football and rugby. Due to the high energy typically required to fracture this protected bone, there is a high association of injuries to the ipsilateral lung, ribs, and shoulder. There may be an association between the mechanism of injury and arm position, with the fracture patterns sustained. Case Photo #8

Patients with isolated scapular fractures typically present with tenderness over the scapula, worse with arm movement, and the arm held in adduction. A scapular x-ray series will identify most fractures and guide the need for a CT scan.

Most scapular fractures are treated non-surgically with sling, ice, analgesics, early ROM exercises, and referral to ortho. Surgery may be necessary for significantly displaced articular fractures of the glenoid, acromial fractures associated with a rotator cuff tear, and some coracoid fractures. A prolonged recovery time of about 4 to 5 months should be expected with these types of injuries.

Editor's Comments:
Scapular fractures typically occur from high energy trauma and are highly associated with other co-morbidities, notably pneumothorax and rib fractures, but interestingly, mortality rates compared to other fracture injuries presenting to the ED are actually similar.

CT scans of the head/chest/thorax/abdomen/pelvis are commonly performed when evaluating scapular fractures (especially from motor vehicle accidents) due to the association with other injuries and to better characterize the extent of the fracture. MRI can also be considered in the pediatric population when there is suspected injury to the physis or for evaluation of a stress process.

Most scapular fractures occur at the neck or body and are typically managed conservatively with good results. General treatment strategies include an initial period of pain control and immobilization with a sling followed by guided activity progression with physical therapy (example: passive-assisted exercises after 14 days, active-assisted exercises after 21 days, then active exercises after 28 days). Fractures to the glenoid, coracoid, scapular spine, or acromion can also be seen, and with these being sites of muscle attachments, these injuries more often require surgery. Other commonly cited surgical indications include medial displacement of the lateral border > 25 mm, angular deformity of > 45 degrees, intra-articular fracture with displacement, and displaced double disruptions of the superior shoulder suspensory complex; however, true indications are controversial as meta-analysis does not clearly show an advantage for surgery at this time.

References:
McIntosh J, Akhbari P, Malhas A, Funk L. Scapula Fractures in Elite Soccer and Rugby Players. Orthop J Sports Med. 2019 Dec 2;7(12):2325967119887388.

Neral M, Knapik DM, Wetzel RJ, Salata MJ, VoosJE. Scapular Body Fracture in the Athlete: A Systematic Review. HSS J. 2018;14(3):328-332.

Brown C, Elmobdy K, Raja AS, Rodriguez RM. Scapular Fractures in the Pan-scan Era. Acad Emerg Med. Jul 2018;25(7):738-743.

Bao MH, DeAngelis JP, Wu JS. Imaging of traumatic shoulder injuries - Understanding the surgeon's perspective. Eur J Radiol Open. 2022;9:100411.

Nanka O, Bartonicek J, Havranek P. Diagnosis and Treatment of Scapular Fractures in Children and Adolescents: A Critical Analysis Review. JBJS Rev. 2022;10(2):10.2106/JBJS.RVW.21.00132.

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.

Pires RE, Giordano V, de Souza FSM, Labronici PJ. Current challenges and controversies in the management of scapular fractures: a review. Patient Saf Surg. Jan 6 2021;15(1):6.

Limb D. Scapula fractures: a review. EFORT Open Rev. Jun 2021;6(6):518-525.

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