What is the recommended management for a patient with a scapula fracture?

Management of Scapula Fracture

Most scapula fractures should be managed nonoperatively with early mobilization and rehabilitation, but CT imaging is essential to identify fracture patterns requiring surgical fixation, particularly those involving the glenoid neck, intra-articular extension, or significant displacement. 1

Initial Assessment and Imaging

• Obtain CT scan immediately after plain radiographs confirm scapula fracture, as the complex osteology and overlying ribs make fracture patterns easily missed or underappreciated on conventional radiography alone. 1

• CT is the best imaging modality for characterizing scapula fracture patterns, specifically assessing intra-articular extension, glenopolar angulation, AP angulation, and lateral border offset—all critical factors in surgical decision-making. 1

• Three-dimensional CT reformations should be obtained to better visualize fracture displacement and angulation. 1

• Provide immediate adequate pain control before diagnostic investigations using multimodal analgesia (acetaminophen, NSAIDs, or opioids if severe). 1

Treatment Decision Algorithm

Indications for Nonoperative Management (Majority of Cases)

• Isolated scapula body fractures heal well without surgical fixation and should be managed conservatively. 1

• Nonoperative treatment consists of:

  • Sling for comfort only, discarded as early as pain allows 1
  • Early range-of-motion exercises within first few days 1
  • Restriction of above-chest-level activities until fracture healing evident 1

Indications for Surgical Fixation

Consider operative management for:

• Displaced intra-articular fractures involving the glenoid 2
• Glenoid rim fractures associated with humeral head subluxation 2
• Unstable fractures of the scapular neck 2
• Fractures with significant glenopolar angulation, AP angulation, or lateral border offset on CT 1

Important caveat: There is no universal consensus on exact surgical indications, but associated rib fractures or higher injury severity scores are associated with worse clinical outcomes and may benefit from more aggressive surgical fixation. 1

Rehabilitation Protocol

Early Phase (First Postoperative Days or Immediately if Nonoperative)

• Begin range-of-motion exercises including shoulder, elbow, wrist, and hand motion within the first postoperative days or immediately after injury if treated nonoperatively. 1

• Aggressive finger and hand motion is essential to prevent edema and stiffness. 1

Intermediate Phase

• Restrict above-chest-level activities in both operative and nonoperative management until fracture healing is evident. 1

• Avoid overly aggressive physical therapy in the postoperative period, as this may increase risk of fixation failure. 1

Long-term Phase

• Continue balance training and multidimensional fall prevention programs long-term. 1

• Implement physical training and muscle strengthening with progressive advancement. 1

Expected Outcomes and Complications

Nonoperative Management

• Union rate is exceptionally high regardless of treatment modality. 3

• Persistent pain is unfortunately common following scapula fractures, even with appropriate treatment. 3

• Approximately 50% of patients with residual scapula deformity develop shoulder symptoms, though most disablement is slight to moderate. 4

• Shoulder range of motion and strength are typically decreased compared to the contralateral shoulder. 3

• Nonoperative glenoid fractures have the lowest reported functional scores among scapula fracture subtypes. 3

Operative Management

• 64% achieve complete functional recovery with open reduction and stable osteosynthesis for appropriate indications. 2

• 79% achieve good to excellent results overall when surgical indications are properly selected. 2

• Common complications include: malunion, need for additional surgeries, and post-traumatic arthritis. 3

• Coracoid fractures treated with ORIF carry risk of shoulder dislocation (3.6%) and brachial plexus injuries (3.0%) at 3 months. 5

• Acromion fractures treated with ORIF have risk of malunion/nonunion (4.6%), ORIF revision (6.2%), and shoulder osteoarthritis (10.3%) at 5 years. 5

Critical Pitfalls to Avoid

• Do not rely on plain radiographs alone—scapula fractures are easily missed or underappreciated without CT imaging. 1

• Do not delay pain management waiting for complete imaging workup. 1

• Do not immobilize excessively—early mobilization is critical to prevent stiffness and optimize functional recovery. 1

• Do not pursue overly aggressive physical therapy in the early postoperative period, as this increases fixation failure risk. 1

• Do not assume all scapula fractures have uniformly favorable outcomes—persistent pain and functional limitations are common, particularly with residual deformity. 4, 3