Fracture of the scapula: causes, symptoms, diagnosis, treatment

ICD-10 code

S42.1 Fracture of scapula.

Epidemiology of scapula fracture

Scapula fractures account for 0.3-1.5% of all skeletal bone injuries.

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What causes a scapula fracture?

Scapula fractures in most cases occur with a direct mechanism of injury: a blow to the scapula or a fall on it. With an indirect mechanism (a fall on the wrist or elbow joint of an abducted arm), another group of injuries most often occurs: fractures of the glenoid cavity, neck of the scapula, acromion and coracoid process.

Anatomy of the scapula

The scapula is located from the 2nd to the 7th rib along the back surface of the chest, is a flat triangular bone with three edges (superior, medial and lateral), converging and forming three angles (superior, lateral and inferior). The lateral angle is thickened and forms the neck of the scapula, passing into the glenoid cavity. Near the cavity, the coracoid process departs from the upper edge. The anterior surface of the scapula is formed by the subscapularis muscle, the posterior is divided by the spine into two unequal fossae: the smaller one - the supraspinatus, filled with the muscle of the same name, and the larger one - the infraspinatus, filled with the infraspinatus, minor and major teres muscles. The spine of the scapula, continuing laterally, ends in the acromion, hanging behind and above the glenoid cavity. The deltoid muscle originates from the spine and acromion, and the coracobrachialis, short head of the biceps, and pectoralis minor muscles extend from the coracoid process to the shoulder. The long head of the biceps and long head of the triceps are attached to the tubercles of the glenoid cavity above and below the cartilaginous zone, respectively.

The muscle that lifts the scapulae starts from the transverse processes of C1-4 with four teeth, goes obliquely down and attaches to the upper angle of the scapula. Two more muscles approach the medial edge of the scapula: the rhomboid muscle, which originates from the spinous processes of C6-7 and Th3-4, and the anterior serratus, which starts with nine teeth from the upper ribs (from I to VIII or IX).

This abundance of muscles makes the scapula very mobile. In addition, all of the listed muscles participate in abduction, adduction, external and internal rotation of the shoulder, and the trapezius and anterior serratus muscles perform shoulder abduction beyond 90°.

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Symptoms of a scapula fracture

The nature of the symptoms of a scapula fracture depends on the location of the scapula injury. A constant symptom is pain at the site of injury.

Classification of scapula fracture

The fracture line can pass through various anatomical formations of the scapula. In this regard, fractures of the body, spine of the scapula and its angles are distinguished.

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Diagnosis of scapula fracture

The anamnesis includes a corresponding injury with a characteristic mechanism of damage.

Inspection and physical examination

Fractures of the body, spine and angles of the scapula are accompanied by pain, swelling due to hemorrhage - the "triangular cushion" symptom. Palpation sometimes reveals deformation, pathological mobility, crepitus. The functions of the limb suffer moderately.

A fracture of the glenoid cavity is manifested by pain, hemarthrosis, and a sharp disruption of the functions of the shoulder joint.

In case of a fracture of the neck of the scapula with displacement of fragments, the shoulder joint seems to slide forward and downward. Its contours change. The acromion protrudes excessively under the skin, and the coracoid process goes backward. Some depression is formed under the acromion. Movements in the shoulder joint are possible, but sharply limited due to pain. Palpation reveals pain, sometimes crepitation in the neck of the scapula, especially if an attempt is made to perform passive movements at the same time. The site of injury is accessible for examination from the anterior and posterior surfaces of the armpit.

Fractures of the acromion and coracoid process are characterized by swelling at the site of injury, the presence of a bruise (best seen on the 2nd-3rd day), local pain and bone crunching, detected by palpation of the processes. Movements in the shoulder joint are limited, since an attempt to perform them causes pain at the fracture sites.

Laboratory and instrumental studies

The scapula is covered with muscles, and its outer corner is covered with tissues of the shoulder joint and is located in their depth. Pronounced swelling of the tissues due to edema and hemorrhage, repeating the shape of the scapula (the "triangular cushion" symptom), in some cases complicates the examination and diagnosis. In order to avoid possible errors, at the slightest suspicion of a scapula fracture, it is necessary to perform an X-ray in two projections: direct and lateral.

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Treatment of scapula fracture

Non-drug and drug treatment of scapula fracture

Scapula fractures are treated mainly conservatively. For all types of fractures, pain relief is provided by injecting 1% procaine solution from 10 to 40 ml into the injury site. The fragments of the body, spine and angles of the scapula are slightly displaced and do not require repositioning. A Desault bandage with a roller is applied in the armpit for 3-4 weeks.

In case of fractures of the neck of the scapula without displacement, fracture of the acromion and coracoid process with displacement, the limb is fixed with an abduction splint or a plaster thoracobrachial bandage. The shoulder is abducted by 80-90° and tilted posteriorly from the axis of the shoulders by 10-15°. The immobilization period is 4-6 weeks.

In case of a fracture of the neck of the scapula with displacement, reposition is performed using skeletal traction on an abduction splint. The pin is passed through the olecranon. The position of the limb is the same as for fractures without displacement.

The traction lasts for 3-4 weeks, then it is replaced with a plaster thoracobrachial bandage for another 3 weeks. The position of the fragments during the traction process is controlled by clinical and radiological methods.

During the immobilization period, functional and physiotherapeutic treatment is carried out, and upon its completion, a course of rehabilitation therapy is prescribed.

Surgical treatment of scapula fracture

Surgical treatment of scapular neck fractures is extremely rare. Indications for open reposition are fractures with significant fragment displacement that has not been corrected, especially angular, when a severe impairment of shoulder joint function is predicted.

The operation is performed under general anesthesia. The patient is placed on his stomach with his arm abducted. An incision is made parallel to the outer edge of the scapula from the posterior edge of the deltoid muscle to the middle of the medial edge of the scapula. The infraspinatus and teres minor muscles are exposed and bluntly separated. The infraspinatus muscle together with the fascia is transected at the deltoid muscle. The edges of the wound are spread upward and downward with hooks to expose the neck of the scapula. The fragments are aligned and secured with metal plates. The dissected tissues are sutured layer by layer. Catgut sutures and a plaster thoracobrachial bandage with abduction and posterior deviation of the shoulder are applied to the skin for 6 weeks. Subsequent treatment is the same as with conservative methods.

Approximate period of incapacity

In case of fractures of the body, spine and angles of the scapula, working capacity is restored within 4-5 weeks.

In case of fractures of the neck of the scapula without displacement, fractures of the acromion and coracoid process with displacement, the patient can return to work after 6-8 weeks.

Working capacity in case of fractures of the neck of the scapula with displacement is restored within 8-10 weeks.

* In cases where a plaster cast is to be applied after surgery, the skin is sutured with catgut.

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