DEPARTMENT OF ORTHOPEDICS & TRAUMATOLOGY

HOSPITAL SUNGAI BULOH

CPC 1:
Scapular Fracture

BY DR ELIAS BIN ADAM

GRAND MENTOR:
DATO’ DR. HAJI ZAMYN ZUKI BIN TAN SRI DATO HAJI MOHD ZUKI

MENTOR:
MR AZLAN SOFIAN
ACKNOWLEDGEMENT
I would like to express my sincere gratitude to Dato’ Dr Haji Zamyn Zuki for his patient guidance,
enthusiastic encouragement for the completion of this CPC 1.
I would also like to thank my mentor, Mr Azlan for his valuable advice, relentless support and unlimited
guidance in the completion of this CPC 1.
Special thanks to all the specialists, medical officers, colleagues, patients and my parents for their
support, prayers and encouragement throughout this CPC 1.
Thank you.

Yours sincerely,

................................
(DR ELIAS BIN ADAM)
Pegawai Perubatan Latihan Siswazah Gred UD 41,
Jabatan Ortopedik & Traumatologi
Hospital Sungai Buloh
 Introduction

Scapular fracture is among the rarest form of fracture, due to the location of scapular bone and sturdyness
of the bone. Thus, it only occurs once the individual exposed to considerable amount of force (high
speed) and that severe chest trauma may be present. Scapular fracture contributes to 1-2.5% associated
mortality rate, contributing 1% of all fracture and 5% of all fracture around shoulder in Malaysia. In most
cases of scapular fracture,early functional treatment gives good or excellent result. However operative
intervention maybe indicated to highly displaced scapular body fracture , glenoid fossa fracture, neck of
scapular fracture. In this CPC, we are discussing a case of closed fracture of bilateral scapular fracture
with left midshaft clavicle fracture presenting with left scapularthoracic dissociation with brachial plexus
injury ( BPI ) over left scapular.
A picture of me with my grand mentor, Dato’ Dr. Haji Zamyn Zuki
A picture of me with my mentor, Mr Azlan Sofian
 Case report
Mr Z is a 23 year old malay gentleman whom is working as an administration assistant presented with a
motor vehicle accident (MVA ) between motor versus car on January 2018 at Hospital Sungai Buloh
He sustained:
1/ Bilateral comminuted scapula fracture with midshaft left clavicle fracture
2/ Left scapulothoracic dissociation with BPI
3/T1 till T3 spinous process fracture
- T4 till T6 spinous process and left transverse process fractures.
- T7 spinous process fracture
4/Bilateral posterior lung contussions with bilateral haemopneumothorax
5/Right 10th and 12th ribs fracture and left 3rd, 6th - 7th posterior ribs fracture
ss and left transverse process fractures.
- T7 spinous process fracture

Post trauma, patient complained of shortness of breath, chest pain, retrograde amnesia, left upper limb
numbness and weakness. Otherwise no loss of concsiousness, no ENT bleeding, GCS full.
Primary survery done by ED team:

AIRWAY:
no gurgling sound, no stridor, trachea central, able to speak in words
C-collar applied

BREATHING:
lungs: reduced a/e bilaterally with crepitaton
Sp02 80% under HFM
respiratory rate 40
chest spring: positive over the left side
bedside scan: absent sliding sign, effusion seen bilaterally

Thus decided for bilateral chest tube insertion, anchored at 14cm bilaterally
right chest tube: 100mls blood drained, fluctuating, no continous bubbling
left chest tube: blood in tubing, fluctuating, no continous bubbling
sP02 picked up to 95% under HFM post chest tube insertion

CIRCULATION:
warm peripheries
crt<2sec
moderate pulse volume
BP 185/139
PA: soft non tender, not distended
no scrotal hematoma
no blood at urinary meatus
FAST x3: negative

DISABILTY
E3-4, V4-5, M6
pupil 2/2 reactive bilaterally

EXPOSURE
adequately exposed and covered
On examination, he is alert and conscious. Her blood pressure was 129/75 mmHg with pulse rate of 18.
He speaked with minimal difficulty, short sentence and tachypnic with respiratory rate of 25. Noted from
arterial blood gas investigation (ABG) patient having type 1 respiratory failure,( pH 7.26, p02 54.4, pc02
57.8, hc03 22.1, lac 2.9, glu 9, s02 81) thus was put on high flow mask (HFM). From lung auscultation
noted reduced air entry bibasally. Upon insertion of chest tube noted total amount of 150cc of blood drain
from chest tube bilaterally. Proceeded with CT Abdomen, noted lung fully expanded bilaterally and
multiple ribs fracture with posterior lung contusion.

Per abdomen soft non tender, pelvic spring is negative, chest spring is positive.

Radiological investigation as follows:

CT Brain / Cervical : No ICB / obvious fractures seen

CXR : Bilateral hemopneumothorax - chest tubes in situ
CT Thoracolumbar : Bilateral comminuted scapula fracture, left midshaft clavicle fracture, no obvious
thoracic spine fractures
Pelvic x-ray : No obvious fracture seen
Doppler test: Radial bilaterally biphasic, Ulnar right triphasic, left biphasic

From examination:

1/ Right upper limb

No open wounds
No bony tenderness along right UL
No wrist / finger drop
Sensation intact
Radial pulse felt
CRT <2s

2/Left upper limb

Multiple abrasion wounds over anterior aspect of left shoulder / chest wall
Left shoulder ecchymoses
Power C5-T1 grade 0
Sensation lost
Radial pulse felt
CRT <2s

3/ Right lower limb

No swelling or tenderness
No deformity
No wound seen
No neurological deficit
Distal pulses palpable
CRT<2secs
Sensation intact

4/ Left lower limb

No swelling or tenderness
No deformity
No wound seen
No neurological deficit
Distal pulses palpable
CRT<2secs
Sensation intact

Power

Right Left
C5 5 0
C6 5 0
C7 5 0
C8 5 0
T1 5 0

Right Left
L2 5 5
L3 5 5
L4 5 5
L5 5 5
S1 5 5

Reflexes were normal for right upper and bilateral lower limb
Sensory are intact except from C5-T1 deramtomes of left upper limb.
Babinski withdrawal and no clonus
Per rectal examination, anal tone was normal with intact superficial and deep sensation and
bulbocavernosus reflex was present.
However, noted that patient becoming more lethargic, with accessories muscle involvement during
breathing, from ABG noted patient having Type 2 repiratory failure, thus proceeded with intubation in
view of impending respiratory collapse and was admitted to intensive care unit (ICU) for stabilization and
close monitoring with presentation of rhabdomyolisis with acute kidney injury based on laboratory and
clinical picture.

Patient condition improving over his stay in ICU for 5 days, thus was discharge from ICU and transferred
to Ward General Surgery and for continuous monitoring. Patient condition remarkably improving and
stable over his stay at ward.
Patient is planned for right scapula plating and left clavicle plating under Meditours on 8/2/18. In the
meantime pateint was put on bilateral arm sling while awaiting for operation.
 Investigations

Blood investigations :
Full blood count (29/1/18)
- WCC 28.3 (Neutrophil 87.5 / Eosinophil 0.0/ Basophil 0.1/ lymphocyte 3.2) / Hb 13.4/ Plt 248
C- reactive protein : 2.71 (29/1/18)
Renal profile (29/1/18) : Urea 20.8/ Na 135/ Potassium 3.8/ Creatinine 279
Renal Profile upon discharge 10/2/18: Urea 3.6/ Na 136/ Potassium 4.4/ Creatinine 59.8
Liver function test : (29/1/18)
albumin 31/ alkaline phosphatase 75/ alanine transaminase 102/ aspartate transaminase 205
Creatinine Kinase: >4267/1538/1490
Amylase: >210

Electrolyte: Calcium 2.0/Magnesium 0.7/Inorganic phosphate 0.99

 Radiological Investigation

Figure 1 : Chest x-ray

Findings : left clavicle fracture, left scapula lateralized, right chest tube in situ, right and left lung fully
expanded
 Figure 2 : X ray pelvis
Findings: Normal, no fracture seen
 CECT THORAX, ABDOMEN AND PELVIS DATED 29/1/2018

Findings:

Thorax
Right chest tube seen traversing the right upper lobe parenchyma with its tip at the T3 spine level.
The left chest tube seen traversing the left lower lobe with the tip abutting the left ventricle at T4 spine
level.
Subcutaneous emphysema at the bilateral lateral chest wall.
Bilateral minimal pneumothorax.
Collapsed consolidations at the bilateral upper lobes and right lower lobe.
Patent tracheo bronchial tree.
The major mediastinal vessels are normal.
Heart normal, no pericardial effusion.

Abdomen:
The liver is homogeneously enhanced, no focal lesion or laceration. No perihepatic fluid.
Portal vein is patent.
No biliary ductal dilatation.
The GB, spleen, pancreas and both adrenals are normal.
Both kidneys are homogeneously enhanced, no focal lesion. No perisplenic fluid.
The aorta, IVC, SMA and SMV are well opacified, no contrast extravasation to suggest active bleed.
No bowel related mass, no bowel thickening, no pneumoperitoneum.
Bladder is underfilled, no contrast leak in the delayed images.
No free fluid within the abdomen and pelvis.

Bones:
- Fracture of the right 10th to the 12ribs posteriorly.
- Fracture of the left 3rd, 6th and 7th ribs posteriorly
- Fracture midshaft left clavicle
- Comminuted fracture of the bilateral scapula
- T1 till T3 spinous process fracture
- T4 till T6 spinous process and left transverse process fractures.
- T7 spinous process fracture

Findings:
1. Multiple bilateral rib fractures with bilateral pneumothorax and bilateral lung contusion.
2. Multiple fractures as detailed.
3. No evidence of solid organ injury US Abdomen (28/4/2017)
 CT BRAIN AND CERVICAL DATED 29/1/2018

Findings:

Brain:
No intracranial bleed.
No focal parenchymal lesion.
No midline shift or mass effect.
No hydrocephalus.
Normal grey-white matter differentiation.
Basal cisterns are patent.
The visualized paranasal sinuses and mastoid air cells are clear.
No skull vault fracture.

Cervical:
Loss of normal cervical lordosis.
Mild assymetry of the atlantoaxial distances (R-4.0mm; L-5.0mm) no lateral off set , this due to positional
during scan.However, ligamentous injury cannot be ruled out.
The cervical spine alignment is maintained.
The vertebral body heights are maintained.
No fracture or dislocation of the cervical spine.
The prevertebral soft tissue thickness is normal.

Other fractures:
Midshaft left clavicular fracture
Left 3rd rib posteriorly

Dense consolidation at the bilateral lung apices.

Impression:
1. No intracranial bleed or skull fracture.
2. No evidence of cervical spine fracture or dislocation
3. Left 3rd rib fracture with bilateral lung contusion.
4. Left clavicular fracture.
 Discussion

In this case, Mr Z was presented with a history MVA dated 29/1/18 . Polytrauma with intraabdominal
injury should be considered.Radiological findings suggestive of bilateral scapula fracture with left
midshaft clavicle fracture, complicated with BPI secondary to left scapulothoracic dissociation.
Scapular fracture is bone fracture involving body, neck, or spine of scapular. The mechanism of injury
involving high speed/energy of injury, blunt trauma with direct impact/collision. The impact usually
associated with chest trauma due to localization of scapular which located posterior of lung. 75% percent
of scapular fracture associated with high speed car/motorcycle collision. Second mechanism would be an
impact coming posteriorly to shoulder area such as fall from certain height and direst blows to shoulder
area. In rare incidence, during cardiopulmonary resuscitation, scapular fracture may occurred as the chest
is compressed significantly.
Most patient who sustained scapular fracture experiencing pain, and limitation of range of motion of
shoulder joint. There is also swelling, tenderness over shoulder area. One must compared with unaffected
shoulder to detect any deformity.
Scapula Anatomy:
Scapular fracture can be classified according to:

 Coracoid fractures (Direct impact to superior aspect of shoulder)

Type I Fracture occurs proximal to the coracoclavicular ligament

Type II Fracture occurs towards the tip of the coracoid

 Acromial Fractures (Direct downward impact to shoulder)

Type I Nondisplaced or minimally displaced

Type II Displaced but does not compromise the subacromial space
Type III Displaced and compromises the subacromial space

 Glenoid Fractures (Force transmitted from impact at humerus in flexed elbow)

Type Ia Anterior rim fracture

Type Ib Posterior rim fracture
Type II Fracture line through glenoid fossa exiting scapula laterally
Type III Fracture line through glenoid fossa exiting scapula superiorly
Type IV Fracture line through glenoid fossa exiting scapula medially
Type Va Combination of types II and IV
Type Vb Combination of types III and IV
Type Vc Combination of types II, III, and IV
Type VI Severe comminution
  Scapular Neck Fractures (anterior or posterior force applied to shoulder)
o Associated with acromioclavicular joint separation or clavicle fracture
o Also known as floating shoulder

 Scapular body Fractures

The following treatment for scapular fracture divided into non operative and operative intervention.
For non operative, arm sling was applied at least for 2 weeks following by early motion through
physiotherapy. Its indicated for majority of scapular fracture where 90% of the fractures are minimally
displaced and acceptably aligned
However we should considered for operative intervention, which primed for open reduction and internal
fixation by implants (screws, plate, et cetera). The indications are follow:

 Glenohumeral instability
o >25% of glenoid involvement with subluxation of humerus
o >5mm of glenoid articular surfaces major gap
o Excessive medialization of glenoid

 Displace neck of scapula fracture

o With 40 degrees of angulation

 Open Fracture

 Loss of rotator cuff function

 Coracoid fracture with >1cm of displacement

The outcomes of surgery exceeding 70% with excellent result combined with good post operative care,
physio-compliant
The critical point in this case is how to make an accurate diagnosis and giving early treatments for these
two infections are radically different and delayed treatment can significantly increase morbidity and
mortality.
For this patient, we’re proceeded with right scapular plating and left clavicle plating.
 Operation
Operation done by Mr Azlan, assisted by Dr Thow and me, Dr Elias. Total duration of operation is 3hours
with no complication throughout operation.
The finding as follow:
Comminuted fracture body of scapula
Surrounding muscle contused
Soft callus seen
No sign of infection

Comminuted fracture midshaft left clavicle

Surrounding tissue contused
Estimated blood loss: 300mls
Procedure description:
Patient under general anaesthesia
Put on prone position
area of interest was washed with povidone and draped.
incision made over medial border of scapula region extending to lateral over spine of scapula
tissue dissect layer by layer (detached from medial border of scapula)
Fracture site exposed
Fraacture site reduced under image intensifier guidance
Lateral and medial plate applied under image intensifier guidance
Wound washed with copious amount of normal saline and hydrogen peroxide
Drain inserted
Deep fascia and muscles layers sutured with Vircyl 1
subcutaneous layer sutured with vircyl 2/0
skin sutured with dafilon 2/0
Wound dressed with gauze and primapore

Patient was laid on beach chair position

area over the left clavicle washed with povidone and draped
Incision made over anterior clavicle
Tissue dissect layer by layer
Supraclavicular nerve identified and preserved
Fracture site exposed
Fracture reduced under image intensifier guidance
Plate applied and screws inserted under image intensifier guidance
Wound washed with copious amount of normal saline and hydrogen peroxide
Deep fascia and muscles sutured with Vircyl 1
Subcutaneous layer sutured with Vircyrl 2/0
Skin suture with Dafilon 3/0
Wound dressed with gauze, primapore
 Figure 1
Patient under general anaesthesia. Patient positioned in prone position
 Figure 2
Area of interest cleaned and draped
 Figure 3

Incision made over medial border of scapula region extending to lateral over spine of scapula
 Figure 4
tissue dissect layer by layer (detached from medial border of scapula)
Figure 4.1
 Figure 5
Fracture site exposed
 Figure 6
Fracture site reduced under Image intensifier
 Figure 7
Kirshner wire inserted at lateral and medial border of scapula
 Figure 8
Medial Plate inserted, checked under image intensifier
 Figure 9
Lateral plate inserted and checked under image intensifier
 Figure 10
Medial and lateral plate checked under Image Intensifier
 Figure 11
Deep fascia and muscles layers sutured with Vircyl 1
subcutaneous layer sutured with vircyl 2/0
 Figure 12
skin sutured with dafilon 2/0
Wound dressed with gauze and primapore
 Conclusion

Scapular fracture is a non threatening condition which can be treated conservatively or operatively. It is
important for clinician and surgeon to determine method of treatment as operative scapular fracture will
develop various complication if treated conservative i.e subacromial impringement, abductor weakness, et
cetera. Post operative care is crucial in rehabilitation for restoring normal function of shoulder joint
movement. The suspicion of scapular fracture should be raised if patient has a history of chest trauma.
The scapular fracture should be ruled out should patient came with complain of limited movement of
shoulder joint.
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Internet references
1. Orthobullet
2. Emedicine
3. AAOS
4. Medscape