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Changes in the Way Scapular Fractures Are Treated Today
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Posted on: 04/26/2012
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Scapular fractures (the shoulder blade) are rare but can be life-threatening. That's because a traumatic force strong enough to break the scapula usually also causes other serious injuries. There can be head, neck, arm, chest, rib and even pelvic injuries along with the scapular fracture.
These other injuries are serious enough to threaten life and can prove fatal. For example, a broken rib can puncture the lung, a chest wound can lead to pneumonia, and head, neck, and spinal cord injuries can be very disabling.
Many times the scapular fractures are missed because the bone is well-covered by surrounding soft-tissues. It isn't until the patient is out of the intensive care unit (ICU) that symptoms of neck, back or arm pain, along with numbness and tingling in the arm alert the physician to yet another problem. X-rays and three-dimensional CT (3D-CT) scans are needed to make a clear and accurate diagnosis.
The next dilemma is to decide the best treatment approach. Research-based evidence is not available so expert opinion is the next best thing for making treatment decisions. And experts in different parts of the world have not always agreed. In the United States, until recently, the approach has been nonsurgical while in France, surgeons have used a more aggressive surgical approach.
Several French studies have reported on the successful results using internal fixation (metal plates, screws, pins) to realign the misaligned pieces of the scapula and hold them together until healing takes place. This approach is gaining recognition based on a more complete understanding of these kinds of fractures and improved surgical techniques.
The challenge now is to identify which patients require surgery and which ones can still be successfully treated conservatively. Surgeons have started classifying scapular fractures according to the anatomical location of the fracture: scapular body, neck, or process. Scapular body fractures can be further classified according to the direction of the fracture line (longitudinal, transverse, and oblique).
The imaging studies mentioned (especially 3-D CT scans) show if the fracture extends into the shoulder joint. CT scans also show if the bony displacement has changed the angles, shortened the bone or caused other deformities. These are key features that can alter shoulder function and point to the need for surgical intervention. The surgeon can measure displacement and angulation in order to assess soft tissue structures and scapular stability.
There's no magic formula or one-size-fits-all treatment plan for these patients. Management is individually determined. Surgery is going to be more likely when there is excessive bony displacement or deformity, joint damage, and/or both. Scapular fractures in the presence of rib or chest injury are more likely to need surgery. Without sure proof that surgery will benefit the patient, surgeons must make these decisions based on their expertise and evaluation of the case.
For those patients who may be able to successfully heal and rehab without surgery, a shoulder sling is worn for several weeks. They should be warned that the healing process often involves pain, loss of control over the shoulder, and what feels like paralysis.
Physical therapy begins approximately one month after injury. The therapist progresses the patient gradually through a full range of rehabilitation activities. Therapy begins with passive motion and eventually includes strengthening and endurance training. The patient can expect to be in therapy for three to six months.
In this update summary of management for scapular fractures, the authors provide a history of such injuries recorded from 1579 to the present day. They also describe the surgical techniques used for each type of scapular fracture including 1) isolated scapular acromion or coracoid process fractures, 2) intra-articular glenoid fractures (fractures that extend inside the shoulder socket), 3) damage to the scapular neck and clavicle (collar bone), and 4) isolated fractures of the scapular neck or body that do not include the shoulder joint.
One final tool is offered to surgeons facing treatment decisions for scapular fractures and that is an algorithm or flow sheet. This algorithm is presented in a chart describing conservative (nonoperative) and surgical approaches along with postoperative rehabilitation protocols for both.
A very complete summary is provided outlining current indications for surgery with specific numbers associated with angles and displacements measured on X-rays. The authors strongly urge continued research to create evidence-based treatment guidelines. They suggest future changes will be seen in the treatment of scapular fractures as more information comes to light. In the meantime, they suggest that surgeons must evaluate each patient carefully and thoroughly and prepare for surgery in the same manner.
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References:
Peter A. Cole, MD, et al. Management of Scapular Fractures. In Journal of the American Academy of Orthopaedic Surgeons. March 2012. Vol. 20. No. 3. Pp. 130-141.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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