Scapula (Shoulder Blade) Fracture Management in the Emergency Department 

Updated: Mar 23, 2020
Author: Joseph C Schmidt, MD; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Practice Essentials

Scapular fractures are usually the result of significant blunt trauma. Scapular fractures include fractures of the body or spine of the scapula; acromion fracture; scapular neck fracture; glenoid rim fracture; glenoid stellate fracture; and coracoid process fracture. The most significant complications associated with scapular fractures are those that result from accompanying injuries to adjacent and distant osseous and soft-tissue structures. The ipsilateral shoulder girdle, upper extremity, lung, and chest wall are most commonly affected. Pulmonary injuries include hemopneumothorax or pulmonary contusion.[1, 2, 3, 4]

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, 5]  Atraumatic scapular fractures may occur following reverse shoulder arthroplasty (RSA), with the reported incidence of acromial fractures ranging from 0.6% to 15.8%.[6, 7, 8]   

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]  

Diagnosis and Treatment

Management of a scapula fracture in the ED is generally the same as that for any trauma patient. Perform fluid resuscitation, stabilize the cardiopulmonary system, and treat life-threatening injuries. Most scapula fractures can be managed with closed treatment. More than 90% of scapula fractures have minimal displacement, primarily because of the thick, strong support provided by the surrounding soft tissues. Treatment is symptomatic. Short-term immobilization in a sling and swathe bandage is provided for comfort.[1, 2, 3, 4] ​

Obtain plain radiographs for the shoulder trauma series, including anteroposterior (AP), lateral, and axillary views of the shoulder/scapula. If an injury to the scapuloclavicular linkage is suspected, obtain a stress AP projection with weights. Occasionally, oblique views may be helpful. In patients with a pulseless upper extremity, perform emergency arteriography to define the vascular injury. An AP shoulder view, along with a lateral scapular view, demonstrates the vast majority of scapular fractures. A lateral scapular (trans-scapular) view, combined with an AP shoulder view, provides the necessary 2-plane assessment of the scapula. A lateral axillary view isolates the coracoid process and helps delineate associated shoulder dislocations. Tangential oblique views aid in the evaluation of small or subtle scapular body fractures. A CT scan may be a helpful adjunct in glenoid and coracoid fracture assessment.[1, 9, 10, 2, 3, 4] ​

Most displaced scapula fractures should be evaluated by means of computed tomography, especially if operative intervention is planned. CT helps visualize the complex osseous anatomy of the scapula. Reconstruction views also help define the anatomy (three-dimensional CT is useful for the most complex injuries). If there is concern regarding joint involvement, MRI may be appropriate in order to identify a ligament injury. [9, 11, 12]

Body or spine

Most common findings of fractures of the scapular body or spine 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.  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. Whereas most body or spine fractures can be managed conservatively, surgical management should be considered for significantly displaced fractures.[13, 14]

Acromion

With acromion fractures, there is tenderness directly over the acromion process. Deltoid contraction and arm abduction exacerbate pain. Perform a careful neurologic examination to determine the presence of an associated brachial plexus injury.  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, 

Neck

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. 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.[15]  Displaced neck fractures require urgent orthopedic consultation for traction or surgical reduction.[16]

Glenoid

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. All stellate glenoid fractures require early orthopedic consultation.

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.

Coracoid process

Patients with coracoid process fractures present with tenderness over the coracoid. Forced adduction of the shoulder or flexion of the elbow exacerbates pain. Coracoid fractures respond well to conservative therapy with sling immobilization, ice, analgesics, and early mobilization.

 

(See the scapula fracture images below.)

Scapula fracture on Y view. Scapula fracture on Y view.

 

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
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°)

Pathophysiology

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. 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.[17] 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.[18] 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.[19, 20]

Epidemiology

Scapular fractures occur infrequently and account for approximately 1% of all fractures and 3% to 5% of shoulder girdle injuries.[21, 22, 23, 24]

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.[25] 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.[26]

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.

 

DDx

 

Treatment

Emergency Department Care

Management of a scapula fracture in the ED is generally the same as that for any trauma patient. Perform fluid resuscitation, stabilize the cardiopulmonary system, and treat life-threatening injuries. Most scapula fractures can be managed with closed treatment. More than 90% of scapula fractures have minimal displacement, primarily because of the thick, strong support provided by the surrounding soft tissues. Treatment is symptomatic. Short-term immobilization in a sling and swathe bandage is provided for comfort.[1, 2, 3, 4]  ​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.

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.

Whereas most body or spine fractures can be managed conservatively, surgical management should be considered for significantly displaced fractures.[13]

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.[15]  Displaced neck fractures, as in the image below, require urgent orthopedic consultation for traction or surgical reduction.[16]

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.

 

 

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.