The scapula plays a critical role in the association between the upper extremity and the axial skeleton. Fractures of the scapula account for 0.4% to 1% of all fractures and have an annual incidence of approximately 10 per 100,000 inhabitants. Scapular fractures typically result from a high-energy blunt-force mechanism and are often associated with other traumatic injuries. The present review focuses on the presentation, diagnosis, and treatment of fractures of the scapula. Indications for surgical treatment of glenoid fossa, scapular neck, and scapular body fractures are presented in detail. Finally, the authors’ preferred surgical technique, including positioning, approach, reduction, fixation, and post-operative management, is described.
The scapula plays an integral role in the association between the upper extremity and the axial skeleton. It articulates with the humerus at the glenohumeral joint, with the clavicle at the acromioclavicular joint, and with the thorax at the scapulothoracic joint. Full range of motion at the shoulder entails movement at all three articulations, which is coordinated by the eighteen different muscles that originate from or insert on the scapula. Together, these muscles coordinate six basic movements of the scapula: elevation, depression, upward rotation, downward rotation, protraction, and retraction.
Scapular fractures account for 3% to 5% of all fractures of the shoulder girdle and compose 0.4% to 1% of all fractures [
Fractures of the scapula typically result from a high-energy blunt-force mechanism [
Because of the high-energy nature of scapular fractures, 80% to 95% are associated with additional traumatic injuries [
Patients with scapular fractures present with the ipsilateral upper extremity adducted against the body and protected from movement. Typical physical examination findings may include swelling, ecchymosis, crepitus, and tenderness about the shoulder. Range of motion of the shoulder is limited, particularly with abduction. A meticulous neurovascular examination is necessary in order to evaluate for injury to the ipsilateral brachial plexus and/or vascular structures.
The earliest opportunity to diagnose a scapular fracture may be on the initial routine supine anteroposterior chest radiograph taken in most trauma patients (Figure
Anteroposterior chest radiograph demonstrating a left scapular fracture.
Therefore, all patients with suspected scapular fractures should have dedicated anteroposterior, lateral, and axillary radiographs of the shoulder performed (Figure
Anteroposterior (a) and lateral (b) radiographs of the left shoulder demonstrating a comminuted fracture of the lateral aspect of the left scapula with glenoid involvement.
A computed tomography (CT) scan is recommended for complex fractures and for fractures with significant displacement (Figure
Axial (a–c), coronal (d–f), and saggital (g–i) cuts of the left shoulder CT scan demonstrating a displaced, comminuted scapular fracture that originates at the base of the coracoid process and extends into the posterior glenoid and into the midbody of the scapula.
Three-dimensional reconstructions of the left shoulder CT scan.
Historically, scapular fractures have been treated nonoperatively. In 1805, Desault provided an early description of closed treatment of scapular fractures in his treatise on fractures. More recent research has shown that over 90% of scapular fractures are nondisplaced or minimally displaced and can be effectively managed with conservative treatment [
For glenoid fossa fractures, some surgeons advocate open reduction and internal fixation for patterns that result in articular displacement greater than 5 mm [
While most extra-articular scapular fractures can be treated nonoperatively, surgical intervention should be considered for significantly displaced fractures [
Approximately 50% of scapular fractures involve the scapular body and spine [
Another operative indication for scapular fractures is double disruption of the superior shoulder suspensory complex (SSSC). The SSSC, which consists of the glenoid, coracoid, acromion, distal clavicle, coracoclavicular ligaments, and acromioclavicular ligaments, secures the upper extremity to the axial skeleton [
A final indication for surgical fixation of a scapular fracture is associated scapulothoracic dissociation. Scapulothoracic dissociation is characterized by complete disruption of the scapulothoracic articulation and lateral displacement of the scapula. This relatively rare injury is typically the result of a violent high-energy mechanism [
For the patient with a scapular fracture that does not involve the anterior glenoid, the following procedure is commonly performed in the lateral decubitus position (Figure
The patient is positioned in lateral decubitus on a beanbag with the operative arm in the prone position.
Exposure is obtained via a modified Judet approach. In brief, a curvilinear incision is positioned along the medial border of the scapula and the scapular spine (Figure
The curvilinear incision is positioned along the medial border of the scapula and the scapular spine.
A full-thickness flap overlying the deltoid fascia is created, thereby exposing the posterior deltoid.
The deltoid origin is sharply released from the scapular spine, and the deltoid is retracted laterally.
The interval between the infraspinatus and teres minor is developed with meticulous care taken to avoid the axillary nerve and the innervation to the infraspinatus. The scapular fracture is exposed within this interval.
Once the fracture site is identified, it is gently débrided. Fracture reduction and fixation is dependent on the fracture pattern and the bone quality. The fracture is reduced using a 4 mm Shantz pin placed proximally in the more lateral fragment for mobilization and reduction and using point-to-point clamps for provisional fixation (Figure
Intraoperative photographs demonstrating the scapular fracture before (a) and after (b) reduction using a 4 mm Shantz pin and two point-to-point clamps.
Intraoperative photograph demonstrating three small fragment plates positioned to maintain reduction of the scapular fracture.
Postoperative anteroposterior radiograph of the left shoulder demonstrating an anatomic reduction of the scapular fracture with good positioning of the implants.