Scapular fractures

What is a scapular fracture?

Scapula (shoulder blade) is a triangular shaped bony structure that joins the upper arm to the chest wall on the upper back. Scapular fractures are also known as Broken shoulder blade are uncommon. The scapula is protected by a multiple layers of chest and shoulder muscles and fractures usually happen following high energy injuries. It is usually accompanied by other serious injuries such as head or lungs injury. It occurs as a result of high-energy trauma such as motor vehicle or bicycle accidents or falls from a height during rock climbing, fall of a heavy object over scapula or contact sports such as football.

Scapula fractures accounts for 1% of all fractures and 5% of all fractures around the shoulder. 80 to 90 % of cases will have associated injuries which includes, rib fractures (52%), clavicle (collarbone) fracture (25%), spine (backbone) fracture (29%), pulmonary injuries (30 -40%), head injury (34%) and vascular (blood vessels) injury (11%). Most of the fractures are located on the body and spine (50% near backbone), glenoid neck (25% near shoulder socket), glenoid cavity (10% in shoulder socket), and acromial and coracoid process (7 to 8% near shoulder blade).

 

What are the symptoms of the scapular fracture?

The symptoms of Broken shoulder blade include severe pain, bruising and swelling in the upper back and around the shoulder. The pain aggravates with the movement of the arm (upper limb) and deep breaths even at rest. You will not be able to lift the affected arm. You may also feel grinding sensation, crepitus or popping sound while moving the shoulder. Weakness or continued tingling sensation is also common. Skin abrasion can also occur at the shoulder blade. Patients might present with other symptoms relevant to associated injuries (other fractures and injuries to backbone, heart, lungs, chest or spinal cord).

 

How is it diagnosed?

Its diagnosis is made by detailed medical history, physical examination, X-ray and CT scan. X-ray detects the exact location of the fracture.  CT scan detects the extent of fracture and helps in planning the treatment. In some patients MRI scans are needed to assess soft tissues, relationship to neurovascular structures and other injured parts.

 

 How is it treated?

The scapular fracture can be treated with conservative or surgical methods. More than 90% of these fractures heal with conservative methods. Conservative treatment involves the use of a sling, painkillers and physiotherapy.

Surgery is indicated in-

  • Displaced Intra-articular fractures in glenoid fossa (shoulder joint)
  • Fractures in the neck of scapula > 40 degrees angulation or 1cm translation
  • Open fracture
  • Associated fractures of clavicle (floating shoulder)
  • Displaced acromial fractures,
  • Loss of rotator cuff function
  • Coracoid fracture >1cm of displacement

 

What are the non-operative treatments?

The non-operative methods include

  • The patient is advised to take full rest and avoid contact sports.
  • Ice packs are placed on the shoulder every two to three hours for about 20-30 minutes.
  • A shoulder sling is applied on the shoulder for 3-6 weeks for healing. The duration of the sling on your shoulder totally depends on the type of the fracture.
  • Painkillers like codeine and paracetamol are prescribed to relieve the pain during healing.
  • Anti-inflammatory drugs such as aspirin and ibuprofen are prescribed to control swelling. However, using anti-inflammatory medications for a long time could lead to delayed bone healing and could kidney function.
  • Physical therapy is started early with gentle exercises to restore full function of the shoulder. The elbows, wrist and hand are kept mobile during immobilization. Strenuous exercises are gradually introduced by your physiotherapist after the fracture is healed.

 

What does the operation involve?

Surgery is performed in the cases that have high displacements of the scapula and fracture at the socket (glenoid cavity) or neck of the bone.  The operation is focussed on the realignment and stabilization of the broken bone parts of the scapula.

  • Surgery is usually performed under general anaesthetic, a cut is made in the skin over the fracture site and the fragments of the scapula are first repositioned to their normal position.
  • Then, internal fixation of the fragments is done with the help of plates, pins and screws to keep the bone in proper position during healing. In some cases with multiple fracture fragments, bone substitutes are used to accelerate healing and to bridge the gap.
  • The skin is stitched using absorbable sutures and a shoulder sling is applied. The surgical time is usually 1-3 hrs and the majority of the patients go home the following day.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • You should take adequate rest avoiding the sports and any new injury for at least 3 months and the sling is kept for 4-6 weeks.
  • Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and pendulum exercises for the shoulder. This is necessary to prevent stiffness and pain and to maintain the strength of the muscles in your upperlimb.
  • The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness, helps scar to mature).
  • The physical therapy in scapula fractures begins with gentle exercises like pendulum exercises which progresses to active assisted and full range of movement exercises at about 6-8 weeks of surgery. Strengthening exercises are started around 12 weeks after surgery. This depends on the X-ray reports and clinical union of fracture as guided by your surgeon.

 

Are there any risks?

The risks in operative treatment are minimal in the fractures of the scapula. They can be-

  • Non-union (very rare)
  • Nerve and blood vessel damage
  • Bleeding
  • Infection
  • Frozen shoulder

 

What happens if nothing is done?

If the fracture in the scapula is left untreated, it may heal incorrectly in the wrong position. This condition is called malunion. Malunion can cause stiffness, limited movement, residual pain and a bump or deformity on the affected part. If this happens inside the shoulder joint, this could lead to early arthritis.

 

What are the results of the operation?

The outcome of the operation is 70% good with minimal complications. Most broken shoulder blades heal within 6-8 weeks. Highly displaced scapular fractures also have good results surgically with early mobilization of the arm and fewer complication rates.  The stability and range of motion of shoulder joint are better in operative treatment than non-operative one in selected cases.

 

When can I return to driving and work?

You can return to work between a week and 3 months & can start driving from 6 weeks in simple fractures, however could take 3 months in complex injuries. Both depends on the nature of your job, type of the injury and the treatment involved, your surgeon will be able to advise.

  Scapular fractures

  1. Shoulder blade and its relation to humerus and collar bone
  2. Complex shoulder blade and proximal humerus fracture, treated with plates and screws.

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