What is the management plan for a missed scapular and clavicle fracture on Magnetic Resonance Imaging (MRI)?

Management of Missed Scapular and Clavicle Fractures on MRI

CT imaging is the recommended next step for management of missed scapular and clavicle fractures on MRI, as it provides superior characterization of fracture patterns and is essential for surgical planning. 1

Diagnostic Approach

Initial Assessment

• When scapular or clavicle fractures are missed on MRI, a targeted approach is needed:
  • CT without IV contrast is the preferred imaging modality for detailed fracture characterization
  • Three-dimensional CT reconstructions are particularly valuable for scapular fractures due to the complex anatomy 1, 2

Imaging Considerations

1. CT Imaging:

   • Superior for identifying and characterizing scapular fracture patterns 1
   • Provides detailed assessment of:
     • Intra-articular extension
     • Glenopolar angulation
     • AP angulation
     • Lateral border offset 1
   • 3D reconstructions help visualize displacement and angulation 1, 2

2. MRI Limitations:

   • While highly sensitive for detecting fractures, MRI may not provide adequate detail for fracture characterization 1
   • Can be difficult to differentiate bone contusion from non-displaced fractures 3
   • Less specific than CT for detailed fracture morphology 3

Treatment Decision Algorithm

For Scapular Fractures:

1. Isolated scapula body fractures:

   • Generally stable and can be treated conservatively 4
   • Exceptions: significant displacement or high injury severity score 1

2. Scapular neck fractures:

   • If isolated and minimally displaced: conservative treatment
   • If displaced or with ipsilateral clavicle fracture ("floating shoulder"): surgical fixation recommended 4

3. Glenoid fractures:

   • Surgical intervention typically needed for:
     • Intra-articular extension
     • Significant displacement
     • Articular step-off 1

For Clavicle Fractures:

1. Isolated clavicle fractures:

   • Often stable and can be treated conservatively 4

2. Combined injuries:

   • Ipsilateral clavicle and scapular fractures create an unstable "floating shoulder" pattern
   • Surgical fixation recommended to prevent sequelae such as drooping shoulder and limited range of motion 4, 5

Surgical Considerations

Timing of Intervention

• Early surgical intervention is preferred when indicated to prevent:
  • Malunion
  • Functional impairment
  • Chronic pain 4

Surgical Options

• For floating shoulder (combined scapular and clavicle fractures):
  • Fixation of clavicle alone may be sufficient in some cases
  • Combined fixation of both clavicle and scapular fractures may be necessary for more unstable patterns 4, 5

Common Pitfalls to Avoid

1. Diagnostic Challenges:

   • Scapular fractures are among the most difficult fractures to diagnose on radiographs 6
   • Often obscured by overlying structures 6
   • Incomplete imaging due to patient positioning difficulties 6

2. Management Errors:

   • Underestimating the instability of combined injuries
   • Inadequate imaging leading to missed fracture components
   • Failure to recognize the "floating shoulder" pattern requiring surgical intervention 4

3. Complications of Missed Diagnosis:

   • Malunion
   • Functional impairment
   • Chronic pain
   • Limited range of motion 4, 6

By following this structured approach with appropriate CT imaging and treatment based on fracture characteristics, patients with missed scapular and clavicle fractures can achieve excellent functional outcomes and avoid long-term complications.