Working Diagnosis:
Physical examination and radiographic imaging results were consistent with an inferior angle scapular avulsion fracture.

Treatment:
Due to the age of the fracture and level of symptoms upon evaluation, as well as the absence of clear scapular winging, the decision was made to manage this fracture conservatively. The patient was placed back in his sling for two weeks with the recommendation to practice daily elbow range of motion and was scheduled to follow-up with repeat x-rays four weeks after his initial visit.

Outcome:
At six weeks, the patient demonstrated full pain free range of motion, symmetric strength bilaterally, including scapular protraction, with no evidence of scapular winging. Repeat x-rays demonstrated bony callus formation at the fracture site, and evidence of resorption of the cartilage fragment Case Photo #7 , Case Photo #8 . Follow up was scheduled for 12 months to confirm appropriate bony healing.

Author's Comments:
This case represents the first reported pediatric case of hyper-abduction traction as the mechanism of injury for an avulsion fracture of the inferior angle of the scapula. Of the nearly 70 pediatric scapular fractures identified in literature, 16% were inferior angle of the scapula fractures, with a mean age of 10 years old. Only one previous case of definitive indirect traumatic inferior angle of the scapula fracture in the pediatric population is described, involving an extreme shoulder extension mechanism.

Editor's Comments:
This case highlights the importance of performing a careful exam to specify the location of bony tenderness when fracture is on the differential diagnosis. If tenderness is found, this should prompt a critical review of previous imaging and/or trigger ordering of additional studies to identify the etiology of the tenderness. Chest CT scan is the preferred modality for suspected scapula fractures, which also allows for evaluation of associated thoracic injuries in high-energy trauma. In pediatric patients, ultrasound or MRI may be useful modalities for identifying cartilaginous injuries, as ossification of the inferior angle of the scapula does not begin until around puberty.

Literature reviews have shown that displaced inferior angle of the scapula fractures respond best to operative management, while non-displaced fractures can be managed non-operatively. Due to the rarity of these fractures in the young pediatric population however, these patients have not been well represented in these reviews. Additionally, it has been observed that patients with displaced fractures who initially trial conservative management, do well clinically after later opting for surgery. The successful outcome in this patient further supports the notion that even for displaced fractures, an initial trial of non-surgical management may be reasonable in pediatric patients.

References:
Edgington J, Antonacci CL, Alberta FG. Nonoperative management of a displaced cartilaginous avulsion fracture of the inferior aspect of the scapula. JSES Int. 2020;4(2):280-286. Published 2020 Apr 4. doi:10.1016/j.jseint.2019.12.004

Goss TP. Scapular Fractures and Dislocations: Diagnosis and Treatment. J Am Acad Orthop Surg. 1995;3(1):22-33. doi:10.5435/00124635-199501000-00004

Mousafeiris VK, Kalyva N, Rigopoulos N, Mulita F, Mousafiris K. Characteristics, Management, and Outcomes of Inferior Scapula Angle Fractures: A Systematic Review of the Literature. Cureus. 2022;14(7):e27192. Published 2022 Jul 24. doi:10.7759/cureus.27192

Alder-Price AC, Pilch W, Zhuang CB, McLean J, Bain GI. Inferior angle of scapula fractures: A retrospective case series. J Orthop Surg (Hong Kong). 2022;30(1):10225536221088633. doi:10.1177/10225536221088633

Bartonicek J, Nanka O. History of diagnostics and treatment of scapular fractures in children and adolescents and its clinical importance. Arch Orthop Trauma Surg. 2022;142(6):1067-1074. doi:10.1007/s00402-021-03800-8

Shannon SF, Hernandez NM, Sems SA, Larson AN, Milbrandt TA. High-energy Pediatric Scapula Fractures and Their Associated Injuries. J Pediatr Orthop. 2019;39(7):377-381. doi:10.1097/BPO.0000000000000969

Heyse-Moore GH, Stoker DJ. Avulsion fractures of the scapula. Skeletal Radiol. 1982;9(1):27-32. doi:10.1007/BF00367377

Brindle TJ, Coen M. Scapular avulsion fracture of a high school wrestler. J Orthop Sports Phys Ther. 1998;27(6):444-447. doi:10.2519/jospt.1998.27.6.444

Pouliart N, Gagey O. Significance of the latissimus dorsi for shoulder instability. I. Variations in its anatomy around the humerus and scapula. Clin Anat. 2005;18(7):493-499. doi:10.1002/ca.20185

Chang AC, Phadnis J, Eardley-Harris N, Ranawat VS, Bain GI. Inferior angle of scapula fractures: a review of literature and evidence-based treatment guidelines. J Shoulder Elbow Surg. 2016;25(7):1170-1174. doi:10.1016/j.jse.2015.11.007

Martin SD, Weiland AJ. Missed scapular fracture after trauma. A case report and a 23-year follow-up report. Clin Orthop Relat Res. 1994;(299):259-262.

Gupta R, Sher J, Williams GR Jr, Iannotti JP. Non-union of the scapular body. A case report. J Bone Joint Surg Am. 1998;80(3):428-430. doi:10.2106/00004623-199803000-00017

Speigner B, Verborgt O, Declercq G, Jansen EJ. Medial scapular winging following trauma--a case report. Acta Orthop. 2016;87(2):203-204. doi:10.3109/17453674.2015.1117370

Miller C, Grainger AJ, Phillips RS, Sabouni MY, Kraft JK. Bowing fracture of the inferior angle of the scapula, a difficult diagnosis. Pediatr Radiol. 2018;48(1):146-149. doi:10.1007/s00247-017-3945-3

Neopoulos G, Henninger HB, Suter T. Acute surgical treatment of entrapped avulsion fractures of the inferior angle of the scapula in adults: Two case reports. Trauma Case Rep. 2023;48:100972. Published 2023 Nov 21. doi:10.1016/j.tcr.2023.100972

Hayes JM, Zehr DJ. Traumatic muscle avulsion causing winging of the scapula. A case report. J Bone Joint Surg Am. 1981;63(3):495-497.

Chan J, Hourston GJM, Robinson P. Inferior scapula avulsion fracture: an unusual presentation of winged scapula. BMJ Case Rep. 2023;16(8):e255645. Published 2023 Aug 10. doi:10.1136/bcr-2023-255645

Park HY, Jang HJ, Sur YJ. Scapular body fracture and concomitant inferior angle apophyseal separation with intrathoracic displacement: a case report. J Pediatr Orthop B. 2017;26(5):429-432. doi:10.1097/BPB.0000000000000404

Szopinski KT, Adamczyk G, Drwiega M. Traumatic detachment of the inferior angle of the scapula in a 5-year-old boy--a sonographic diagnosis. Skeletal Radiol. 2012;41(5):615-618. doi:10.1007/s00256-011-1311-3

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