What is the treatment approach for scapula fractures?

Treatment Approach for Scapula Fractures

Most scapula fractures can be managed non-operatively with good outcomes, but surgical intervention is indicated for specific fracture patterns involving the glenoid neck, displaced intra-articular fractures, or fractures with significant displacement. 1

Initial Assessment and Imaging

• Plain radiographs are the first-line imaging modality, but they often underestimate fracture severity
• CT scanning is essential for proper characterization of scapula fractures due to the complex anatomy and overlying ribs 1
• 3D-reformatted CT images provide superior visualization of fracture displacement and angulation 1

Treatment Algorithm

Non-operative Management (Recommended for most cases)

• Indicated for:

  • Isolated scapula body fractures
  • Minimally displaced fractures
  • Non-articular fractures
  • Stable fracture patterns

• Treatment protocol:

  • Brief immobilization (1-2 weeks) with sling
  • Early progressive range of motion exercises
  • Gradual strengthening program
  • Pain management

Surgical Management

• Indications for surgery:

  1. Displaced intra-articular fractures (especially glenoid fractures)
  2. Fractures of the glenoid rim associated with humeral head subluxation
  3. Unstable fractures of the scapular neck with significant displacement
  4. Displaced inferior angle fractures with persistent symptoms 2

• Surgical approaches:

  • Traditional posterior approach for complex fractures
  • Minimally invasive approaches may be considered to minimize soft tissue damage 3
  • Internal fixation with plates and screws

Special Considerations

Fracture Location

1. Scapular body fractures:

   • Generally heal well with non-operative treatment 4
   • 79-90% good to excellent results with conservative management 5

2. Glenoid neck fractures:

   • Higher risk of poor outcomes with non-operative treatment 6
   • May require surgical fixation if significantly displaced

3. Glenoid articular fractures:

   • Often require surgical intervention to restore joint congruity
   • Poor outcomes with non-operative treatment if displaced

4. Inferior angle fractures:

   • Undisplaced fractures do well with non-operative treatment
   • Displaced fractures may have poor outcomes without surgery 2

Associated Injuries

• Scapula fractures often occur with high-energy trauma
• 87% of patients have associated injuries, particularly thoracic injuries 6
• Thorough evaluation for associated injuries is essential:
  • Rib fractures
  • Pneumothorax
  • Pulmonary contusion
  • Brachial plexus injury
  • Vascular injury

Rehabilitation

• An appropriate rehabilitation program should consist of:

  • Early post-fracture introduction of physical training
  • Muscle strengthening
  • Long-term continuation of balance training 1

• Progressive protocol:

  1. Pendulum exercises (1-2 weeks post-injury)
  2. Active-assisted range of motion (2-4 weeks)
  3. Active range of motion (4-6 weeks)
  4. Strengthening exercises (6+ weeks)

Outcomes and Prognosis

• Long-term outcomes after scapula fracture are generally favorable with appropriate treatment
• 75-80% of patients achieve good to excellent results with appropriate management 5, 4
• Residual scapular deformity may be associated with shoulder symptoms in approximately 50% of cases 4

Pitfalls and Caveats

• Scapula fractures are easily missed or underappreciated on conventional radiography 1
• CT is essential for accurate diagnosis and treatment planning
• Displaced fractures of the glenoid neck and articular surface have worse outcomes with non-operative treatment
• Inferior angle fractures are frequently missed on plain radiographs but may require surgical intervention if displaced 2
• Long-term follow-up is important as not all scapula fractures have uniformly favorable outcomes 4