What is the diagnosis?

The patient has a scapular fracture. See Image 2 for annotation of the findings. 

Image 2. Plain radiograph of the shoulder, AP (left) and scapular Y view (right). Annotations by Author. Case courtesy of Ashesh Ishwarlal Ranchod, Radiopaedia.org, rID: 167844

What is the mechanism of injury?

This usually requires a high-energy mechanism such as MVC, fall from height, or occasionally athletic injuries [1]. 

• Pearl: If a scapular fracture is discovered, you should look for other concomitant injuries, as there are commonly other injuries, such as rib fracture, pneumothorax, and pulmonary contusion [1]. 

What physical exam findings are expected?

Patients will typically have significant upper back pain. Often, they have concomitant injuries and will have pain associated with those as well. Patients will have tenderness to palpation along the scapula and could have potential asymmetry with winging, depending on the severity of injury. These, of course, are not specific to scapula fracture only. There are no special exam maneuvers that will help elicit this diagnosis. 

• Pearl: The rate of associated injuries includes ipsilateral extremity injury (50%), thoracic injury (80%), head injuries (48%), and spinal fractures (26%) [2]. Due to this, scapula fractures can be missed frequently. 

Which imaging modalities can be used?

An X-ray (AP, lateral, scapular Y, axillary) can be done to diagnose the fracture, but the scapula is difficult to fully capture on x-ray and, therefore, can be missed. Non-displaced fractures can especially be difficult to diagnose on x-ray. CT scan has a much better sensitivity for identifying scapular fractures. 

Image 3. CT scan of fractured scapula. Annotations by Author. Case courtesy of Ashesh Ishwarlal Ranchod, Radiopaedia.org, rID: 167844

What is the management in the ED?

Patients should be thoroughly evaluated for concomitant injuries - a trauma assessment is recommended. The patient's pain should be controlled with multimodal pain management. Consider CT imaging for better evaluation of the fracture pattern and amount of displacement. 

In general, most of these fractures can be managed with sling and pain control, especially if it is an isolated nondisplaced scapula fracture. 

• Pearl: If there is ≥ 1 cm of displacement in the body, OR > 2 mm of displacement in the glenoid, then surgical repair should be considered [2]. 

When do you consult Orthopedics?

Orthopedics should be consulted for neurovascular compromise, or significant displacement as noted in the pearl above. Otherwise, patients can follow up as an outpatient.