Scapular Fractures

We are well aware that children seem like to test Gravity daily and that some days Gravity wins! This leads to numerous injuries and fractures (ex, Supracondylar, Hand, Finger, Face, Toddler’s). Unfortunately, pediatric trauma involves more than just Gravity (ex, Non-accidental Trauma) and, as we are accustomed to when dealing with children, some significant injuries can be easily missed. Vigilance for signs of more ominous injuries is paramount. Let us review one injury that should make you ponder more than the injury itself – Scapula Fracture:

Scapular Fractures in Children

  • Scapular fractures are rare in pediatric patients. [Shannon, 2019; Park, 2017]
    • Only 3-5% of all shoulder related fractures.
    • Anatomy matters:
      • Children, generally, have more compliant bones.
      • Scapula has a thick periosteum (especially in children).
      • Scapula is surrounded by dense muscles
        • Has 17 muscular attachments.
        • Only the dorsal aspect of the spine and acromion are not covered by muscle.
        • Muscles can act like cushions.
  • Takes a lot of energy to fracture a scapula!
    • Similar to rib fractures and pelvic fractures in children, scapular fractures are rare and can be indication of a substantial force being applied.
    • Like with adults, scapular fractures are associated with high-energy mechanisms.
    • Associated with higher Injury Severity Scores [Shannon, 2019]
  • Not all Scapular Fractures require Car Accidents! [Neral, 2018]
    • They can also occur due to sporting “mis-adventures.”
    • Scapular body fractures occur from muscle contraction against a resistant force during contact sports.
    • Unlike the other mechanisms, these involve LOW-energy and are NOT associated with additionally injuries. [Neral, 2018]
    • Some may even be classified as “fatigue fractures.” [Neral, 2018]
    • Conservative treatment is very successful.

Scapular Fracture: Management

  • Majority of pediatric scapular fractures involve the scapula body. [Shannon, 2019]
    • Intra-articular involvement is rare.
    • Less likely, compared to adults, to involve the humeral head. [Shannon, 2019]
    • Scapular Neck, Glenoid, and Acromion occur less commonly.
    • Scapular Neck Fractures are second most common.
  • The majority of scapula fractures are treated without surgery. [Neral, 2018; Park, 2017]
    • Short term of immobilization with Sling or Sling and Swathe
    • Early progressive Range of Motion exercises
    • Most fractures heal within 6 weeks.
  • Surgical Treatment Considerations [Neral, 2018; Park, 2017]
    • Open fractures
    • Associated with Neurovascular compromise
    • Intra-articular fractures (ex, Glenoid fractures with Humeral Head Instability)
    • Acromion fractures that impinge into subacromial space (may impact function of rotator cuff)
    • Scapular Neck fractures with severe angulation
    • Coracoid fractures with AC separation
    • Scapular fractures with concurrent Clavicle fractures

Moral of the Morsel

  • It take a lot of force! The Scapula is cushioned and tough to break.
  • Scapular Fracture? Think about the Head, Chest, and Extremities! There may be a hiding concurrent injury.
  • Sports are not Car Crashes (in general). The scapular fracture may be isolated … but you should still remain mentally vigilant!

References

Shannon SF1, Hernandez NM, Sems SA, Larson AN, Milbrandt TA. High-energy Pediatric Scapula Fractures and Their Associated Injuries. J Pediatr Orthop. 2019 Aug;39(7):377-381. PMID: 31305382. [PubMed] [Read by QxMD]
Neral M1,2, Knapik DM1, Wetzel RJ1, Salata MJ1, Voos JE1. Scapular Body Fracture in the Athlete: A Systematic Review. HSS J. 2018 Oct;14(3):328-332. PMID: 30258341. [PubMed] [Read by QxMD]
Shannon SF1, Hernandez NM, Sems SA, Larson AN, Milbrandt TA. Pediatric Orthopaedic Trauma and Associated Injuries of Snowmobile, ATV, and Dirtbike Accidents: A 19-Year Experience at a Level 1 Pediatric Trauma Center. J Pediatr Orthop. 2018 Sep;38(8):403-409. PMID: 27442216. [PubMed] [Read by QxMD]
Abd El-Shafy I1, Rosen LM, Prince JM, Letton RW, Rosen NG. Blunt traumatic scapular fractures are associated with great vessel injuries in children. J Trauma Acute Care Surg. 2018 Nov;85(5):932-935. PMID: 29787531. [PubMed] [Read by QxMD]
Park HY1, Jang HJ, Sur YJ. Scapular body fracture and concomitant inferior angle apophyseal separation with intrathoracic displacement: a case report. J Pediatr Orthop B. 2017 Sep;26(5):429-432. PMID: 27846037. [PubMed] [Read by QxMD]
Buckley SL1, Gotschall C, Robertson W Jr, Sturm P, Tosi L, Thomas M, Eichelberger M. The relationships of skeletal injuries with trauma score, injury severity score, length of hospital stay, hospital charges, and mortality in children admitted to a regional pediatric trauma center. J Pediatr Orthop. 1994 Jul-Aug;14(4):449-53. PMID: 8077425. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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