Introduction[edit | edit source]
Scapula/shoulder blade is a large triangular bone that lies postero-lateral on the upper back/throracic cage and connects the and is well connected by complex system of muscles. Shoulder blades connect the arm to the thorax while the muscles of scapula ensure correct movement of arm over the thorax. 
Scapular fracture represents less than 1% in prevalence among all other broken bones and 3% to 5% of all shoulder girdle fractures. 80% to 95% of all scapular fractures are accompanied by other injuries like fractures of shoulder, collarbone and ribs, or during injury to the head, lungs and spinal cord, typically because it requires high - energy/torque trauma to cause an injury to scapula . 
Scapular fractures occur during high-energy trauma such as motor vehicle collisions, falls, and other high impact traumas. Motor vehicle collisions account for over 70% of scapular fractures, with 52% associated with drivers and 18% associated with pedestrians struck by motor vehicles. Other reported mechanisms include electric shock and seizure because of forces on the scapula. Isolated scapular fractures are extremely rare. 
Classification of scapular fractures[edit | edit source]
One or more parts of scapula may get fractured:
- Scapular body (45% of patients):The body of scapula fractures into three patterns; transverse, oblique, and longitudinal.
- Scapular neck (25% of patients): Three types of neck fractures are described as follows: fracture of surgical neck, fracture of the anatomical neck and fracture of neck inferior to scapula spine.
- Glenoid (35% of patients)
Causes of scapular fracture[edit | edit source]
Scapular fracture or broken shoulder blades are caused by direct trauma involving a large amount of force, hence in 80% of scapular fracture cases there are other associated injuries to chest, lungs, and internal organs.
- Motor vehicle accidents
- Falls with direct trauma to the shoulder
- Falls onto an outstretched arm
- Blunt trauma such as from a baseball bat or hammer
- Fall from height
- Contact sports
- Direct blow to the scapula
Symptoms of fractured scapula[edit | edit source]
- Localized pain at rest
- Extreme pain when moving the arm
- Swelling around the back of the shoulder
- Severe bruising and scrapes around the affected area
- Holding injured arm close to the body where shoulder is in 90-90 degree position with elbow with shoulder internal rotation.
- Inability to lift the arm
- Flattened and deformed shoulder appearance
- Pain during breathing due to associated chest wall injury
- Numbness, tingling, or coldness of the arm due to impaired blood and nerve supply
- Crepitus and popping sound at the end feel of the shoulder joint movements
Evaluation and diagnosis of scapular fractures[edit | edit source]
Diagnosis of fractured scapula is possible only after a proper physical examination and investigations.
- Most scapula fractures are clearly seen in a shoulder and chest x-ray but can easily be missed during examination of the x-ray film. 
- 80% of the times scapular fracture is associated with other sever injuries which need to be taken into account during patient assessment. Some of these injuries can be potentially life-threatening. For example, thoraco-scapular dissociations with disruptions of the subclavian vein and axillary vessels which can lead to life-threatening hemorrhage. 
- CT or MRI scan may be required especially to diagnose the fracture of glenoid which accounts for 35% of all scapular fractures. 
- MRI will give a clearer picture of the extent of injury to the surrounding soft tissue, joints, ligaments and nerves. 
Differential diagnosis[edit | edit source]
Christopher Libby; Nicholas Frane; Thomas P. Bentley. have stated the following possibilities of differential diagnosis in their article "Scapula Fracture".
- Abdominal pain in elderly people
- Acromioclavicular injury
- Fractures of clavicle
- Mechanical back pain
- Rib Fracture
- Shoulder Dislocation
Management of scapular fractures[edit | edit source]
Over 90% of scapular fractures are non-displaced fractures, hence scapular fractures are best managed without surgery and fractures with little or no displacement heal without problems.
Fractures of the scapular body with displacement may heal with malunion, but the scapular region is musculated in a way that even this may not interfere with movement of the affected shoulder. 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.
Therefore, while most scapular fractures are managed without surgery, surgical reduction is required for fractures in the neck or glenoid; otherwise range of motion of the shoulder joint may become impaired.
Medical Management[edit | edit source]
Pain after an injury or surgery is a natural part of the healing process. Medications are often prescribed for short-term pain relief after injury or surgery.
Numerous varieties of medications are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and local anesthetics. Doctors may prescribe a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Medical team as well as the patient needs to be aware that although opioids help relieve pain after an injury or surgery, they are a narcotic and can be addictive. Opioid dependency and overdose have become a critical public health issue in the United States and around the world. It is important to use opioids only as directed by the physician/surgeon. As soon as patients pain begins to improve, one should stop taking opioids. 
Non-surgical/conservative Management[edit | edit source]
Nonsurgical treatment with a shoulder immobilisation sling works best for most fractures of the scapula. The sling holds the shoulder in place while the bone heals. Immobilisation using the sling is generally kept in place for 6to 12 weeks as that's how long it takes for the fracture to heal. Ice application is suggested to reduce swelling. 
Surgical Management[edit | edit source]
The scapula has a privileged muscular envelope which enables great healing of scapular fractures in 90% of the cases. Though in some cases, scapular malunion may significantly impair the shoulder girdle function, causing chronic pain, aesthetic deformities, impingement syndrome and scapulothoracic dyskinesis.
Certain types of scapular fractures that may need surgery are:
- Displaced fractures of the glenoid articular surface
- Fracture of the neck of the scapula with angulation
- Fractures of the acromion process that cause the arm bone to hit against it (impingement syndrome) 
- A bandage is present around the operated shoulder, and the operated arm is placed in a sling to support the shoulder.
- Application of ice to reduce pain and swelling is recommended.
- Incision is to be kept clean and dry at all times.
- Specific instructions regarding activity and rehabilitation are to be provided to the patient.
- Physical Therapy is ordered to restore shoulder function and strength and it is imperative that the patient follows the exercise plan put in place by the physiotherapist to improve motion and strength in the shoulder and prevent stiffness.
- Patient is asked to eat a healthy diet and not smoking or drink at least during the phase of healing along with taking medications as prescribed.
Risks and Complications of a surgery: Bleeding, infection, anesthetic reactions such as fever or nausea, blood clots or deep venous thrombosis, damage to nerves and blood vessels, shoulder stiffness, fat embolism, failure to heal properly and the need for repeat surgery.
Rehabilitation[edit | edit source]
Early physical therapy with exercises designed to improve the range of motion of shoulder joint is essential. It is important to start these exercises early to avoid frozen shoulder. Loss of motion in the shoulder can occur if the shoulder joint is not used for a prolonged period. It is advisable to start moving your shoulder within the first week after the injury to minimize the risk of shoulder and elbow stiffness. Exercises should be continued until complete shoulder motion returns. This may also take 6 months to 1 year.
Initial exercises are started with-in the first- and second-week post injury as guided by the physical therapist provided there is no increase in pain because of the exercises.
Exercises for the uninvolved joints can be started within the first two days of injury.
Week 0 to 3 - Stage 1 Exercises
- Hand open and close
- Wrist flexion to extension
- Elbow flexion and extension in the pain free range
- Forearm rotation
Week 3 to 6 - Stage 2 Exercises
- Shoulder pendular exercises
- Active assisted shoulder flexion
- Active assisted shoulder abduction
- Active assisted external rotation
After week 6 - Stage 3 Exercises
- Active forward flexion of shoulder
- Active shoulder abduction
- Active external rotation of shoulder
- Strengthening exercises for the upper extremity using weights and resistance bands.
- Shoulder retraction exercise – also called as shoulder blade squeeze
- Wall push-ups
- Rotator cuff strengthening: Static rotator cuff – push in and push out
- External rotation of shoulder using resistance band
Note: All exercises are to be repeated 10 times each, 4-5 times a day. Patient is advised only to go as far as he/she can naturally go without doing any trick movements to try and get further. Range of motion will increase over time and should not be forced.
Prognosis[edit | edit source]
- Scapular fractures are mostly and usually healed well by conservative management with excellent results in 86% of the cases.
- Less than 1% cases require operative measures which also show excellent and quick recovery with amazing function outcome.
- Rehabilitation plays a major role in gaining back the associated, normal functional movements of the scapular region/shoulder complex.
- 3-4 moths of physical therapy/rehabilitation is essential post injury/surgery. 
References[edit | edit source]
- Sciascia A, Kilber B, Athwal G, Fischer S. Scapular (shoulder blade) problems and disorders - orthoinfo - AAOS. OrthoInfo. The American Academy of Orthopaedic surgeons ; 2017 . Available from: https://orthoinfo.aaos.org/en/diseases--conditions/scapular-shoulder-blade-disorders#:~:text=The%20scapula%2C%20or%20shoulder%20blade,help%20you%20move%20your%20arm.
- Scapula . Wikipedia. Wikimedia Foundation; 2022. Available from: https://en.wikipedia.org/wiki/Scapula
- Scapula fracture (shoulder blade fracture). Johns Hopkins Medicine. Health. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/scapula-fracture-shoulder-blade-fracture#:~:text=What%20is%20a%20scapula%20fracture,from%20the%20back%20or%20side.
- Scapular fracture. Wikipedia. Wikimedia Foundation; 2021]. Available from: https://en.wikipedia.org/wiki/Scapular_fracture#:~:text=The%20scapula%20is%20fractured%20as,can%20also%20cause%20the%20injury.
- Scapula (shoulder blade) fractures - orthoinfo - AAOS. OrthoInfo. 2014. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/scapula-shoulder-blade-fractures/
- Libby C, Frane N, Bentley TP. Scapula fracture. StatPearls. 2020 Jul 21.
- Pires RE, Giordano V, de Souza FS, Labronici PJ. Current challenges and controversies in the management of scapular fractures: A review. Patient Safety in Surgery. 2021 Dec;15(1):1-8.
- Felson S. Broken shoulder Blade. WebMD. WebMD; 2021. Available from: https://www.webmd.com/first-aid/broken-shoulder-blade
- Hinchey J. Scapula fractures / Orif. John W. Hinchey MD.. Available from: https://www.hincheyshoulderandelbow.com/scapula-fractures-orif-orthopaedic-surgeon-san-antonio-boerne-texas.html
- Scapula fracture. NHS. 2021. Available from: https://www.esht.nhs.uk/wp-content/uploads/2017/06/0631.pdf
- Demetrious T, Harrop B. Scapula fracture - shoulder blade fracture. PhysioAdvisor. 2017. Available from: https://www.physioadvisor.com.au/injuries/shoulder/scapula-fracture/
- Scapula fracture. Scapula fracture · Virtual Fracture Clinic. Brighton & Sussex University Hospital Trust. Available from: https://www.fracturecare.co.uk/care-plans/shoulder/scapula-fracture/scapula-fracture/