Abstract

Fractures of the scapula are relatively rare and constitute 3-5% of all shoulder girdle injuries and 1% of all fractures. Isolated scapular fractures are uncommon because the scapula is well-protected by large muscle masses and by virtue of its mobility about the posterolateral aspect of the thorax. We report a case of a 65-year-old man fell from an auto and presented with swelling and tenderness over the right scapula with painful and restricted right shoulder movements. Radiographs revealed an unusual stellate fracture of the body of the scapula with an involvement of the neck of the scapula.

Keywords: Isolated scapular fractures, high-energy vehicular trauma, broad arm sling, conservative management

Introduction

Fractures of the scapula are relatively rare and constitute 3-5% of all shoulder girdle injuries and 1% of all fractures.^1,2 Scapular fractures are usually caused by high-energy vehicular trauma or by falling from a height and can be associated with injuries of the ipsilateral limb, shoulder girdle and thorax.² Isolated scapular fractures are uncommon because the scapula is well-protected by large muscle masses and by virtue of its mobility about the posterolateral aspect of the thorax.³

Case Report

A 65-year-old man fell from an auto and sustained a direct injury to the right shoulder. On examination, the patient had swelling and tenderness over the right scapula with painful and restricted right shoulder movements, especially protraction and retraction of the shoulder. Radiographs revealed an unusual stellate fracture of the body of the scapula with an involvement of the neck of the scapula (Fig. 1).

There were no associated fractures of the shoulder, which was in joint. He was admitted for cardiac monitoring and analgesia. He was discharged 24 hours later with a broad arm sling and physiotherapy exercises to mobilize the shoulder as much as pain allowed.

Discussion

In patients with multiple injuries, scapular fractures may be overlooked or neglected because other life threatening problems are the focus of attention.⁴ Extensive chest injuries overshadowing the scapula on the chest trauma radiographs, inappropriately performed computer tomography or an unusual mechanism of injury can all lead to delay in the diagnosis of scapular fractures.^3,5 It is recommended that the presence of ipsilateral regional skeletal injuries and soft-tissue injuries after major blunt chest trauma should prompt a diligent search for concomitant scapular fractures.³

As the supine chest radiograph is obtained routinely in patients who sustain major blunt chest trauma, it provides the earliest opportunity to detect scapular fractures.^3,5 When a scapular fracture is clinically suspected and the patient’s condition permits, an axial (‘V view’) of the scapula identifies the fracture and establishes the magnitude of fragment separation.³ Most of the scapular fractures need conservative management with good to excellent results and operative treatment is recommended only when bone and soft-tissue damage are such that with conservative measures function would not be restored and there is a risk of post-traumatic osteoarthritis.^1,6 Early identification and proper management are integral to decrease symptoms, for example, scapular snapping syndrome and we should be aware of scapular injuries that will need further investigations particularly scapular Y views.

References

1. Goss TP. Fractures of the scapula. In: The Shoulder. 3rd edition, Rockwood CA Jr, Matsen FA, Wirth MA, Lippitt SB (Eds.), Saunders: Philadelphia 2004:p.413-54.
2. 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 2006;20(3): 230-3.
3. Harris RD, Harris JH Jr. The prevalence and significance of missed scapular fractures in blunt chest trauma. AJR Am J Roentgenol 1988;151(4):747-50.
4. Hardegger FH, Simpson LA, Weber BG. The operative treatment of scapular fractures. J Bone Joint Surg Br 1984;66(5):725-31.
5. Tadros AM, Lunsjo K, Czechowski J, Abu-Zidan FM. Causes of delayed diagnosis of scapular fractures. Injury 2008;39(3):314-8.
6. DePalma AF. Fractures and dislocations of the scapula. In: Surgery of the Shoulder. 3rd edition, Lippincott: Philadelphia/London/New York 1983:p.362-71.