Scapular fracture

Last updated

Scapular fracture
ScapulaFracture.png
A right sided scapula fracture with rib fractures underneath seen on a 3D reconstruction of a CT scan
Specialty Orthopedic

A scapular fracture is a fracture of the scapula, the shoulder blade. The scapula is sturdy and located in a protected place, so it rarely breaks. When it does, it is an indication that the individual was subjected to a considerable amount of force and that severe chest trauma may be present. [1] High-speed vehicle accidents are the most common cause. This could be anywhere from a car accident, motorcycle crash, or high speed bicycle crash but falls and blows to the area can also be responsible for the injury. Signs and symptoms are similar to those of other fractures: they include pain, tenderness, and reduced motion of the affected area although symptoms can take a couple of days to appear. Imaging techniques such as X-ray are used to diagnose scapular fracture, but the injury may not be noticed in part because it is so frequently accompanied by other, severe injuries that demand attention. The injuries that usually accompany scapular fracture generally have the greatest impact on the patient's outcome. However, the injury can also occur by itself; when it does, it does not present a significant threat to life. Treatment involves pain control and immobilizing the affected area, and, later, physical therapy.

Contents

Signs and symptoms

As with other types of fractures, scapular fracture may be associated with pain localized to the area of the fracture, tenderness, swelling, and crepitus (the crunching sound of bone ends grinding together). [1] Since scapular fractures impair the motion of the shoulder, a person with a scapular fracture has a reduced ability to move the shoulder joint. [2] Signs and symptoms may be masked by other injuries that accompany the scapular fracture. [2]

Causes

Usually, it takes a large amount of energy to fracture the scapula; the force may be indirect but is more often direct. [3] The scapula is fractured as the result of significant blunt trauma, as occurs in vehicle collisions. [4] About three quarters of cases are caused by high-speed car and motorcycle collisions. [4] Falls and blows to the shoulder area can also cause the injury. [4] Crushing injuries (as may occur in railroad or forestry accidents) and sports injuries (as may occur in horseback riding, mountain biking, bmxing or skiing) can also fracture the scapula. [2] Scapular fracture can result from electrical shocks and from seizures: muscles pulling in different directions contract powerfully at the same time. [5] In cardiopulmonary resuscitation, the chest is compressed significantly; scapular fracture may occur as a complication of this technique. [4]

Anatomy

The scapula has a body, neck, and spine; any of these may be fractured. The most commonly injured areas are the scapular body, spine, neck, and glenoid rim; the scapular body or neck is injured in about 80% of cases. Fractures that occur in the body may be vertical, horizontal, or comminuted (involving multiple fragments). Those that occur in the neck are usually parallel to the glenoid fossa. When they occur in the glenoid fossa, fractures are usually small chips out of the bone or extensions of fractures occurring in the scapular neck. [4]

The scapula is protected from the front by the ribcage and chest, and from the back it is protected by a thick layer of muscles. [3] Also, the scapula is able to move, so traumatic forces exerted on it are dissipated, not absorbed by the bone. [3] Thus a large amount of force is required to fracture it. [4]

Diagnosis

X-ray showing a fracture of the clavicula and scapula FracturedGlenoid.png
X-ray showing a fracture of the clavicula and scapula

Most fractures of the scapula can be seen on a chest X-ray; however, they may be missed during examination of the film. [1] Serious associated injuries may distract from the scapular injury, [4] and diagnosis is often delayed. [3] Computed tomography may also be used. [1] Scapular fractures can be detected in the standard chest and shoulder radiographs that are given to patients who have had significant physical trauma, but much of the scapula is hidden by the ribs on standard chest X-rays. [4] Therefore, if scapular injury is suspected, more specific images of the scapular area can be taken. [4]

Classification

Body fractures

Described based upon anatomic location

Neck fractures

Coracoid process fractures

TypeDescription
IFracture proximal to the coracoclavicular ligament
IIFracture distal to the coracoclavicular ligament

Acromion fractures

TypeDescription
INon- or minimally-displaced
IIDisplaced but not affecting the subacromial space
IIIDisplacement compromising the subacromial space

Glenoid fossa fractures

Described by the Ideberg classification

Treatment

Treatment involves pain medication and immobilization at first; later, physical therapy is used. [1] Ice over the affected area may increase comfort. [6] Movement exercises are begun within at least a week of the injury; with these, fractures with little or no displacement heal without problems. [6] Over 90% of scapular fractures are not significantly displaced; therefore, most of these fractures are best managed without surgery. [3] Fractures of the scapular body with displacement may heal with malunion, but even this may not interfere with movement of the affected shoulder. [6] However, displaced fractures in the scapular processes or in the glenoid do interfere with movement in the affected shoulder if they are not realigned properly. [6] Therefore, while most scapular fractures are managed without surgery, surgical reduction is required for fractures in the neck or glenoid; otherwise motion of the shoulder may be impaired. [7]

Epidemiology

Scapular fracture is present in about 1% of cases of blunt trauma [1] and 3–5% of shoulder injuries. [4] An estimated 0.4–1% of bone fractures are scapular fractures. [2]

The injury is associated with other injuries 80–90% of the time. [1] Scapular fracture is associated with pulmonary contusion more than 50% of the time. [8] Thus when the scapula is fractured, other injuries such as abdominal and chest trauma are automatically suspected. [1] People with scapular fractures often also have injuries of the ribs, lung, and shoulder. [4] Pneumothorax (an accumulation of air in the space outside the lung), clavicle fractures, and injuries to the blood vessels are among the most commonly associated injuries. [4] The forces involved in scapular fracture can also cause tracheobronchial rupture, a tear in the airways. [9] Fractures that occur in the scapular body are the type most likely to be accompanied by other injuries; other bony and soft tissue injuries accompany these fractures 80–95% of the time. [3] Associated injuries can be serious and potentially deadly, [3] and usually it is the associated injuries, rather than the scapular fracture, that have the greatest effect on the outcome. [4] Scapular fractures can also occur by themselves; when they do, the death rate (mortality) is not significantly increased. [4]

The mean age of people affected is 35–45 years. [2]

Notes

  1. 1 2 3 4 5 6 7 8 Livingston DH, Hauser CJ (2003). "Trauma to the chest wall and lung". In Moore EE, Feliciano DV, Mattox KL (eds.). Trauma. Fifth Edition. McGraw-Hill Professional. p. 516. ISBN   0-07-137069-2.
  2. 1 2 3 4 5 Wiedemann et al. (2000) pp. 504–507
  3. 1 2 3 4 5 6 7 Goss TP, Owens BD (2006). "Fractures of the scapula: Diagnosis and treatment". In Iannotti JP, Williams GR (eds.). Disorders of the Shoulder: Diagnosis and Management. Hagerstown, MD: Lippincott Williams & Wilkins. pp. 794–795. ISBN   0-7817-5678-2.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Queiroz R, Sucov A (1999). "The clavicle and scapula". In Schwartz DM, Reisdorff E (eds.). Emergency Radiology. New York: McGraw-Hill, Health Professions Division. pp. 117–134. ISBN   0-07-050827-5.
  5. Wiedemann et al. (2000) p. 504. "Scapular fractures may be caused by forceful contraction of divergent muscles elicited by a seizure or by electrical shock."
  6. 1 2 3 4 Wiedemann et al. (2000) p. 510
  7. Miller LA (March 2006). "Chest wall, lung, and pleural space trauma". Radiologic Clinics of North America. 44 (2): 213–24, viii. doi:10.1016/j.rcl.2005.10.006. PMID   16500204.
  8. Allen GS, Coates NE (November 1996). "Pulmonary contusion: A collective review". The American Surgeon. 62 (11): 895–900. PMID   8895709.
  9. Hwang JC, Hanowell LH, Grande CM (1996). "Peri-operative concerns in thoracic trauma". Baillière's Clinical Anaesthesiology. 10 (1): 123–153. doi:10.1016/S0950-3501(96)80009-2.

Related Research Articles

Trapezius Muscle between the lower spine and the shoulder blade

The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the spine and laterally to the spine of the scapula. It moves the scapula and supports the arm.

Scapula Bone that connects the humerus (upper arm bone) with the clavicle (collar bone)

In anatomy, the scapula, also known as the shoulder bone, shoulder blade, wing bone, speal bone or blade bone, is the bone that connects the humerus with the clavicle. Like their connected bones, the scapulae are paired, with each scapula on either side of the body being roughly a mirror image of the other. The name derives from the Classical Latin word for trowel or small shovel, which it was thought to resemble.

Coracoid process Small hook-like structure on the lateral edge of the superior anterior portion of the scapula

The coracoid process is a small hook-like structure on the lateral edge of the superior anterior portion of the scapula. Pointing laterally forward, it, together with the acromion, serves to stabilize the shoulder joint. It is palpable in the deltopectoral groove between the deltoid and pectoralis major muscles.

Thorax Frontal part of an animals body, between its head and abdomen

The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the creature's body, each of which is in turn composed of multiple segments.

Dorsal scapular nerve Branch of the brachial plexus that supplies rhomboid muscles and levator scapulae

The dorsal scapular nerve is a branch of the brachial plexus. It supplies rhomboid major muscle, rhomboid minor muscle, and levator scapulae muscle. It causes the scapula to be moved medially towards the vertebral column. Dorsal scapular nerve syndrome can cause a winged scapula, with pain and limited motion.

Shoulder problem Medical condition

Shoulder problems including pain, are one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.

Shoulder Part of the body

The human shoulder is made up of three bones: the clavicle (collarbone), the scapula, and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The shoulder joint, also known as the glenohumeral joint, is the major joint of the shoulder, but can more broadly include the acromioclavicular joint. In human anatomy, the shoulder joint comprises the part of the body where the humerus attaches to the scapula, and the head sits in the glenoid cavity. The shoulder is the group of structures in the region of the joint.

Teres minor muscle

The teres minor is a narrow, elongated muscle of the rotator cuff. The muscle originates from the lateral border and adjacent posterior surface of the corresponding right or left scapula and inserts at both the greater tubercle of the humerus and the posterior surface of the joint capsule.

Clavicle fracture Medical condition

A clavicle fracture, also known as a broken collarbone, is a bone fracture of the clavicle. Symptoms typically include pain at the site of the break and a decreased ability to move the affected arm. Complications can include a collection of air in the pleural space surrounding the lung (pneumothorax), injury to the nerves or blood vessels in the area, and an unpleasant appearance.

Shoulder joint Synovial ball and socket joint in the shoulder

The shoulder joint is structurally classified as a synovial ball-and-socket joint and functionally as a diarthrosis and multiaxial joint. It involves an articulation between the glenoid fossa of the scapula and the head of the humerus. Due to the very loose joint capsule that gives a limited interface of the humerus and scapula, it is the most mobile joint of the human body.

Flail chest Medical condition

Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. Two of the symptoms of flail chest are chest pain and shortness of breath.

Rib fracture Break in a rib bone

A rib fracture is a break in a rib bone. This typically results in chest pain that is worse with inspiration. Bruising may occur at the site of the break. When several ribs are broken in several places a flail chest results. Potential complications include a pneumothorax, pulmonary contusion, and pneumonia.

Middle back pain, also known as thoracic back pain, is back pain that is felt in the region of the thoracic vertebrae, which are between the bottom of the neck and top of the lumbar spine. It has a number of potential causes, ranging from muscle strain to collapse of a vertebra or rare serious diseases. The upper spine is very strong and stable to support the weight of the upper body, as well as to anchor the rib cage which provides a cavity to allow the heart and lungs to function and protect them.

Shoulder girdle Set of bones which connects the arm to the axial skeleton on each side

The shoulder girdle or pectoral girdle is the set of bones in the appendicular skeleton which connects to the arm on each side. In humans it consists of the clavicle and scapula; in those species with three bones in the shoulder, it consists of the clavicle, scapula, and coracoid. Some mammalian species have only the scapula.

Winged scapula Skeletal muscle condition around the shoulder blade

A winged scapula is a skeletal medical condition in which the shoulder blade protrudes from a person's back in an abnormal position.

Shoulder surgery is a means of treating injured shoulders. Many surgeries have been developed to repair the muscles, connective tissue, or damaged joints that can arise from traumatic or overuse injuries to the shoulder.

Humerus fracture Medical condition

A humerus fracture is a break of the humerus bone in the upper arm. Symptoms may include pain, swelling, and bruising. There may be a decreased ability to move the arm and the person may present holding their elbow. Complications may include injury to an artery or nerve, and compartment syndrome.

Pulmonary contusion Internal bruise of the lungs

A pulmonary contusion, also known as lung contusion, is a bruise of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). Unlike pulmonary laceration, another type of lung injury, pulmonary contusion does not involve a cut or tear of the lung tissue.

Pulmonary laceration Medical condition

A pulmonary laceration is a chest injury in which lung tissue is torn or cut. An injury that is potentially more serious than pulmonary contusion, pulmonary laceration involves disruption of the architecture of the lung, while pulmonary contusion does not. Pulmonary laceration is commonly caused by penetrating trauma but may also result from forces involved in blunt trauma such as shear stress. A cavity filled with blood, air, or both can form. The injury is diagnosed when collections of air or fluid are found on a CT scan of the chest. Surgery may be required to stitch the laceration, to drain blood, or even to remove injured parts of the lung. The injury commonly heals quickly with few problems if it is given proper treatment; however it may be associated with scarring of the lung or other complications.

Sternal fracture Medical condition

A sternal fracture is a fracture of the sternum, located in the center of the chest. The injury, which occurs in 5–8% of people who experience significant blunt chest trauma, may occur in vehicle accidents, when the still-moving chest strikes a steering wheel or dashboard or is injured by a seatbelt. Cardiopulmonary resuscitation (CPR), has also been known to cause thoracic injury, including sternum and rib fractures. Sternal fractures may also occur as a pathological fracture, in people who have weakened bone in their sternum, due to another disease process. Sternal fracture can interfere with breathing by making it more painful; however, its primary significance is that it can indicate the presence of serious associated internal injuries, especially to the heart and lungs.

References