What are the treatment options for lateral displacement of the scapula?

Treatment Options for Lateral Displacement of Scapula

The most effective treatment for lateral displacement of the scapula involves a combination of physical therapy, strengthening exercises, and surgical intervention when conservative measures fail after 3-6 months.

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• CT imaging is the gold standard for evaluating scapular displacement patterns, as conventional radiography may miss or underappreciate scapular abnormalities due to overlying ribs and complex osteology 1
• Three-dimensional CT reformatting helps better visualize displacement and angulation 1
• MRI without contrast may be indicated if symptoms persist despite conservative management for 6-8 weeks to evaluate associated soft tissue injuries 2

Conservative Management

Initial treatment should focus on non-surgical approaches:

1. Physical Therapy and Rehabilitation:

   • Phased approach to rehabilitation:
     • Initial phase (0-4 weeks): Pain control and protected range of motion
     • Intermediate phase (4-8 weeks): Progressive strengthening exercises
     • Advanced phase (8-12 weeks): Occupation-specific training 2

2. Pain Management:

   • NSAIDs as first-line treatment for pain control 2
   • RICE protocol (Rest, Ice, Compression, Elevation) for initial pain and inflammation management 2
   • Avoid activities that exacerbate symptoms during the acute phase

3. Strengthening Exercises:

   • Focus on strengthening the trapezius, rhomboids, and serratus anterior muscles
   • Begin with low-load strengthening exercises and progress to more challenging exercises as tolerated 2
   • Immediate functional treatment rather than immobilization is recommended 2

4. Protective Padding:

   • Padded supports may be used to decrease the risk of associated upper extremity neuropathy 1
   • Chest rolls in the laterally positioned patient may help decrease the risk of upper extremity neuropathy 1

Monitoring for Progressive Displacement

Close monitoring of conservatively treated scapular displacement is crucial:

• Some scapular fractures with displacement may progressively worsen over time 3
• Follow-up imaging is recommended at 9-15 days after injury to assess for progressive displacement 3
• Certain extra-articular transverse fracture patterns (AO/OTA Type A3, Ada-Miller Type IIC) are particularly prone to progressive displacement 3

Surgical Management

Surgical intervention should be considered in the following scenarios:

1. Indications for Surgery:

   • Persistent symptoms despite 3-6 months of well-managed conservative treatment 2
   • Significant functional limitations impacting quality of life 2
   • Progressive displacement on follow-up imaging 3
   • Medial/lateral displacement ≥20 mm, angulation ≥45°, or glenopolar angle ≤22° 4

2. Surgical Options:

   • Direct Lateral-Column Approach: Less invasive technique for extra-articular scapular fractures with good clinical outcomes and minimal complications 4
   • Modified Eden-Lange Procedure: Effective for lateral scapular winging caused by trapezius paralysis, particularly in cases with spinal accessory nerve injury persisting beyond 20 months 5

3. Post-Surgical Rehabilitation:

   • Structured physical therapy program following surgical intervention
   • Return to full activity when patient demonstrates:
     • Complete resolution of pain during and after activity
     • Full range of motion compared to uninjured side
     • Strength symmetry >90% compared to uninjured side 2

Special Considerations

• In cases of traumatic lateral displacement with associated vascular injury (subclavian artery) and brachial plexus involvement, more aggressive management may be required 6
• Understanding the biomechanics of displacement is crucial - research shows that in many scapular fractures, the glenoid fragment often retains its anatomic position while the proximal scapula body fragment lateralizes 7

Follow-up Protocol

• Follow up within 1-2 weeks if symptoms persist
• Return to full activity permitted when there is complete resolution of pain during and after activity and full range of motion compared to the uninjured side 2
• Consider orthopedic referral if pain persists despite 3-6 months of conservative management 2

This treatment approach prioritizes functional restoration and pain management while reserving surgical intervention for cases that fail to respond to conservative measures, thus optimizing patient outcomes in terms of morbidity, mortality, and quality of life.