View source for Medicine:Scapular fracture

{{Short description|Injury of the shoulder blade}}
{{Infobox medical condition (new)
| name            = Scapular fracture
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| image           = ScapulaFracture.png
| caption         = A right sided scapula fracture with rib fractures underneath seen on a 3D reconstruction of a CT scan
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| field           = orthopedic
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A '''scapular fracture''' is a [[Medicine:Bone fracture|fracture]] of the [[Biology:Scapula|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.<ref name="Moore03">{{cite book | chapter=Trauma to the chest wall and lung |vauthors=Livingston DH, Hauser CJ | title=Trauma. Fifth Edition |veditors=Moore EE, Feliciano DV, Mattox KL | year=2003 | publisher=McGraw-Hill Professional | isbn=0-07-137069-2 |page=516 }}</ref>  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, [[Medicine:Physical therapy|physical therapy]].

==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 [[Medicine:Crepitus|crepitus]] (the crunching sound of bone ends grinding together).<ref name="Moore03"/>  Since scapular fractures impair the motion of the shoulder, a person with a scapular fracture has a reduced ability to move the shoulder joint.<ref name="Wiedemann00">Wiedemann ''et al.'' (2000) pp. 504–507</ref>  Signs and symptoms may be masked by other injuries that accompany the scapular fracture.<ref name="Wiedemann00"/>

==Causes==
Usually, it takes a large amount of energy to fracture the scapula; the force may be indirect but is more often direct.<ref name="Goss06"/>  The scapula is fractured as the result of significant [[Medicine:Blunt trauma|blunt trauma]], as occurs in vehicle collisions.<ref name="Schwartz"/> About three quarters of cases are caused by high-speed car and motorcycle collisions.<ref name="Schwartz"/> Falls and blows to the shoulder area can also cause the injury.<ref name="Schwartz"/>  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.<ref name="Wiedemann00"/>  Scapular fracture can result from electrical shocks and from [[Medicine:Seizure|seizure]]s: muscles pulling in different directions contract powerfully at the same time.<ref name="Wiedemann00q">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."</ref>  In cardiopulmonary resuscitation, the chest is compressed significantly; scapular fracture may occur as a complication of this technique.<ref name="Schwartz"/>

==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.<ref name="Schwartz">{{cite book|vauthors=Queiroz R, Sucov A |chapter=The clavicle and scapula |chapter-url=https://books.google.com/books?id=pOGtwBQ9aBMC&pg=PA117 |veditors=Schwartz DM, Reisdorff E |title=Emergency Radiology |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1999 |pages=117–134 |isbn=0-07-050827-5 }}</ref>

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.<ref name="Goss06">
{{
cite book |vauthors=Goss TP, Owens BD |veditors=Iannotti JP, Williams GR |chapter=Fractures of the scapula: Diagnosis and treatment|title=Disorders of the Shoulder: Diagnosis and Management |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2006 |pages=794–795|isbn=0-7817-5678-2
}}
</ref>  Also, the scapula is able to move, so traumatic forces exerted on it are dissipated, not absorbed by the bone.<ref name="Goss06"/>  Thus a large amount of force is required to fracture it.<ref name="Schwartz"/>
<gallery>
Image:Pectoral girdles-en.svg|The scapula, on left.
Image:Gray205 left scapula lateral view.png|Lateral view of the left scapula
</gallery>

==Diagnosis==
[[File:FracturedGlenoid.png|thumb|right|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.<ref name="Moore03"/>  Serious associated injuries may distract from the scapular injury,<ref name="Schwartz"/> and diagnosis is often delayed.<ref name="Goss06"/>  Computed tomography may also be used.<ref name="Moore03"/>  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 [[Physics:X-ray|X-ray]]s.<ref name="Schwartz"/> Therefore, if scapular injury is suspected, more specific images of the scapular area can be taken.<ref name="Schwartz"/>

===Classification===

====Body fractures====
Described based upon anatomic location

====Neck fractures====

====Coracoid process fractures====
{| class="wikitable"
|-
! Type
! Description
|-
| I
| Fracture proximal to the coracoclavicular ligament
|-
| II
| Fracture distal to the coracoclavicular ligament
|}

====Acromion fractures====
{| class="wikitable"
|-
! Type
! Description
|-
| I
| Non- or minimally-displaced
|-
| II
| Displaced but not affecting the subacromial space
|-
| III
| Displacement compromising the subacromial space
|}

====Glenoid fossa fractures====
Described by the [[Medicine:Ideberg classification|Ideberg classification]]

==Treatment==
Treatment involves pain medication and immobilization at first; later, [[Medicine:Physical therapy|physical therapy]] is used.<ref name="Moore03"/> Ice over the affected area may increase comfort.<ref name="Wiedemann00a">Wiedemann ''et al.'' (2000) p. 510</ref> Movement exercises are begun within at least a week of the injury; with these, fractures with little or no displacement heal without problems.<ref name="Wiedemann00a"/> Over 90% of scapular fractures are not significantly displaced; therefore, most of these fractures are best managed without surgery.<ref name="Goss06"/>  Fractures of the scapular body with displacement may heal with malunion, but even this may not interfere with movement of the affected shoulder.<ref name="Wiedemann00a"/>  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.<ref name="Wiedemann00a"/>  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.<ref name="MillerLA06">
{{
cite journal |author=Miller LA |title=Chest wall, lung, and pleural space trauma |journal=Radiologic Clinics of North America|volume=44 |issue=2 |pages=213–24, viii |date=March 2006 |pmid=16500204 |doi=10.1016/j.rcl.2005.10.006
}}
</ref>

==Epidemiology==
Scapular fracture is present in about 1% of cases of [[Medicine:Blunt trauma|blunt trauma]]<ref name="Moore03"/> and 3–5% of shoulder injuries.<ref name="Schwartz"/> An estimated 0.4–1% of bone fractures are scapular fractures.<ref name="Wiedemann00"/>

The injury is associated with other injuries 80–90% of the time.<ref name="Moore03"/>  Scapular fracture is associated with [[Medicine:Pulmonary contusion|pulmonary contusion]] more than 50% of the time.<ref name="Allen96">
{{
cite journal |vauthors=Allen GS, Coates NE |title=Pulmonary contusion: A collective review |journal=The American Surgeon |volume=62 |issue=11 |pages=895–900 |date=November 1996 |pmid=8895709
}}
</ref>  Thus when the scapula is fractured, other injuries such as [[Medicine:Abdominal trauma|abdominal]] and chest trauma are automatically suspected.<ref name="Moore03"/>  People with scapular fractures often also have injuries of the ribs, lung, and shoulder.<ref name="Schwartz"/>  [[Medicine:Pneumothorax|Pneumothorax]] (an accumulation of air in the space outside the lung), [[Medicine:Clavicle fracture|clavicle fracture]]s, and injuries to the blood vessels are among the most commonly associated injuries.<ref name="Schwartz"/>  The forces involved in scapular fracture can also cause tracheobronchial rupture, a tear in the airways.<ref name="Hwang96">
{{
cite journal |vauthors=Hwang JC, Hanowell LH, Grande CM |title=Peri-operative concerns in thoracic trauma |journal= Baillière's Clinical Anaesthesiology |volume = 10 |issue = 1 |pages=123–153 |doi= 10.1016/S0950-3501(96)80009-2 | date=1996
}}
</ref> 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.<ref name="Goss06"/>  Associated injuries can be serious and potentially deadly,<ref name="Goss06"/> and usually it is the associated injuries, rather than the scapular fracture, that have the greatest effect on the outcome.<ref name="Schwartz"/>  Scapular fractures can also occur by themselves; when they do, the death rate ([[Mortality rate|mortality]]) is not significantly increased.<ref name="Schwartz"/>

The mean age of people affected is 35–45&nbsp;years.<ref name="Wiedemann00"/>

==Notes==
{{Reflist}}

==References==
* {{cite book |vauthors=Wiedemann E, Euler E, Pfeifer K |chapter=Scapular fractures|veditors=Wulker N, Mansat M, Fu FH |title=Shoulder Surgery: An Illustrated Textbook |publisher=Martin Dunitz |year=2000 |pages=504–510 |isbn=1-85317-563-3 }}

== External links ==
* American Academy of Orthopaedic Surgeons (2007). [http://orthoinfo.aaos.org/topic.cfm?topic=A00359 Fracture of the shoulder blade (scapula)]. Retrieved on 2008-08-03.
{{Medical resources
|  DiseasesDB     = <!--none found-->
|  ICD10          = {{ICD10|S|42|1|s|40}}
|  ICD9           = {{ICD9|811}}
|  MedlinePlus    =
|  eMedicineSubj  = EMERG
|  eMedicineTopic = 205
|  MeshID         = <!--none found-->
}}

{{Chest trauma}}
{{fractures}}

[[Category:Injuries of shoulder and upper arm]]
[[Category:Bone fractures]]

{{Sourceattribution|Scapular fracture}}