Management of Scapular Fractures
Most isolated scapular body fractures should be managed nonoperatively with early rehabilitation, as they heal well without surgery and achieve satisfactory functional outcomes 1.
Initial Imaging and Assessment
After plain radiographs identify a scapular fracture, obtain a CT scan with 3D reconstruction to fully characterize the fracture pattern 1. The scapula's complex anatomy and overlying ribs make fractures easily missed or underappreciated on plain films alone. CT is essential for assessing:
- Intra-articular extension
- Glenopolar angulation
- Anteroposterior angulation
- Lateral border offset
- Displacement measurements
This imaging determines whether surgical intervention is warranted 1.
Surgical Indications
Surgery is indicated based on specific anatomic criteria measured on CT 2:
For Scapular Neck and Body Fractures:
- Glenopolar angle <20°
10 mm frontal displacement (medialization)
- Sagittal angulation >40°
For Glenoid Fractures:
4 mm articular step-off
- Involvement of >30% of joint surface
- Persistent glenohumeral subluxation
Glenoid neck fractures may require surgical fixation even when body fractures do not 1. The evidence shows that displaced glenoid fossa fractures and scapular neck fractures displaced >10 mm lead to better functional outcomes with operative management 3.
Nonoperative Management
For fractures not meeting surgical criteria:
- Sling immobilization for pain control
- Early rehabilitation - this is the gold standard for most scapular fractures 2
- Scapular neck fractures displaced <10 mm have satisfactory outcomes with conservative treatment 3
- Isolated scapular body fractures heal well without surgery 1
Operative Management
When surgery is indicated, the posterior Judet approach is the workhorse technique 4, 5. This provides excellent exposure for posterior scapular fixation. Key technical points:
- Full-thickness flap reflected laterally (or medially in the boomerang modification)
- Access through internervous plane between infraspinatus and teres minor
- Protect suprascapular neurovascular bundle cranially and axillary nerve inferiorly
- Consider longitudinal arthrotomy for intra-articular fractures
Surgical fixation provides good functional results but is technically difficult with high complication rates 2. Operative union rates range from 69-100%, significantly higher than nonoperative rates of 30-79% 6.
Important Caveats
Associated injuries are common - scapular fractures typically result from high-energy trauma. Look for:
- Rib fractures (associated with worse outcomes) 1
- Clavicle fractures (evaluate superior shoulder suspensory complex) 2
- Vascular injuries
- Pulmonary injuries
Higher injury severity scores correlate with worse clinical outcomes and may benefit from more aggressive surgical fixation 1.
The ACR guidelines acknowledge there is no consensus on surgical indications for scapular fractures 1, but the most recent evidence from 2026 provides the specific measurement thresholds listed above to guide decision-making 2.
Pain Control
Standard multimodal analgesia appropriate for fracture management, though specific protocols are not detailed in the available evidence. Adequate pain control facilitates early mobilization in nonoperative cases.