Scapula fracture is a violation of the integrity of the scapula as a result of traumatic exposure. It occurs quite rarely and is usually combined with rib fractures. It is manifested by pain in the scapular area, swelling and restriction of movements of the upper limb. In some cases, subcutaneous hemorrhage or brachial hemarthrosis is noted. Pathology is diagnosed on the basis of anamnesis, physical examination data and X-ray examination. The method of treatment depends on the site of the scapula fracture, may consist in applying a fixing bandage or skeletal traction lasting 1 month.
S42.1 Scapula fracture
Scapula fracture are rarely observed in traumatology, they account for 0.3-1.5% of the total number of skeletal injuries. As a rule, they occur simultaneously with rib fractures. A fracture of the acromial process can be combined with a fracture or dislocation of the acromial end of the clavicle, a fracture of the articular process – with a dislocation of the shoulder. Traumatic injury is more often detected in men of working age, the peak incidence is 40-60 years.
Scapula fracture occur in domestic, street and industrial injuries, road accidents. Localization of damage is determined by the mechanism of injury:
- Direct impact: falling on the back, a strong blow. Predominates in the structure of morbidity, observed with fractures of the angles, spine, body of the scapula.
- Indirect impact: falling with an emphasis on the hand or on the area of the elbow joint with the limb withdrawn. It causes fractures of the neck, cranial, acromial processes of the scapula, articular cavity.
The scapula is a flat paired bone. It is located on the back surface of the chest to the side of the spine. It is part of the so-called upper shoulder girdle and participates in the movements of the upper limb. It has a complex structure, including a body, an awn, two processes, a neck and an articular cavity. Scapula fracture due to the peculiarities of its location are usually not accompanied by a pronounced displacement.
The most difficult are multi-fragmented fractures of the body, as well as fractures of the acromial process, the neck of the scapula, in which displacement of bone fragments is more often observed. A fracture of the articular cavity belongs to the category of intra-articular, can have a negative impact on the function of the shoulder joint due to a violation of the integrity of the articular surface, especially in the presence of free-lying fragments.
In modern traumatology and orthopedics, the systematization of scapula fracture is used, taking into account localization, which allows you to choose the optimal treatment tactics and make a prognosis. There are the following types of injuries:
- multi-splintered, transverse, longitudinal scapula fracture body;
- fractures of the acromial and cranial processes of the scapula;
- fracture of the surgical and anatomical neck of the scapula;
- fracture of the articular cavity;
- fracture of the lower and upper inner corners;
- fracture of the spine of the scapula.
The clinical picture is determined by the localization of the fracture. When the corners, spine and bone body are damaged, a pain syndrome occurs, swelling appears in the affected area due to hemorrhage into nearby soft tissues. Local edema usually corresponds to the shape of the scapula, interpreted as a symptom of a “triangular pillow”. Moderate limitations of movements of the upper limb are revealed, independent lifting of the arm is impossible.
Deformity in fractures with displacement is not always visualized due to pronounced swelling, which also complicates palpation and can cause underdiagnosis. When feeling, the displacement of fragments, bone crepitation, pathological mobility can be determined. Palpation of the injury area is sharply painful.
With fractures of the articular cavity, the patient complains of pain in the projection of the shoulder joint. The joint is swollen, deformed, and there is a sharp restriction of movements. The contours of the surrounding bone structures have been changed, there is a standing of the acromion, a sinking of tissues under the acromial process. Palpation sometimes reveals bone crunch.
Fractures of the cranial process and acromion are manifested by local soreness and swelling of the surrounding soft tissue structures. In the projection of the fracture, a bruise forms, reaching a maximum by 2-3 days. Movements are limited, palpation is painful, sometimes crepitation is detected.
Occasionally scapula fracture are complicated by injuries of the brachial plexus, axillary artery or nerve. If the integrity of the vessel is violated, intense internal bleeding may occur. With rupture and compression of the nerve, disorders of sensitivity and movement are noted, which sometimes fully or partially persist after the fracture heals. When the articular cavity of the scapula is damaged, hemarthrosis occurs.
In some patients, in the long-term period, a “floating” (excessively mobile) scapula is detected, the development of which is due to atrophy of the surrounding muscles. The late complications of intra-articular fractures include shoulder arthrosis, restriction of movements of varying degrees of severity. After conservative treatment of intra-articular injuries, habitual shoulder dislocations are sometimes diagnosed.
The examination is carried out in the emergency room of the traumatology department, the diagnosis is made based on the results of a consultation with a traumatologist. The following methods are used:
- External inspection. In favor of a scapula fracture, depending on its localization, the presence of a “triangular pillow”, a characteristic restriction of movements, sharp soreness indicate. The undoubted signs of a fracture are pathological mobility of fragments and bone crepitation.
- Radiography. It is the main method of instrumental diagnostics. In most fractures, X-rays of the scapula are performed in direct and lateral projections. If the articular cavity is damaged, an shoulder x-ray is shown.
- Other visualization techniques. Have an auxiliary value. To clarify the features of the fracture and the location of fragments in multi-ring fractures, CT of the scapula is prescribed. To assess the condition of the surrounding structures, soft tissue MRI is performed.
- Puncture of the shoulder joint. It is carried out with injuries of the articular cavity. It is a therapeutic and diagnostic manipulation, allows you to confirm the presence of blood in the joint cavity, to carry out its evacuation.
In the presence of concomitant injuries (injuries of the chest, spine), the list of diagnostic techniques is expanded. In case of rupture or compression of the neurovascular bundle, the examination plan includes consultations with a vascular surgeon, neurologist or neurosurgeon.
Treatment of a shoulder blade fracture
At the prehospital stage, the arm on the side of the lesion is fixed with a kerchief bandage or a wire splint. If intra-articular damage or rupture of the vessel is suspected, cold is applied (a bag or a hot water bottle with ice wrapped in a towel) to the joint area. With intense pain, analgesics are given. Attempts at correction are strictly prohibited due to the possibility of secondary displacement.
Upon admission, the traumatologist performs local anesthesia of the fracture area. The method of immobilization is determined by the localization of damage:
- For fractures without displacement, a Dezo bandage is applied, supporting the forearm and fixing the shoulder to the chest. A roller is placed in the armpit. On the 10th-11th day, the bandage is removed, the patient’s arm is suspended on a kerchief bandage.
- In case of acromion fracture with dislocation of fragments, a diverting splint is used for a period of 4-6 weeks.
- Treatment of fractures of the articular cavity and the neck of the scapula with displacement is carried out using cutaneous or skeletal traction for a period of 1 month. Subsequently, a thoracobrachial bandage is applied for 3 weeks.
Complete fusion occurs within 1-2.5 months. In the first days, with severe pain, analgesics are administered intramuscularly. Patients are prescribed physical therapy, massage, physiotherapy. The following physiotherapy procedures are used:
- UHF – promotes vasodilation, activation of blood circulation and tissue metabolism;
- magnetotherapy – stimulates the formation of bone tissue;
- interference currents – accelerate the resorption of bruises, reduce pain, eliminate swelling;
- medicinal electrophoresis – the use of local anesthetics reduces the severity of pain syndrome, the use of hydrocortisone reduces inflammation.
Surgical treatment for scapula fracture is rarely used.
- Intra-articular injuries are considered as indications, if the fragments are displaced by 5 or more millimeters, the fracture line extends to a quarter or more of the articular surface;
- neck fractures, if the fragments are displaced by more than 10 mm, the angle of inclination of the articular cavity is changed by 40 degrees or more;
- shoulder subluxations;
- damage to the upper supporting complex (dislocations and fractures of the collarbone).
In isolated injuries, bone osteosynthesis of the scapula is usually carried out with small plates. Damage to the supporting complex may require complex interventions with simultaneous plasty of the acromioclavicular joint, external or intramedullary fixation of the clavicle, immobilization of the scapula using screws or plates. After the operation, the upper limb is fixed in the retraction position. The patient is prescribed antibiotic therapy and painkillers, rehabilitation measures are carried out.
The prognosis for a scapula fracture is favorable in most cases. Fractures without displacement fuse well, do not entail negative consequences. With injuries with displacement, especially intra-articular, movement restrictions, degenerative-dystrophic changes are possible. With concomitant nerve injuries, neuropathies may be observed.
Preventive measures include the prevention of domestic injuries, compliance with traffic rules, and compliance with safety regulations at work. In case of injuries to the upper chest, the traumatologist’s alertness regarding possible concomitant injuries of the scapula is important.
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