Fractured Scapula

Related Subjects: |Fractured Neck of Femur |Fractured Shaft Femur |Supracondylar Femur Fractures |Femoral fractures and Injuries |Acromio-clavicular joint |Shoulder Joint Structure and Form |Knee Joint Structure and Form |Wrist Joint Structure and Form |Types of Joints |Biceps tendon rupture |Upper Limb fractures and injuries |Hand fractures and Injuries |Lower Limb Fractures and Injuries |Fractured Scapula

🦴 Scapular Fractures – High-Yield Overview
Rare (<1% of all fractures, 3–5% of shoulder girdle fractures) due to thick muscular envelope & chest wall protection.
⚠️ Almost always high-energy trauma → 80–95% have associated injuries (think: "look beyond the scapula!").

ℹ️ Epidemiology & Mechanism

• 📉 Isolated scapular fractures are very rare.
• 👴 Frail elderly: low-energy falls (minimally displaced body fractures).
• 💥 Young adults (25–50 y, M >> F): high-energy trauma (MVCs >70%, falls from height, direct blow).
• 🚗 Typical: motor vehicle collision, pedestrian vs vehicle, fall onto shoulder/back or FOOSH with axial load.

📍 Common Fracture Sites & % (Approximate)

• 🪶 Scapular body / spine: 45–50% (most common, usually minimally displaced)
• 🔗 Glenoid neck: ~25%
• 🏹 Glenoid cavity / rim / fossa: 10–35% (intra-articular → instability risk)
• 📐 Acromion: ~8%
• 🪝 Coracoid process: ~7%

⚡ Associated Injuries (80–95% of cases – always screen!)

• 🫁 Thoracic: rib fractures (53%), pneumothorax/haemothorax (>30%), pulmonary contusion (>40%)
• 🧠 Head injury (35–50%)
• 🦴 Orthopaedic: ipsilateral clavicle (25%), humerus, spine (26–30%), pelvis/acetabulum (15%)
• ⚡ Vascular: subclavian/axillary artery (11%, esp. scapulothoracic dissociation)
• 🧬 Brachial plexus (5–13%; 75% resolve spontaneously)
• 🔥 Scapulothoracic dissociation ("floating shoulder" if double SSSC disruption) → life/limb threat!

🔎 Investigations

• 🩻 Shoulder series: True AP (Grashey), scapular Y-view, axillary lateral (if tolerated)
• 📏 Key measurements on imaging:
  • Glenopolar angle (GPA) on Grashey AP: normal 30–45°; <20–22° = surgical consideration
  • Lateral border offset (medialization): >20 mm = relative indication
  • Angulation on Y-view: >40–45° = relative indication
  • Intra-articular step-off: >4 mm or >20–25% glenoid involvement
• 🖥️ CT ± 3D recon: gold standard for displacement, comminution, intra-articular extension, surgical planning
• 🫁 CXR / CT chest: mandatory to rule out pneumothorax, contusion, haemothorax
• 🩸 Neurovascular exam: document brachial plexus, axillary nerve, pulses

💊 Management

• 🫁 ABCs first → stabilise life-threatening injuries (pneumothorax, haemorrhage, head)
• 🩹 Non-operative (vast majority >90%): broad-arm sling 2–3 weeks, analgesia, early pendulum exercises & mobilisation to prevent stiffness
• 🏥 Orthopaedic referral → fracture clinic follow-up (serial X-rays first 3 weeks to monitor displacement)
• 🔪 Surgical (ORIF) – relative indications (most controversial; discuss with trauma team):
  • Intra-articular glenoid: step-off >4 mm, >20–25% articular involvement with instability/subluxation
  • Body/neck: medialization >20 mm, angulation >40–45°, GPA <20–22°, combination (e.g., >15 mm + >35°)
  • Floating shoulder (double SSSC disruption with ≥10 mm displacement each)
  • Acromion: Kuhn III (subacromial impingement), painful non-union
  • Coracoid: >1 cm displacement, painful non-union, Ogawa I extending into body
  • Open fracture, neurovascular compromise, failed conservative
• 🪽 Assess for scapular winging (serratus anterior/long thoracic nerve palsy) – document early!

📌 Exam & OSCE Pearls
– Isolated scapular fracture? → Search aggressively for occult chest / head / vascular injuries (80–95% associated).
– Scapular winging = long thoracic nerve injury (serratus anterior palsy).
– Surgical triggers: GPA <20–22°, medialization >20 mm, angulation >40°, intra-articular step >4 mm.
– "Floating shoulder" = unstable SSSC double disruption → often needs fixation of at least one component.
– Most body fractures heal well non-op with near-normal function due to compensatory scapulothoracic motion.

📚 Key References

• Orthobullets – Scapula Fractures (gold standard for classifications & indications)
• AAOS OrthoInfo – Scapula Fractures
• StatPearls / Physiopedia / recent reviews (e.g., EFORT Open Reviews 2021)