What is the appropriate management at day 28 after a scapular body fracture with good radiographic alignment?

Management of Scapular Body Fracture at Day 28 Post-Injury with Good Alignment

Continue nonoperative management with progressive rehabilitation focusing on active range of motion and strengthening exercises, as isolated scapular body fractures with good alignment heal well without surgery and should be approaching functional recovery at 4 weeks. 1, 2

Current Status at Day 28

At 4 weeks post-fracture, you are in the active rehabilitation phase where fracture healing is well underway:

• Fracture union is progressing: All displaced scapular body fractures treated nonoperatively heal uneventfully, typically achieving complete bony union by 3-6 months 2
• Early mobilization period has passed: The initial immobilization and pain management phase should be complete 3
• Functional recovery is underway: Patients treated surgically show better outcomes at 1-3 months but no significant difference by 12 months compared to conservative treatment, indicating that nonoperative patients catch up during this timeframe 4

Rehabilitation Protocol at This Stage

Active range of motion and strengthening should be the primary focus:

• Progress to active stretching and mobilization techniques, particularly emphasizing external rotation and abduction movements 3
• Begin progressive strengthening of rotator cuff muscles to restore shoulder stability and function 3
• Implement neuromuscular re-education exercises to optimize shoulder mechanics 3
• Avoid overhead pulleys as they encourage uncontrolled abduction that may worsen the injury 3

Pain Management

If pain persists at this stage:

• Use acetaminophen or ibuprofen for ongoing discomfort if no contraindications exist 3
• Consider subacromial corticosteroid injection if pain is related to subacromial inflammation 3
• Intra-articular corticosteroid injections have demonstrated significant pain reduction effects 3

Monitoring and Follow-Up

Clinical assessment is more important than repeat imaging at this point:

• Limit follow-up imaging to situations that will change management decisions 3
• Monitor for complications: Assess for complex regional pain syndrome (shoulder-hand syndrome), which may require early corticosteroid intervention 3
• Evaluate for neurological deficits at each visit, as nerve involvement would alter management 3

When Additional Imaging Is Indicated

CT without contrast should be obtained only if:

• Clinical examination suggests fracture displacement or malalignment despite initial radiographs showing good position 1
• There is concern for glenoid involvement, intra-articular extension, or glenopolar angulation that was underappreciated on plain films 1
• Surgical decision-making is being reconsidered due to poor clinical progress 5

MRI without contrast is indicated if:

• Persistent pain suggests soft tissue pathology such as rotator cuff injury or labral damage 3
• Neurological symptoms develop suggesting nerve involvement 3

Surgical Considerations (Unlikely at This Point)

Surgery is not indicated for your patient given good alignment, but would have been considered initially if: 1, 4

• Significant displacement with glenoid neck involvement
• Intra-articular extension with step-off
• Associated glenohumeral instability
• High injury severity score with multiple rib fractures

Expected Outcomes

Realistic expectations for nonoperative management:

• Functional recovery: Mean DASH score improvement of 10.2 points, representing minimal clinically important change 2
• Complete healing: All nonoperatively treated displaced scapular body fractures heal without complication 2
• Radiographic changes: Expect mean glenopolar angle change of approximately 9° (range 0-20°), representing some scapular shortening and medialization 2
• Return to baseline: By 12 months, functional outcomes are equivalent to surgically treated patients 4

Critical Pitfalls to Avoid

• Do not immobilize beyond the early phase: Prolonged immobilization leads to stiffness and poor outcomes 3
• Do not order routine repeat radiographs unless clinical findings suggest complications 3
• Do not miss associated injuries: Rib fractures and higher injury severity scores adversely affect clinical outcomes 2
• Do not delay physical therapy: Early rehabilitation after initial immobilization prevents complications 3