| A fracture of the shoulder blade (scapula) is a fracture of the flat, triangular bone that rests against the upper posterior chest wall. The scapula attaches the upper extremity to the central skeleton and provides a stable base for upper extremity movement. One end attaches by ligaments to the collarbone (clavicle) at the acromion (acromioclavicular joint, or AC joint) and coracoid process and to the shoulder joint at the glenoid fossa (glenohumeral joint); the other attachments of the scapula are muscular attachments to the ribcage and spine. The scapula is the attachment site for 18 thoracic, spinal, and upper extremity muscles (Goss).
Fractures may be stable and bone fragments may remain properly aligned (nondisplaced fracture), or the pieces of the broken scapula may move out of alignment (displaced fracture). More than 90% of scapular fractures are nondisplaced due to the thick protective cushion of muscular attachments (Goss). Fifty percent of scapula fractures occur at the body and spine of the scapula, 10% to 25% occur at the glenoid neck or glenoid fossa, 8% occur at the acromial process, and 7% occur at the coracoid process (Goss). There are many different classification systems for scapular fractures. Fractures of the scapular body and glenoid are most likely to be associated with other major injuries. Fractures involving the coracoid process frequently involve tearing (avulsion), and fractures involving the glenoid rim are usually associated with a glenohumeral dislocation. These types of scapular fracture are most likely to require surgical intervention.
Considerable force and energy are required to fracture the scapula. Fracture occurs when a high-energy force is applied directly to the shoulder or posterior chest wall. Most fractures of the scapula result from a direct blow to the shoulder or back, such as in a motor vehicle accident or during a fall. Less often, the scapula may fracture indirectly through a fall onto an outstretched arm. When combined with fracture of the clavicle, a displaced fracture of the scapula is called a "floating shoulder," or a double disruption of the superior shoulder suspensory complex. Because scapular fractures result from high-energy force, they are frequently associated with other injuries such as rib fractures, pulmonary injuries (pneumothorax, hemothorax, pulmonary contusion), humeral fractures, skull fractures, and significant vascular injuries.Risk: Individuals at increased risk for fracture of the scapula are those who engage in contact sports such as hockey or football, sustain motor vehicle injuries, or experience blunt trauma to the shoulder blade.
Fracture of the scapula is most common in males between 25 and 45 years of age due to the increased frequency of blunt trauma encountered by these individuals (Freudenthal). Incidence and Prevalence: Scapular fractures are relatively uncommon and account for 1% of all fractures, 3% of shoulder girdle injuries, and 5% of all shoulder fractures (Goss). The incidence of scapular fracture is 10 to 12 per 100,000 individuals per year (Daya). The incidence of combined scapular neck fracture with clavicle fracture (floating shoulder) is 0.1% of all fractures (Gaenslen). |
Source: Medical Disability Advisor
| History: A complete medical history is taken, including the circumstances surrounding the injury, any underlying medical conditions, current medications, allergies, and occupation. The individual may report an acute injury, usually a fall or a high-velocity trauma resulting in a direct blow to the scapula. Individuals may complain of pain, localized swelling (edema), a crackling sensation or sound (crepitus), and inability to move the arm on the affected side. Attempts at arm movement may result in significant pain. Deep breaths may prove painful from rib movement during breathing. Physical exam: Physical examination begins with observation of the injured area. There may be an obvious deformity over the scapula, or the shoulder may appear flattened or deformed. There may be swelling and bruising (ecchymosis) at the site of the fracture. The injured area should be inspected carefully for abrasions or wounds that may indicate an open fracture. Feeling the site of fracture with the hands (palpation) will reveal tenderness and swelling. Shoulder range of motion is usually decreased. Crepitus may be heard or felt as range of motion is tested. A thorough neurovascular examination should be performed to detect any associated vascular or nerve (brachial plexus) injury. Tests: Individuals who have sustained a high-energy scapular fracture will probably be treated as a trauma patient. Typical laboratory studies include a complete blood count (CBC), blood chemistries, urinalysis, prothrombin time (PT) and partial thromboplastin time (PTT), and type and cross match.
X-rays of the scapula, shoulder, and chest are usually adequate to determine the severity and location of the fracture. CT scan may be indicated for displaced scapular fractures, to improve visualization of the glenoid fossa, or to prepare for surgery. Arteriography may be done if a problem with blood circulation (vascular compromise) is suspected. Electromyography (EMG) testing may be performed 3 weeks after injury in individuals with scapular fracture and brachial plexus injury. EMG helps to determine the extent of neurological injury and the prognosis.
Acromioclavicular joint dislocation (AC joint separation), humerus fracture, or rib fracture may occur concurrently and require appropriate diagnostic testing. |
Source: Medical Disability Advisor
| The majority of scapular fractures (90%) have little or no displacement and will heal with nonoperative treatment (Goss). Even some displaced scapula fractures will heal with conservative treatment. Treatment begins with immobilization of the scapula, shoulder, and arm in a sling and swathe (a bandage that reduces movement by binding the arm close to the body). Early progressive range of motion exercises can help prevent painful adhesions, sometimes referred to as a “frozen shoulder.” Activities can be increased gradually as pain subsides, with emphasis on range of motion and muscle strengthening. Most scapula fractures heal within 6 to 8 weeks, but full recovery of function takes several months. Normal activities may be resumed only when healing is complete. If there is significant displacement of bone fragments, more than one site of scapula fracture, or an articular glenoid fracture, surgical treatment (open reduction, internal fixation, or ORIF) may be necessary. Surgery generally prolongs recovery time. |
Source: Medical Disability Advisor
| Most nondisplaced fractures of the scapula will heal without surgery. Those that require ORIF have a good prognosis for functional return if bony alignment and glenohumeral stability are restored. Fractures of the surgical neck of the scapula or intra-articular glenoid fractures are the most likely to result in long-term pain and loss of shoulder range of motion (Melhorn, "Shoulder Injuries: Diagnosis, Causation and Treatment"). |
Source: Medical Disability Advisor
| Note on research and authorship The goals of rehabilitation for a scapula fracture are to reduce pain and to restore function. The rehabilitation protocol takes account of the type, location, and severity of the fracture, as well as the physician protocol. Consideration must be based on the method used for stabilizing the fracture (operative, nonoperative) and, in the cases of operative method, the type of fixation device used.
After a period of immobilization determined by the treating physician, the therapist begins gentle range of motion and strengthening exercises of the shoulder, progressing as tolerated. If indicated, individuals are instructed to exercise adjacent joints to prevent loss of motion and strength.
Thermal modalities may be used to control pain before and after exercise (Braddom). One of the primary goals of rehabilitation following a scapula fracture is to restore the normal glenohumeral motion pattern in order to regain functional use of the involved upper extremity. A home program should be taught to complement supervised rehabilitation.
Occupational therapy may also be indicated to maximize independence in activities of daily living. An ergonomic evaluation may be beneficial to adapt work tasks and promote employability.
Additional information may provide greater insight into the rehabilitation needs of individuals with scapula fractures (Bucholz; Chapman; Rockwood). |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical | |
| Physical or Occupational Therapist | | Up to 24 visits within 12 weeks | | | | | | | | Surgical | |
| Physical or Occupational Therapist | | Up to 18 visits within 12 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Complications related to scapular fractures such as nonunion or malunion are relatively uncommon. Complications from ORIF include the usual conditions that can occur as a result of major surgery: bleeding, infection, and damage to nerves and blood vessels. Most complications are due to associated injuries that occur at the time of initial trauma. Eighty percent to 95% of scapular fractures are associated with other injuries such as rib fractures (25% to 45%), pulmonary contusion or pneumothorax (15% to 55%), humerus fractures (12%), brachial plexus injury (5% to 10%), skull fracture (25%), major vascular injury (11%), and ruptured spleen (8%) (Goss). Scapular fractures with significant bone displacement have a poor long-term prognosis, including pain and shoulder stiffness, if not treated with open surgical reduction. Other complications include malunion, shoulder impingement, adhesive capsulitis, and glenohumeral joint disease or instability (Melhorn, "Shoulder Injuries and the Workplace"). |
Source: Medical Disability Advisor
| The location and type of fracture affects the ability to return to work. Fractures requiring open reduction and internal fixation heal more slowly than nondisplaced fractures (Melhorn, "Common Upper Extremity Problems"). Access to ice packs and a place to rest may be required. Breaks from job activities may be necessary every 2 hours or as pain and swelling dictate. Restrictions may include no lifting, carrying, reaching or driving for several weeks or even months until the fracture has healed and rehabilitation has progressed sufficiently.
Individuals with fractures requiring surgery and/or fractures involving the dominant arm will require longer periods of work restrictions, depending on the individual's situation. If the dominant shoulder is injured, individuals who write or perform fine motor skills may experience more work limitations than if the nondominant hand were injured. In some cases, an alternative to a standard computer keyboard, such as a one-handed keyboard or a computer equipped with speech recognition software, may be an appropriate accommodation. Some individuals may find ergonomically adjusted or pneumatic tools useful during the healing period. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did individual report high-velocity trauma, fall, or direct blow to the scapula?
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Are there complaints of pain, swelling, or crepitus?
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Were x-rays of the scapula, shoulder, and chest taken?
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Was CT scan or electromyogram (EMG) performed?
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Was diagnosis of fracture of the scapula confirmed?
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Were other major injuries noted (rib fracture, pulmonary contusion, pneumothorax, humerus fracture, brachial plexus injury, skull fracture, major vascular injury, ruptured spleen)?
Regarding treatment:
- Were bone fragments separated (displaced fracture) or not (nondisplaced fracture)?
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If individual experienced displaced fracture, was surgical realignment required?
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If open reduction was performed, did any complications occur?
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Were analgesics required to relieve pain?
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Was rehabilitation therapy (physical or occupational therapy) recommended for this individual?
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Was individual compliant with all treatment recommendations (e.g., sling use or physical therapy)?
Regarding prognosis:
- Was this an uncomplicated, nondisplaced fracture or a displaced fracture?
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If fracture was displaced, was there associated glenohumeral joint, nerve, or tissue damage requiring significant recovery time?
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Were other traumatic injuries sustained at time of scapular fracture (e.g., rib fracture, pulmonary contusion, pneumothorax, humerus fracture, brachial plexus injury, skull fracture, major vascular injury, or ruptured spleen)?
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Did complications occur (e.g., malunion, adhesive capsulitis, shoulder impingement, or shoulder instability)?
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Has physical therapy been completed as recommended? Would additional therapy benefit the individual?
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Has injury affected the individual's daily activities?
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Has individual’s employer been able to provide necessary accommodations or adjust to temporary activity restrictions?
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Has adequate time elapsed for full recovery?
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Source: Medical Disability Advisor
| Braddom, Randolph L. Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: W.B. Saunders, 2000.Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, 2002. Chapman, Michael W. Chapman's Orthopaedic Surgery. Philadelphia: Lippincott, Williams & Wilkins, 2001. Daya, Mohamud. "Shoulder." Rosen's Emergency Medicine: Concepts and Clinical Practice. Ed. J. A. Marx. 6th ed. Philadelphia: Mosby Elsevier, 2006. Freudenthal, William, and J. V. Ritchie. "Broken Shoulder Blade." eMedicine Consumer Health. Eds. Marian Gambrell and Francisco Talavera. 10 Aug. 2005. Medscape. 3 Dec. 2004 <http://www.emedicinehealth.com/broken_shoulder_blade/article_em.htm>. Gaenslen, Eric S. "Floating Shoulder." eMedicine. Eds. Cato T. Laurencin, et al. 13 Aug. 2002. Medscape. 16 Mar. 2009 <http://emedicine.medscape.com/article/1261072-overview>. Goss, Thomas P., and Robert V. Cantu. "Scapula Fracture." eMedicine. Ed. Lynn A. Crosby. 19 Dec. 2008. Medscape. 3 Dec. 2004 <http://emedicine.medscape.com/article/1263076-overview>. Melhorn, J. M. "Shoulder Injuries: Diagnosis, Causation and Treatment." Advanced Clinical Topics. Ed. J. B. Talmage. Philadelphia: American Academy of Disability Evaluating. . ., 2003. Melhorn, J. M., ed. "Shoulder Injuries and the Workplace." Mid - Atlantic Regional Conference on Occupational Medicine. Richmond: Virginia Commonwealth University, 2000. Rockwood, C. A., et al., eds. The Shoulder. 3rd ed. Philadelphia: W.B. Saunders, 2004. Talmage, J. B., J. M. Melhorn, and , eds. "Working with Common Upper Extremity Problems." A Physician's Guide to Return to Work. Chicago: AMA Press, 2005. |
Source: Medical Disability Advisor
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