A forty-three-year-old man presented to our emergency department with a painful right shoulder after falling through a hole in the floor and landing in the basement of a house under construction. Advanced Trauma Life Support (ATLS) guidelines7 were used in the initial assessment. Physical examination revealed tenderness in the right flank, severe pain of the right shoulder at the posterior aspect, and pain over the scapula. Motion of the right shoulder was limited. The elbow, forearm, and wrist had full passive motion, and there were no neurovascular abnormalities.
Vital signs included a blood pressure of 159/89 mm Hg, a heart rate of 54 beats per minute, and a respiratory rate of 15 breaths per minute. The patient had no respiratory distress, and the partial oxygen saturation on room air was 100%. No head or spinal cord injuries were present. Abdominal ultrasound revealed no abnormalities.
The initial chest radiograph demonstrated a possible scapular fracture and showed a deformity of the right apical hemithorax, without a pneumothorax or subcutaneous emphysema (Fig. 1). A computed tomography (CT) scan revealed a fracture of the dorsal and ventral aspects of the third rib (without pneumothorax) and a comminuted scapular fracture consisting of a minimally displaced glenoid fracture as well as multiple fragments of the scapular body. A large part of the inferior angle fragment of the scapula had penetrated the thoracic wall and was lodged inside the thorax (Figs. 2 and 3). The patient was admitted to the intensive care unit; the vital signs were stable. Because of concerns about the possibility of the development of pulmonary complications caused by the intrathoracic scapular fragment, an open reduction of the scapular fragment was performed the next day. The fragment was locked in place by the rib fragments, and a limited thoracotomy through the fifth intercostal space was performed. The fracture fragment was released and repositioned through the penetrated muscles. Remarkably, the parietal pleura was intact despite the spiked bone fragment that made contact with the lung. A thoracic drain was left in situ. No additional interventions were performed during the operation. An epidural catheter was used for analgesic management during the first few postoperative days. A postoperative CT scan of the shoulder demonstrated that the intra-articular glenoid fracture was nondisplaced. Ten days after the accident, the patient was discharged from the hospital. He reported no pain or problems during the follow-up visit at the outpatient clinic two weeks later.
Scapular fractures are uncommon and account for only 3% to 5% of all fractures involving the shoulder4. Because the scapula is protected by a thick soft-tissue layer and the chest wall, a substantial force is normally required for this fracture to occur8. For this reason, high-energy traffic accidents are the leading cause of these fractures1,8, which are often associated with multiple injuries.
In 90% of patients who sustain scapular fractures, there is often an associated life-threatening injury9,10. Because attention is usually first directed toward any other severe injuries, fractures of the shoulder region, particularly the scapula, are often initially overlooked or treatment is postponed to a later time. Complications caused by the fracture itself, such as intrathoracic displacement of the fracture parts, are very uncommon.
A search of the literature revealed only four articles reporting cases of intrathoracic scapular displacement3-6 and eight articles reporting intrathoracic displacement of the humeral head with a proximal fracture of the humerus11-18.
Nettrour et al.3 reported a case of traumatic intrathoracic displacement of the inferior angle of the scapula in an eleven-year-old boy who fell from a moving car, but this injury was not associated with a fracture of the scapula. Blue et al.4 described a case of a thirteen-year-old boy who was struck by a truck while riding a bicycle. He sustained a scapular fracture with inferior fragment impaction and had severe accompanying injuries, including bilateral rib fractures with a hemopneumothorax, pelvic fractures, and a splenic laceration. Schwartzbach et al.5 reported a case of a seventy-two-year-old pedestrian who sustained a comminuted scapular fracture with intrathoracic impaction of the inferior fragment after being struck by an automobile. Porte et al.6 described a case of a thirty-year-old woman with a scapular fracture involving the glenoid fossa and scapular body, with intrathoracic displacement of the inferior fragment. She sustained multiple injuries, including bilateral rib fractures as well as an ipsilateral pneumothorax and subcutaneous emphysema of the chest wall.
After a shoulder injury, physical examination may reveal bruising and tenderness to palpation over the site of soft-tissue and bone injury, but the degree of ecchymosis is not related to the degree of injury. The arm is typically held in an adducted position, and there is a resistance to motion because of pain. Any associated neurological injury should be sought and documented19.
Because a supine chest radiograph is routinely obtained in patients who sustain major blunt chest trauma, it often provides the earliest opportunity to detect shoulder girdle fractures. Nevertheless, scapular fractures are often missed. In a retrospective analysis of 100 patients, Harris and Harris20 found that only 57% of scapular fractures were identified on an initial chest radiograph. These fractures are often radiographically obscure; additionally, the scapulas are only partially included on the radiographs. Because scapular fractures are commonly associated with other regional injuries, they can be masked or simply overlooked20.
In addition, it is difficult, if not impossible, to determine if the scapula is displaced into the thorax on a two-dimensional radiograph of the chest. A standard radiographic series for the evaluation of scapular fractures should include a true anteroposterior view along with an axillary and scapular “Y” view. A CT scan should be considered in order to fully image the scapula and thorax.
In conclusion, scapular fractures are uncommon and easily overlooked. Complete characterization of the location of the scapula and fracture fragments may require additional evaluation with a CT scan.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.