What are the recommendations for outpatient treatment of a scapular fracture with a rotator cuff tear?

Outpatient Treatment for Scapular Fracture with Rotator Cuff Tear

For patients with scapular fracture and concomitant rotator cuff tear, the recommended outpatient treatment includes a multimodal pain management approach with paracetamol, NSAIDs, regional analgesia techniques, and a structured rehabilitation program, with surgical intervention reserved for cases that fail conservative management. 1, 2

Pain Management

Pharmacological Approach

• First-line medications:
  • Paracetamol (acetaminophen): Regular administration to prevent pain escalation 1, 2
  • NSAIDs: Lowest effective dose for shortest duration necessary, considering patient's renal function and comorbidities 1, 2
  • Opioids: Reserved only for rescue analgesia when other methods fail 1

Regional Analgesia

• Recommended techniques:
  • Interscalene brachial plexus block: First-choice regional analgesic technique 1
  • Suprascapular nerve block (with or without axillary nerve block): Alternative when interscalene block is contraindicated 1
  • Single dose of IV dexamethasone: Increases analgesic duration of nerve blocks, decreases analgesic use, and provides anti-emetic effects 1

Injections

• Corticosteroid injections:
  • Moderate evidence supports short-term improvement in pain and function 1, 2
  • Should be limited to a single injection with local anesthetic 1
  • Consider potential adverse effects on tendon healing if surgical repair is anticipated 1

Rehabilitation Program

Initial Phase (0-4 weeks)

• Immobilization with appropriate shoulder support device
• Pain control as outlined above
• Gentle passive range of motion exercises within pain-free range
• Avoid complete immobilization to prevent muscle atrophy 2

Intermediate Phase (4-8 weeks)

• Progressive active-assisted range of motion exercises
• Initiation of rotator cuff strengthening exercises
• Scapular stabilization exercises
• Can be either supervised or home-based physical therapy programs 2

Advanced Phase (8-12 weeks)

• Progressive strengthening of rotator cuff and periscapular muscles
• Functional exercises specific to patient's goals
• Continue for at least 8-12 weeks for optimal results 2

Imaging and Monitoring

• Initial imaging:

  • Plain radiographs: Anteroposterior views in internal and external rotation, axillary or Y-view of scapula 2
  • MRI, MRA, or ultrasonography: Strongly recommended to identify and characterize rotator cuff tears 1, 2
  • 3D CT reconstruction: Particularly useful for complex scapular fractures 3

• Follow-up imaging:

  • Periodic radiographs to assess fracture healing
  • Consider follow-up MRI if symptoms persist despite appropriate treatment

Surgical Considerations

• Indications for surgical intervention:

  • Failure to respond to conservative treatment after 3-6 months 2
  • Traumatic acute tears, especially in young patients 2
  • Significant displacement of scapular fracture fragments
  • Glenohumeral joint instability 3

• Surgical approach:

  • Arthroscopic approach is recommended when surgery is necessary 1, 2
  • For combined scapular fracture and rotator cuff tear, staged surgery may be considered:
    1. Open reduction and internal fixation of scapular fracture
    2. Secondary arthroscopic repair of rotator cuff tear 3

Prognostic Factors

• Factors associated with poorer outcomes:
  • Older age: Strong evidence for higher failure rates and poorer outcomes 1, 2
  • Comorbidities: Moderate evidence for association with poorer outcomes 1, 2
  • Tear size, muscle atrophy, and fatty infiltration can progress over time with non-surgical management 2

Common Pitfalls and Caveats

• Avoid these common mistakes:
  • Complete immobilization of the shoulder can lead to muscle atrophy and worsen outcomes 2
  • Overlooking rotator cuff injury when treating scapular fractures 3
  • Inadequate pain management before bedtime can lead to sleep disruption and potential chronic pain development 2
  • Overuse of corticosteroid injections may impair tendon healing 1
  • Delaying physical therapy beyond the appropriate timeframe for the specific injury

By following this structured approach to outpatient management of scapular fracture with rotator cuff tear, clinicians can optimize pain control, promote healing, and improve functional outcomes while minimizing complications and the need for more invasive interventions.