Scapula Bone Fractures: Anatomy, Classification, Clinical Features and Treatment

Scapula fractures are uncommon and they only result from high energy trauma because scapula is in protected position

Common causes include:

Scapula anatomy

Scapula (aka shoulder blade) is a triangular flat bone located on the posterolateral aspect of the thorax

The posterior surface of scapula is divided by a thick ridge of a bone which is called the spine of scapula

It is divided into a smaller supraspinous fossa (origin of supraspinatus muscle) and a larger infraspinous fossa (origin of infraspinatus and teers minor muscles)

The spine of scapula continues laterally to form the acromion, acromion articulates with the acromial end of the clavicle and it is also a point of attachment to trapezius muscle

The anterior surface of scapula forms the subscapular fossa (origin of subscapular muscle

Superolateral of the scapula, there is the glenoid cavity, which articulate with the head of the humerus at the glenohumeral joint

Superior to the glenoid, there is the coracoid process which projects anterolaterally, it provide attachment to CC ligaments, and it is the origin of the short head of biceps and brachialis muscles

Right scapula osteoanatomy, posterior view, Frederick Henry Gerrish (1845-1920), Public domain, via Wikimedia Commons

Right scapula osteoanatomy, posterior view; by Frederick Henry Gerrish (1845-1920), Public domain, via Wikimedia Commons

Right scapula osteoanatomy, anterior view, Frederick Henry Gerrish (1845-1920), Public domain, via Wikimedia Commons

Right scapula osteoanatomy, anterior view; by Frederick Henry Gerrish (1845-1920), Public domain, via Wikimedia Commons

Areas of muscular attachment, posterior surface of right scapula, Frederick Henry Gerrish (1845-1920), Public domain, via Wikimedia Commons

Areas of muscular attachment on the posterior surface of right scapula, by Frederick Henry Gerrish (1845-1920), Public domain, via Wikimedia Commons

Areas of muscular attachment, anterior surface of right scapula, Frederick Henry Gerrish (1845-1920), Public domain, via Wikimedia Commons

Areas of muscular attachment on the anterior surface of right scapula, by Frederick Henry Gerrish (1845-1920), Public domain, via Wikimedia Commons

Clinical features

Patient arm is held immobile and there is severe bruising over the scapula and the chest wall due to the high energy injury sustained by that area

Patient complain of severe diffused shoulder pain, shortness of breath and chest wall pain

Evaluate and resuscitate patient based on ATLS trauma protocol

There is usually associated severe injuries to the chest, brachial plexus, spine, abdomen and head, look for them

Careful neurological and vascular examinations are essential

Imaging

In addition to trauma labs and radiographs, send the patient for Scapula AP and Y views and shoulder axially view are the most helpful radiographs in detecting scapula fractures

But these fractures might be difficult to be seen on X ray due to surrounding soft tissues

CT scan are useful in detecting and classifying scapula fractures and detecting associated injuries

Classification

Fractures of the scapula are classified anatomically into:

Last 3 types are subclassified into different grades

Scapular body fractures classification

Scapular body fractures are described based on anatomical location

Most of these fractures are minimally displaced and treated non operatively with sling immobilization

Patient is advised to exercise the shoulder, elbow and fingers from the beginning to prevent stiffness

Isolated glenoid neck fractures classification

This is one of the more common fractures involving scapula

They are extra articular (don’t involve the glenohumeral joint)

CT scan is required to make sure that the fracture is not intraarticular

Intraarticular Glenoid fractures classification

Fractures involving the glenoid fossa and rim are subclassified according Ideberg modified by Goss classification

This is the most commonly used classification to describe Glenoid fractures

Ideberg modified by Goss classification

Type I

Fracture involving the glenoid rim

Mostly minimally displaced and treated non operatively

If the fracture involve more than a 25% of the glenoid surface and is displaced by 5 mm then this is indication of surgical fixation of Type I fractures

Ideberg modified by Goss Type I, Anatomography, CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons

Ideberg modified by Goss Type I, Anatomography, CC BY-SA 2.1 JP, via Wikimedia Commons

Type II

Fracture through glenoid fossa

Inferior fragment significantly displaced, The attached long head of the triceps may drag the fractured glenoid downwards and laterally

Associated with humeral head subluxation => unstable shoulder joint

Treatment is with open reduction and internal fixation since shoulder joint is unstable

Ideberg modified by Goss Type II, Anatomography, CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons

Ideberg modified by Goss Type II, Anatomography, CC BY-SA 2.1 JP, via Wikimedia Commons

Type III

Oblique fracture through the glenoid exiting superiorly

Significant displacement

Maybe associated with AC joint dislocation

Treatment is with open reduction and internal fixation if the humeral head is centered on the major portion of the glenoid and shoulder is stable then a non operative approach is taken but if not then treated operatively

Ideberg modified by Goss Type III, Anatomography, CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons

Ideberg modified by Goss Type III, Anatomography, CC BY-SA 2.1 JP, via Wikimedia Commons

Type IV

Horizontal fracture exiting through the vertebral border of the scapula

Significant displacement

Treatment is with open reduction and internal fixation if the humeral head is centered on the major portion of the glenoid and shoulder is stable then a non operative approach is taken but if not then treated operatively

Ideberg modified by Goss Type IV, Anatomography, CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons

Ideberg modified by Goss Type IV, Anatomography, CC BY-SA 2.1 JP, via Wikimedia Commons

Type V

Combination of type IV and another fracture separating the inferior part of the glenoid

Significant displacement

Treatment is with open reduction and internal fixation if the humeral head is centered on the major portion of the glenoid and shoulder is stable then a non operative approach is taken but if not then treated operatively

Ideberg modified by Goss Type V, Anatomography, CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons

Ideberg modified by Goss Type V, Anatomography, CC BY-SA 2.1 JP, via Wikimedia Commons

Type VI

Severe comminution of the glenoid surface

Significant displacement

Treated operatively

Ideberg modified by Goss Type VI, Anatomography, CC BY-SA 2.1 JP <https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en>, via Wikimedia Commons

Ideberg modified by Goss Type VI, Anatomography, CC BY-SA 2.1 JP, via Wikimedia Commons

Fractures involving acromion classification

Classified according to Kuhn acromial fracture classification, this classification include three types:

Type I minimally displaced => treated non operatively

Type II displaced but does not compromise the subacromial space => treated non operatively

Type III displaced and compromises the subacromial space => treated operatively

Fractures involving coracoid classification

Those classified according to Ogawa coracoid process fracture classification, it is on two types:

Type I fracture occurs proximal to the coracoclavicular ligament => associated with AC joint separation => mostly treated operatively

Type II fracture occurs distal to the coracoclavicular ligament => doesn’t hurt AC joint => treated non operatively

Combined fractures

If there was a fracture involving the scapula + there is associated fracture of the clavicle or disruption of AC ligament => glenoid gets displaced => it is called “ the floating shoulder”

Scapulothoracic dissociation

Disruption of the scapulothoracic articulation where the scapula is displaced by > 1 cm from the spinous processes in comparison with the contralateral side

It is caused by high energy trauma

Associated with severe neurovascular injuries and fractures

Complications

Post traumatic glenohumeral arthritis: high risk for this if it was intra articular glenoid fractures

Malunion

Recurrent glenohumeral instability

Neurovascular injury

Course Menu

This article is a part of the Shoulder and Arm Trauma Free Course, this course also contains: