Scapula fracture documentation for orthopaedic

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Scapula Fracture - Orthopaedic Documentation

1. Epidemiology & Incidence

Scapular fractures are uncommon, representing approximately 0.4-1% of all fractures and 3-5% of shoulder girdle injuries. Due to the scapula's well-protected position (surrounded by thick musculature, mobile on the chest wall), significant energy is required to fracture it. The majority (88-94%) occur in males, with a mean age in the mid-40s. They are predominantly caused by high-energy trauma - motor vehicle accidents, falls from height, and crush injuries.

Rockwood and Green's Fractures in Adults 10th ed 2025, Chapter 33

2. Anatomy Relevant to Fractures

The scapula has a highly uneven distribution of bony mass:

Thickest bone: glenoid, scapular neck (including coracoid base), and lateral border
Thinnest bone: infraspinous fossa (central biomechanical body), spinomedial angle (most common fracture site)

Two bony pillars transmit compressive forces from the glenoid:

Lateral pillar: lateral border connecting inferior glenoid to inferior angle
Spinal pillar: arises from glenoid, continues to the base of the scapular spine

These two pillars form the biomechanical body of the scapula (distinct from the anatomical body). The spinomedial angle - the connection between the scapular spine and the medial border - is the weakest circumferential area, and most scapular body fracture lines pass through this region.

$3D model showing scapular body fracture lines highlighted in red, involving the body and glenoid$

Scapula fracture involving the body and glenoid - Schwartz's Principles of Surgery

3. Mechanisms of Injury

Scapular fractures result from four basic mechanisms:

Mechanism	Details
Direct blow	Traffic accident, fall from height, heavy object falling onto shoulder - most common; fractures body and upper processes
Humeral head impact	Force transmitted through elbow to humerus → glenoid, acromion, lateral spine, or coracoid fracture
Glenohumeral dislocation	Anterior dislocation → anteroinferior glenoid rim fracture (most common); posterior dislocation → posterior rim fracture (rare)
Violent muscular contracture	Seizures, electrical injury; causes scapular body compression fractures or muscle-insertion avulsions

Stress fractures: coracoid in overhead athletes; acromion/scapular spine with chronic rotator cuff insufficiency and proximal humeral migration.

Rockwood and Green's Fractures in Adults 10th ed 2025, pp. 1152-1153

4. Associated Injuries

Scapular fractures are high-energy injuries - approximately 80% have associated injuries:

Thoracic: rib fractures (most common), pneumothorax, hemothorax; pulmonary contusion in >1/3 of patients
Vascular: subclavian/axillary artery injury (especially scapulothoracic dissociation)
Neurological: brachial plexus injury (most commonly upper trunk)
Ipsilateral upper extremity: clavicle fracture, glenohumeral dislocation, humeral fracture
Head/neck injury: in high-energy mechanism

Clinical Pearl: Discovery of a scapular fracture on plain chest X-ray in a polytrauma patient should immediately prompt a thorough search for associated life-threatening injuries.

Schwartz's Principles of Surgery 11th Edition, p. 1911

5. Classification

OTA/AO Classification (Current Standard)

The OTA/AO system classifies scapular fractures under Group 14:

Code	Type
14F1	Extra-articular (body, neck, process fractures)
14F2	Intra-articular (glenoid fossa involvement)
14F2.1	Simple glenoid fossa fracture (single fracture line, two articular fragments)
14F2.2	Multifragmentary glenoid fracture (≥3 articular fragments)

Ideberg Classification (Glenoid Fractures)

Type	Description
I	Anterior rim fracture (IA: avulsion; IB: large fragment)
II	Transverse fracture through glenoid fossa extending to lateral border
III	Oblique fracture through glenoid extending to superior border (may involve coracoid)
IV	Horizontal fracture through body extending to medial border
V	Combination of types II + IV (T-fracture through glenoid)
VI	Comminuted glenoid fracture

Ada & Miller Classification (Scapular Neck)

Type	Description
I	Undisplaced neck fracture
IIA	Fracture of the surgical neck (glenoid fragment displaces as a unit)
IIB	Trans-spinous neck fracture
III	Associated with glenoid fracture

Fracture Type Distribution (Tüček Series of 514 fractures)

Fracture Type	Frequency	Surgical Rate
Scapular body	47%	25%
Glenoid	25%	46%
Processes (acromion, coracoid, spine)	23%	lower
Neck	5%	58%

Rockwood and Green's Fractures in Adults 10th ed 2025, pp. 1161-1162

6. Diagnosis

Clinical Presentation

Pain, swelling, tenderness over the posterior shoulder/scapular region
Arm held adducted and internally rotated
Limited and painful shoulder motion
Possible crepitus on palpation
Localized bony tenderness over axillary border (suggests body/neck fracture)
Always examine for associated injuries (chest, neurovascular)

Radiological Algorithm

$Diagnostic flowchart for scapular fractures$

Radiologic diagnosis algorithm - Rockwood and Green's Fractures in Adults 10th ed 2025

For the cooperative patient:

AP shoulder girdle view - covers entire scapula, whole clavicle, AC/SC joints, and proximal humerus; general survey but insufficient alone to characterize displacement
Neer I (True AP of scapula) - assesses glenohumeral joint space, glenoid displacement, and glenopolar angle (GPA)
Neer II (Scapular Y-view / True lateral) - assesses scapular body in translation, angulation, and fragment overlap
Axillary view - complementary for glenoid, acromion, and coracoid process fractures

For the polytrauma patient: Body CT covering both entire scapulae is first-line.

CT Examination

CT is now the standard imaging study for scapular fractures:

Axial CT: glenoid fossa assessment; reveals undisplaced coracoid and acromion fractures
2D CT reconstructions (coronal): glenoid articular surface, especially with coracoid base involvement
3D CT reconstructions: most accurate for spatial understanding; essential for surgical planning; subtract surrounding bones for optimal scapular visualization
Rockwood and Green's Fractures in Adults 10th ed 2025, pp. 1154-1155

7. Key Displacement Measurements

Four criteria quantify displacement and guide treatment decisions for scapular neck/body fractures:

Parameter	How Measured	Surgical Threshold
Mediolateral displacement	Neer I or 3D CT anterior view	≥9 mm (some use ≥2 cm)
Angulation	Neer II or 3D CT lateral view	≥40-45 degrees
Anteroposterior translation	Neer II / lateral 3D CT	No firm consensus
Glenopolar Angle (GPA)	Angle between glenoid pole line and glenoid-inferior angle line on Neer I	≤20-22 degrees

Normal GPA: 41 degrees (range 35-51 degrees). A GPA ≤20 degrees indicates significant rotational deformity and is associated with poor functional outcomes. Note: GPA may actually increase up to 70 degrees in anatomical neck fractures, so values must be interpreted in context.

Rockwood and Green's Fractures in Adults 10th ed 2025, pp. 1156-1157

8. Treatment

Non-Operative Treatment (Majority)

Indicated for: undisplaced or minimally displaced fractures (scapular body, neck, most process fractures)

Sling immobilization for 3-4 weeks for comfort
Early gentle pendulum exercises from 1-2 weeks
Progressive range-of-motion and strengthening
Good/excellent results in approximately 82% of patients with this approach

Surgical Indications

Absolute indications (near universal agreement):

Displaced glenoid fractures with articular step-off >2-4 mm
Glenoid rim fractures with glenohumeral subluxation
Open fractures
Fractures with associated neurovascular injury requiring exploration

Relative indications (evolving evidence):

Glenoid medialization/lateral displacement >9 mm
Scapular body angulation ≥40-45 degrees
GPA ≤20-22 degrees
Medial/lateral fragment displacement ≥2 cm
Floating shoulder (ipsilateral clavicle + scapular neck fracture) with significant displacement

Note: Despite these criteria being widely cited, there are currently no prospective randomized studies confirming the superiority of operative over nonoperative treatment for displaced extra-articular scapular fractures. - Campbell's Operative Orthopaedics 15th Ed 2026, p. 3702

Surgical Approaches

Judet (Posterior) Approach - workhorse for scapular body/neck fractures:

Patient in semiprone (lateral decubitus) position, injured side up
Boomerang skin incision: from posterior acromion along scapular spine to spinomedial angle, curving distally along medial border to inferior angle
Raise skin flap; identify posterior deltoid border
T-shaped fascial incision along posterior deltoid edge and perpendicular across infraspinatus fascia
Release spinal portion of deltoid from scapular spine; reflect laterodistally
Identify and ligate scapular circumflex vessels (3-4 cm distal to inferior glenoid rim, lateral border)
Detach infraspinatus from all borders; reflect proximally - caution re: suprascapular nerve bundle at spinoglenoid notch
This exposes entire posterior scapular surface for fracture reduction and fixation

Limited Judet approach: Release only deltoid (not infraspinatus) to reduce dissection for selected fractures.

Anterior (Coracoid/Deltopectoral) approach: For anterior glenoid rim fractures.

Rockwood and Green's Fractures in Adults 10th ed 2025, pp. 1171-1173

Fixation Methods

Anatomic locking plates and reconstruction plates along lateral border and/or body
Lag screws for simple glenoid fractures
Plate and screw constructs for complex intra-articular glenoid fractures (inferior approach, anterior approach, or combined)
For glenoid fractures: reduction and fixation aims at restoring congruence and stability

9. Special Patterns

Floating Shoulder

Defined as an ipsilateral fracture of the scapular neck + ipsilateral clavicle fracture that disrupts the Superior Shoulder Suspensory Complex (SSSC) at two points, creating an unstable situation. First described by Ganz & Noesberger; popularized by Herscovici et al.

SSSC components: glenoid, coracoid, CC ligament, lateral clavicle, AC joint, AC ligament, acromion - an osseofibrous ring with two bony struts (middle clavicle; lateral scapular body/spine junction).

Management is controversial; most agree that severely displaced floating shoulders benefit from clavicle fixation to restore SSSC stability, after which the scapular component often reduces acceptably.

Scapulothoracic Dissociation

A lateral displacement of the scapula from the thorax, caused by massive traction force on the upper extremity. Associated with very high rates of brachial plexus injury and subclavian/axillary vessel disruption. Can be identified on AP chest X-ray by asymmetric scapular position. A limb-threatening emergency.

Stress Fractures Post-Reverse Total Shoulder Arthroplasty

Acromial and scapular spine stress fractures are a recognized complication of reverse shoulder arthroplasty (RSA). A 2023 systematic review with meta-analysis (PMID: 37573934) found conservative treatment achieves acceptable outcomes in selected cases.

10. Outcomes & Prognosis

Non-operative: Good/excellent results in ~82% of patients for undisplaced/minimally displaced fractures
Operative glenoid fractures: 80% treated surgically with good-to-excellent results in 82%
Displaced body/neck fractures treated non-operatively: Increasing evidence of unsatisfactory long-term outcomes (pain, limited range of motion, rotator cuff dysfunction) when significant displacement is present
Scapular malunion: Corrective osteotomy through Judet approach is feasible - Cole et al. reported all five malunion patients became pain-free and returned to their preinjury occupations

Outcome Scores Used:

Constant-Murley Score (joint-specific)
DASH / QuickDASH (patient-oriented, upper extremity)
ASES Score
Short Form-36 (general health)

Note: No scapula-specific outcome score exists.

11. Complications

Complication	Notes
Malunion	Most common after displaced fractures treated non-operatively; causes rotator cuff impingement, pain, restricted motion
Nonunion	Rare for body fractures; more common for process fractures (acromion)
Shoulder stiffness	Adhesive capsulitis; prevented by early mobilization
Brachial plexus injury	From initial trauma or iatrogenic during Judet approach (suprascapular nerve)
Wound complications	Related to posterior approach; relatively low in experienced hands
Implant failure	Thin cortex in scapular body limits screw purchase

Sources:

Rockwood and Green's Fractures in Adults, 10th Ed (2025), Chapter 33 - Scapular Fractures
Campbell's Operative Orthopaedics, 15th Ed (2026), Section on Scapula
Schwartz's Principles of Surgery, 11th Ed, Chapter 43
S Das: A Manual on Clinical Surgery, 13th Ed
PMID 37573934: Cui H et al. (2023) - Outcomes of conservative treatment of acromial/scapular spine stress fractures post-RSA

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SCAPULA FRACTURE - ORTHOPAEDIC CASE SHEET

Examination Documentation

PATIENT DETAILS

Field	Entry
Name
Age / Sex
IP No. / OP No.
Date of Admission
Date of Injury
Mode of Transport	Walk-in / Ambulance / Referred
Referred From
Surgeon / Resident

CHIEF COMPLAINT

Pain / swelling / deformity / inability to move right/left shoulder following __________ [nature of injury] __________ [duration]

HISTORY OF PRESENTING ILLNESS

Onset: Sudden / Gradual

Mode of Injury:

Road traffic accident (driver / pillion / pedestrian)
Fall from height (height: ________ feet)
Direct blow to shoulder
Fall on outstretched hand (FOOSH)
Sports injury
Seizure / electrical injury
Other: ______________

Details of injury: (direction of force, position of arm at time of injury, speed if RTA)

Dominant hand: Right / Left

Symptoms since injury:

Pain: Location __________, Severity (/10) __________, constant / intermittent
Swelling over: scapular region / posterior shoulder / axilla
Deformity: Yes / No
Inability to move shoulder: Yes / No
Numbness / tingling: __________ (distribution)
Weakness of arm: Yes / No
Shortness of breath / chest pain: Yes / No
Any LOC / head injury: Yes / No

Treatment before presentation:

Sling / splint applied: Yes / No
Analgesics given: Yes / No

PAST HISTORY

Previous shoulder problems (rotator cuff, OA, instability): Yes / No - details: __________
Previous fractures or surgery to same shoulder: Yes / No
Diabetes / Hypertension / Cardiac disease / Bleeding disorder: Yes / No - details: __________
Drug history / Allergy: __________
Rheumatoid arthritis / metabolic bone disease / tumor: Yes / No
Tetanus immunization status: __________

GENERAL EXAMINATION

Parameter	Finding
Pulse	________ /min, regular/irregular
BP	_________ mmHg (both arms if vascular injury suspected)
RR	________ /min
SpO2	________%
Temperature	________ °F
GCS	E__ V__ M__ = ____/15
Build / Nutrition
Pallor / Icterus / Cyanosis

LOCAL EXAMINATION

Patient stripped to waist, standing against good daylight, comparing both sides

A. INSPECTION

1. Attitude / Posture on entry

Arm held: adducted and internally rotated / supported by opposite hand
Drooping of the affected shoulder: Present / Absent
Head tilted / neck guarded: Yes / No

2. Look

Feature	Findings
Skin abrasion / contusion	Location: __________ (indicates site of impact)
Laceration / open wound
Swelling	Diffuse / Localized - over: posterior shoulder / scapular region / axilla
Ecchymosis	Present / Absent - location: __________
Deformity	Flattening / prominence - __________
Muscle wasting	Deltoid / supraspinatus / infraspinatus / other
Scapular position	Symmetrical / elevated / laterally displaced (vs. normal side)
Chest wall	Visible rib deformity / paradoxical movement

B. PALPATION

Systematic palpation of the entire shoulder girdle - always compare with the uninjured side

1. Temperature / Tenderness

Structure	Tender	Swelling	Crepitus
Sternoclavicular (SC) joint
Clavicle (medial 1/3, middle, lateral 1/3)
Acromioclavicular (AC) joint
Acromion process
Scapular spine
Spinomedial angle of scapula
Medial (vertebral) border of scapula
Inferior angle of scapula
Axillary (lateral) border of scapula
Coracoid process (½ inch below clavicle at junction of medial 2/3 and lateral 1/3)
Glenoid / scapular neck (palpate medial to glenoid cavity)
Greater tuberosity of humerus
Bicipital groove
Axilla and adjacent chest wall

Key sign: Tenderness and swelling on the axillary border suggests scapular body/neck fracture. In fracture of the neck of scapula: tenderness medial to glenoid + drooping of shoulder + crepitus on axial pressure through flexed elbow (distinguishes from fracture of upper end of humerus).

2. Bony Relationships - Three Bony Point Assessment (Compare with normal side)

Relationship	Normal	Affected Side
Tip of coracoid → acromial end of clavicle	__________ cm	__________ cm
Acromial end of clavicle → greater tuberosity	__________ cm	__________ cm
Coracoid → greater tuberosity	__________ cm	__________ cm

In AC dislocation: acromial end of clavicle becomes prominent; coracoid-to-clavicle distance increases. Normal relationships here help confirm isolated scapular injury.

3. Axillary artery pulse: Palpable / Absent / Diminished 4. Scapulothoracic dissociation screening: Asymmetric scapular position vs. contralateral side: Yes / No

C. MEASUREMENTS

1. Arm length (Angle of acromion to lateral epicondyle of humerus)

Side	Length
Normal side	__________ cm
Affected side	__________ cm
Difference	__________ cm

Arm length is increased in fracture neck of scapula and subglenoid dislocation (vs. shortened in fracture neck of humerus and anterior dislocation).

2. Vertical circumference of axilla (Bryant's test)

Side	Measurement
Normal	__________ cm
Affected	__________ cm

Increased in dislocation, fracture of upper humerus, and fracture neck of scapula.

3. Hamilton's ruler test:

Place a straight ruler along lateral arm touching acromion and lateral epicondyle
Normal: Ruler cannot touch both (greater tuberosity pushes it away)
Positive (abnormal): Ruler touches both - suggests medial displacement of greater tuberosity (dislocation / significant displacement)
Result: Positive / Negative

D. MOVEMENTS

Examination of active ROM is often limited by pain; attempt carefully. Passive ROM of glenohumeral joint assessed gently. Stabilize the scapula during glenohumeral ROM assessment.

Movement	Active (degrees)	Passive (degrees)	Normal
Forward flexion			0-180°
Extension			0-60°
Abduction			0-180°
Adduction			0-50°
Internal rotation (behind back level)			T8-T12
External rotation (at side)			0-60°
Cross-body adduction

Scapulothoracic rhythm: Normal / Abnormal (early scapular shrug = suggests painful glenohumeral restriction)

Dugas' test:

Patient attempts to touch opposite shoulder with hand of affected side while keeping arm in contact with chest
Result: Positive (cannot) / Negative (can) - positive suggests dislocation

E. NEUROVASCULAR EXAMINATION

Critical in all scapular fractures - high energy = high risk of associated nerve/vessel injury

Axillary nerve (most commonly injured in shoulder trauma)

Sensation over regimental badge area (lower deltoid): Intact / Reduced / Absent
Deltoid contraction (isometric abduction): Present / Absent

Note: Asking patient to actively abduct shoulder to test axillary nerve is unreliable in acute fracture due to pain. Test the cutaneous territory only.

Brachial plexus screening

Nerve/Root	Motor Test	Sensation
C5 (axillary + musculocutaneous)	Shoulder abduction, elbow flexion	Lateral arm / lateral forearm
C6 (musculocutaneous / radial)	Wrist extension	Thumb and index finger
C7 (radial)	Finger extension	Middle finger
C8 (ulnar)	Finger abduction	Little finger
T1 (ulnar)	Intrinsic hand muscles	Medial forearm

Radial pulse: Present / Absent / Diminished Capillary refill (fingertips): < 2 sec / > 2 sec Ulnar + radial pulses compared bilaterally: Symmetrical / Asymmetrical

F. CHEST / ASSOCIATED INJURY EXAMINATION

(Mandatory in all high-energy scapular fractures)

System	Findings
Chest auscultation	Air entry: bilateral / reduced on ________ side
Percussion	Resonant / Dull / Hyperresonant
Rib tenderness	__________ ribs
Paradoxical chest movement	Yes / No
Tracheal deviation	Central / Deviated to __________
Jugular venous distension	Present / Absent
Abdominal tenderness	Yes / No
Head / GCS	__________
Contralateral limb injuries	__________

INVESTIGATIONS

Radiology

Imaging	Ordered	Findings
AP shoulder girdle (entire scapula + clavicle + proximal humerus)	Yes / No
Neer I - True AP of scapula (assess GPA, glenoid displacement)	Yes / No
Neer II - Scapular Y-view / True lateral (angulation, translation, fragment overlap)	Yes / No
Axillary view (glenoid, acromion, coracoid)	Yes / No
AP chest X-ray	Yes / No
CT shoulder + 3D reconstruction (standard for all displaced fractures)	Yes / No
CT chest (polytrauma)	Yes / No

Glenopolar Angle (GPA) Measurement

(On Neer I view or 3D CT - angle between glenoid pole line and glenoid-to-inferior scapular angle line)

Parameter	Value
Glenopolar Angle (GPA)	________ degrees (Normal: 35-51°, mean 41°)
Mediolateral displacement	________ mm
Angulation on Y-view	________ degrees
Articular step-off (glenoid)	________ mm

Lab Investigations

Test	Result
CBC
Blood group & Rh type
RBS
Serum electrolytes
Coagulation profile (PT/INR, aPTT)
Renal function (if operative plan)
ECG
Chest X-ray (PA)

DIAGNOSIS

Fracture type:

Scapular body fracture - Undisplaced / Displaced
Scapular neck fracture - Anatomical / Surgical / Trans-spinous (Ada & Miller type: ______)
Glenoid fracture - Ideberg type: ______ / OTA type: ______
Acromion fracture
Coracoid process fracture
Scapular spine fracture
Complex fracture (intra-articular / extra-articular)
Floating shoulder (ipsilateral clavicle fracture + scapular neck fracture)
Scapulothoracic dissociation

Side: Right / Left

Open / Closed

Associated injuries:

Rib fractures: ________
Pneumothorax / Hemothorax
Clavicle fracture
Glenohumeral dislocation
Humeral fracture
Brachial plexus injury (level: ________)
Axillary artery injury
Other: __________

MANAGEMENT PLAN

Non-operative:

Sling immobilization (duration: __________)
Analgesics: __________
Pendulum exercises from: __________
Active ROM exercises from: __________
Physiotherapy referral

Operative indications met:

Glenoid articular step-off ≥ ________ mm
GPA ≤ 20-22 degrees (measured: ________)
Mediolateral displacement ≥ 9 mm (measured: ________)
Angulation ≥ 40-45 degrees (measured: ________)
Floating shoulder with significant displacement
Open fracture
Associated neurovascular injury

Planned surgical approach:

Judet (posterior) approach
Anterior (deltopectoral/coracoid) approach
Combined approach
Fixation method: __________ (plates / lag screws / reconstruction plate)

Consent: Obtained / Pending Pre-op anesthesia review: Done / Pending Optimization required: __________

OUTCOME SCORE (BASELINE)

(Document at admission; repeat at 6 weeks, 3 months, 6 months, 1 year)

Score	Baseline	6 weeks	3 months	6 months	1 year
Constant-Murley
DASH / QuickDASH
ASES
VAS Pain

TREATING CLINICIAN SIGNATURE

Name: ________________________ Designation: __________________ Date / Time: __________________

Sources:

Rockwood and Green's Fractures in Adults, 10th Ed (2025) - Chapter 33 (Signs, Symptoms & Clinical Examination of Scapular Fractures)
S Das: Manual on Clinical Surgery, 13th Ed - Examination of Injuries About the Shoulder
Miller's Review of Orthopaedics, 9th Ed - Physical Examination, Shoulder
Campbell's Operative Orthopaedics, 15th Ed (2026)

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