What is the management for a scapular fracture?

Management of Scapular Fractures

Most scapular fractures can be treated non-operatively with good functional outcomes, with surgical intervention reserved for specific displaced fractures that affect joint stability or function. 1

Diagnostic Evaluation

• Three-dimensional computed tomographic (CT) scans are considered the gold standard for accurate diagnosis and classification of scapular fractures 2
• Plain radiographs may miss scapular fractures due to overlapping structures, making thorough imaging essential for proper diagnosis 2
• Assessment of the glenopolar angle (GPA) is important to evaluate rotational malalignment of the glenoid, with angles less than 20 degrees associated with poorer outcomes 3

Non-Operative Management

• Most scapular fractures respond well to non-operative treatment with early functional rehabilitation 4

• Initial management includes:

  • Pain control with appropriate analgesics 1
  • A sling for comfort that can be discarded as pain allows 1
  • Early finger and hand motion to prevent edema and stiffness 1
  • Early introduction of range-of-motion exercises including shoulder, elbow, wrist, and hand motion 1

• Rehabilitation should focus on:

  • Early physical training and muscle strengthening 1
  • Restriction of above-chest level activities until fracture healing is evident 1
  • Long-term continuation of balance training and fall prevention 1

Surgical Indications

Operative treatment should be considered for:

• Displaced intra-articular fractures affecting joint congruity 4
• Glenoid rim fractures associated with humeral head subluxation 4
• Unstable fractures of the scapular neck 4
• Severe displacement of the glenoid neck (GPA <20°) which is associated with poorer long-term outcomes 3

Surgical Approach and Technique

• The Judet approach (posterior) is the workhorse approach for operative treatment of scapular fractures 5
• Open reduction and internal fixation (ORIF) has shown good to excellent clinical outcomes with minimal complications in appropriately selected patients 5
• Surgical technique involves:
  • Preoperative planning and appropriate patient positioning 5
  • Creation of a full-thickness flap for exposure 5
  • Careful protection of neurovascular structures, particularly the suprascapular and axillary nerves 5
  • Stable fixation with plates and screws 4

Post-Surgical Management

• Range-of-motion exercises should begin within the first postoperative days 1
• A sling is used for comfort only and may be discarded as pain allows 1
• Above chest level activities should be restricted until fracture healing is evident 1
• Caution against overly aggressive physical therapy which may increase risk of fixation failure 1

Special Considerations

• Scapular fractures often result from high-energy trauma, so assessment for associated injuries is essential 4
• In elderly patients with fragility fractures, evaluation for osteoporosis should be considered 1
• Patient education about the injury, expected recovery timeline, and rehabilitation goals is important for optimal outcomes 1

Potential Complications

• Malalignment of the glenoid neck (GPA <20°) is associated with:
  • Moderate to severe pain 3
  • Reduced activities of daily living 3
  • Potential loss of motion 3
• Wound healing complications can occur following extensive surgical approaches 5
• Missed or improperly evaluated fractures can lead to chronic pain and dysfunction 2