Scapular Fractures: Classification, Clinical Picture, Diagnosis, Treatment

The scapula (Latin: scapula) is a flat triangular bone with four major processes (scapular spine, glenoid process, acromion, coracoid process), located in the upper back and forming the posterior part of the shoulder girdle.

The scapula plays a key role in:

• darm movement: contributes to rotation and abduction at the shoulder joint (1/3 of the range of motion is scapulothoracic, 2/3 is scapulohumeral);
• Thestability of the shoulder: is provided by the shoulder joint itself, as well as the scapulothoracic and acromioclavicular joints and the upper shoulder support complex.

Epidemiology

Scapular fractures are rare injuries, accounting for less than 1% of all fractures and 3–5% of shoulder girdle injuries. They are most commonly found in young men (25–50 years old).

Prevalencebyfracture type:

• body of the scapula — the most common type, 50–60% of cases;
• extraarticular glenoid fractures — 20–25%. Often associated with clavicle fractures (“floating shoulder”);
• intraarticular glenoid fractures — 10%;
• acromial process — about 8%;
• coracoid process — 3–5%;
• spine of the scapula — 2–3%.

Due to the high energy impact, scapular fractures are often accompanied by other serious injuries:

• chest injuries (80%) — often include lung contusions (40%) and hemo/pneumothorax (more than 30%);
• fractures of the pectoral girdle bones (50%), including clavicle (25%);
• rib fractures (50%);
• head injuries (35–50%);
• spinal fractures (25–30%);
• pelvic fractures (15%);
• vascular and nerve injuries of the arm (10%).

Etiology

Scapular fractures are almost always the result of high-energy trauma, most often vehicle accidents (80–90%). This is due to the bone being well protected by the surrounding muscles.

Primary mechanisms of injury:

1. Direct trauma: a strong blow directly to the shoulder.
2. Indirect trauma: transfer of force through the arm (e.g., fall on outstretched hand — FOOSH).

Fracture mechanisms for different parts of the scapula:

• body of the scapula: result of direct blow, fall or compression;
• glenoid neck: result of indirect trauma, most commonly a fall on outstretched hand;
• intraarticular glenoid fractures: usually occur during anterior shoulder dislocation (less frequently posterior, for example, due to electrical shock or seizure);
• acromial process: result of direct trauma; stress fractures may also occur in athletes;
• coracoid process: may be caused by direct trauma, sudden muscle contraction, or ligament tension during shoulder dislocation;
• spine of the scapula: result of direct trauma; in rare cases, may be a pathological fracture due to tumor metastasis.

Classification of scapular fractures

Scapular fractures are classified primarily by anatomical location. Additionally, the presence of fragments and the shape of the fracture line are considered in accordance with standard terminology. Below are the most commonly used classifications.

Hardegger classification

This is the simplest and most commonly used classification, based on the localization of the fracture (Hardegger classification).

Anatomical classification of scapular fractures according to Hardegger

3D-models of scapular fractures:

Comminuted fracture of scapular body

Fracture of the neck of the scapular articular process (14F0 according to AO/OTA classification)

Intraarticular glenoid fracture (Type IA according to Ideberg classification)

Fracture of the scapular acromial process (Type II according to Kuhn classification)

Fracture of the scapular coracoid process (Type I according to Ogawa classification; Type II according to Eyres classification)

Classification of glenoid fractures according to Ideberg

For glenoid cavity fractures, the Ideberg classification (1984) includes six types:

• Type I: fracture of the rim of the glenoid cavity:
  • Subtype IA — fracture of the anterior rim (bony Bankart type);
  • Subtype IB — fracture of the posterior rim.
• Type II: transverse fracture across the glenoid cavity extending to the neck of the scapula. In this type of fracture, the shoulder joint is unstable.
• Type III: rare oblique fracture through the upper portion of the cavity extending to the scapular body.
• Type IV: transverse fracture reaching the medial border of the scapula. It results from high-energy impact.
• Type V: combined fracture, representing a combination of several types (II and IV, III and IV, or II, III, and IV), divided into subtypes A, B, C. This fracture is extremely unstable.
• Type VI: severe comminuted damage to the entire articular process.

Classification of acromion fractures according to Kuhn

Fractures of the scapular acromial process are classified according to Kuhn (Kuhn classification). The classification identifies three fracture types, and based on the type, determines the treatment strategy:

• Type I: fracture with minimal displacement, not requiring surgical intervention.
• Type II: displaced fracture without narrowing of the subacromial space. For this type of fracture, both surgical and conservative treatment are possible.
• Type III: displaced fracture with narrowing of the subacromial space. This type of fracture requires surgical treatment.

Classification of coracoid process fractures

There are two main classifications for fractures in this area.

1. Ogawa classification

This classification (Ogawa classification) is based on the relation of the fracture line to the attachment site of the coracoclavicular ligaments:

• Type I: fracture line is located proximal to the attachment site (base fracture).
• Type II: the fracture line runs distal to the attachment of the coracoclavicular ligaments.

Such a division is justified from clinical and functional perspectives. Typically, a Type I fracture is associated with instability of the Superior Shoulder Suspensor Complex (SSSC).

2. Eyres Classification

The classification proposed by Eyres (Eyres’ anatomical classification) includes 5 fracture types:

• Type I: fracture of the tip of the process.
• Type II: fracture of the middle segment of the process.
• Type III: fracture of the base of the process.
• Type IV: fracture involving the upper part of the scapular body.
• Type V: fracture extending into the area of the glenoid cavity of the scapula.

Comprehensive AO/OTA classification

It is a comprehensive and standardized classification of scapular fractures.

Diagnosis of scapular fractures

The diagnosis of scapular fractures relies on clinical assessment and radiological imaging techniques.

Clinical Evaluation

1. History — high-energy trauma or direct blow.
2. Examination — swelling, bruising, abrasions in the scapular area.
3. Palpation — local tenderness or step-off felt beneath the skin.
4. Evaluation of accompanying injuries — check for chest, pelvis, head, and spinal traumas or vascular and nerve injuries.

Radiologic Methods

1. X-ray — standard anteroposterior, lateral (Y-view), and axillary views.
2. Computed tomography (CT) — provides detailed information, particularly for intra-articular or complex fractures, and aids in preoperative planning.

Clinical Manifestations

Typical clinical presentation in scapular fracture:

• Symptoms — acute pain in the shoulder or upper back, swelling, and restricted shoulder mobility.
• Physical findings — visible swelling, tenderness, crepitus (crackling) over the scapula, sometimes deformity.
• Manifestations of concomitant injuries.

Treatment of scapular fractures

Thanks to the scapula’s sturdy structure and its protection by surrounding muscles and the rib cage, many fractures are characterized by minimal displacement and are amenable to conservative treatment. Fractures affecting the glenoid cavity that are significantly displaced and unstable typically require surgical treatment.

Medical therapy

Conservative treatment is indicated in most fractures of the scapular body, spine, acromial and coracoid processes without significant displacement. Intra-articular fractures of the glenoid cavity with less than 2 mm displacement and no shoulder joint instability can also be treated conservatively.

Treatment involves immobilization with a bandage for a period of 2–4 weeks. To prevent the development of adhesive capsulitis, early passive movements are recommended from the second week after injury (controlled by pain). Active movements are permitted no earlier than 4 weeks post-injury. Healing is generally achieved within 6–12 weeks and depends on the severity of the injury.

Surgical Therapy

Surgical treatment is applied in 10–20% of cases. Indications for surgery depend on the fracture location and degree of displacement.

Indications for surgical treatment of scapular fractures based on location

Surgical treatment methodologyfor scapular fracture:

1. Open reduction and internal fixation (ORIF) using plates and screws.
2. Arthroscopic fixation with sutures and screws for small fragments of the glenoid cavity.

Early surgical treatment can improve functional outcomes in appropriately selected patients.

Prognosis for scapular fracture

Scapular fractures generally have a high likelihood of union due to good blood supply and surrounding soft tissues. In the majority of patients, shoulder function is restored in full. In cases of extensive soft tissue injury, pain syndrome may persist for a long time.

Therefore, fractures of the scapular body have an excellent prognosis. A good prognosis is assumed for fractures of the acromial and coracoid processes. Fractures of the glenoid neck are generally prognostically favorable, but improper union can reduce shoulder strength and stability. Intra-articular glenoid fractures have an ambiguous prognosis. The outcome of the fracture may result in post-traumatic osteoarthritis of the glenohumeral joint, joint instability, limitation of movement in the injured joint.

Timely diagnosis, comprehensive treatment of accompanying injuries, and adherence to rehabilitation programs by the patient are the key to achieving optimal results.

Find more scientifically accurate content on our social media

Subscribe and don’t miss out the latest resources

Rehabilitation after scapular fracture

Although the fracture consolidation process is favorable, the restoration of full function of the glenohumeral joint largely depends on a structured and phased rehabilitation program.

Rehabilitation goals:

• restoration of the range of motion in the glenohumeral joint;
• restoration of muscle tone;
• return to work and sports activities.

Principles of structured and sequential rehabilitation:

• initial immobilization for stabilization and fracture healing;
• early mobilization;
• elimination of the consequences of soft tissue injuries;
• progressive load.

Phases of Rehabilitation

The recovery program can be divided into four consecutive stages:

1. pThe first stage (up to 2–3 weeks)— immobilization of the injured limb is indicated. At this time, active movements in unaffected joints (wrist, elbow) are permitted;
2. Theearly mobilization phase (3–6 weeks) — early passive movements in the shoulder joint and isometric (static) exercises for the muscles of the shoulder girdle are indicated;
3. phase of functional recovery (6–12 weeks) — work begins on restoring the full range of active motion. Progressive loading for the muscles using weights and expanders is introduced while avoiding forced movements;
4. Return to full activity (12+ weeks) — involves fully restoring lost endurance and strength through strength training, plyometric exercises, and practicing specific movements for a particular type of activity.

Expected restoration of the full range of motion is projected to be at 3–4 months post-injury. Symmetrical strength compared to the uninjured limb is generally restored by 4–6 months post-injury with completed rehabilitation measures. Return to non-contact sports is permitted after 3–4 months post-injury. Participation in contact sports is allowed no sooner than 6 months.