From the Guidelines
Scapular fractures are often associated with significant internal injuries, and patients should be thoroughly evaluated for potential associated injuries, with management prioritizing both the fracture and any internal injuries to minimize morbidity, mortality, and optimize quality of life. When a scapular fracture occurs, patients should be assessed for injuries including pulmonary contusions, pneumothorax, hemothorax, rib fractures, clavicle fractures, and brachial plexus injuries, as these internal injuries can occur in approximately 80-95% of patients with scapular fractures due to the significant force required to fracture the scapula 1. Initial management should include a thorough trauma assessment following ATLS protocols, with chest imaging (X-ray and CT) to evaluate both the fracture and potential thoracic injuries, noting that CT is the best imaging modality for identifying and characterizing scapula fracture patterns 1.
Key considerations in managing scapular fractures include:
- Thorough evaluation for associated internal injuries
- Use of CT for detailed assessment of the scapular fracture
- Pain management with NSAIDs and opioids as needed
- Non-operative treatment with a sling for comfort, typically for 2-3 weeks, followed by progressive range of motion exercises
- Consideration of surgical fixation for certain types of scapular fractures, such as those involving the glenoid neck or associated with higher injury severity scores 1.
The presence of associated internal injuries often determines the overall prognosis and treatment approach more than the scapular fracture itself, making thorough evaluation and multidisciplinary management essential to optimize patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Scapular Fracture Internal Injuries
- Scapular fractures can be associated with significant internal injuries, including pneumothorax, as seen in a study of 30 patients with scapular fractures, where 16 patients had an associated pneumothorax 2.
- The presence of scapular fractures can also be associated with other thoracic injuries, such as rib fractures, pulmonary contusion, and thoracic spine fracture, as found in a study of 11,477 subjects 3.
- In some cases, scapular fracture fragments can displace into the thoracic cavity, potentially causing pleural breach, as reported in a case study of a patient with a distal lateral margin fracture of the scapula 4.
- The relationship between scapular fractures and mortality and morbidity in cases with blunt thoracic trauma has been investigated, with findings suggesting that scapular fractures are associated with higher admission rates, length of hospital stay, and mortality 5.
Associated Injuries
- Rib fractures are a common associated injury with scapular fractures, occurring in 91.9% of cases with scapular fractures in one study 5.
- Lung contusion is also a common associated injury, occurring in 80.2% of cases with scapular fractures in the same study 5.
- Pneumothorax is another associated injury, occurring in 41.9% of cases with scapular fractures 5.
- Vertebral fractures, intracranial injuries, and clavicle fractures are also associated with scapular fractures, as found in the same study 5.
Diagnosis and Management
- Lung ultrasound (US) has been shown to be a potentially more useful tool in the detection of pneumothorax in the trauma bay compared with chest x-ray (CXR) 6.
- Computed tomography remains the ultimate gold standard for diagnosing pneumothorax, although its utility lies more in confirming the presence and measuring the size of a pneumothorax 6.
- The traditional management of traumatic pneumothorax is shifting toward use of US for diagnosis and more conservative management practices, such as smaller catheters or observation 6.