SplintER Series: Attack by Bat
30-year-old male presents to the ED with pain over the right shoulder after being assaulted by a bat. The right arm is held in adduction and has a limited range of motion due to pain. An x-ray of the right shoulder was obtained and is shown above (Figure 1. Case courtesy of Dr. Ian Bickle, Radiopaedia.org, rID: 74640).
Nondisplaced scapular neck and spine fracture (labeled in red in Figure 2).
Figure 2. Case courtesy of Dr. Ian Bickle, Radiopaedia.org, rID: 74640. Annotations by author
The scapula is relatively mobile and surrounded by large muscles that can absorb a significant amount of force. Therefore, in the presence of a scapular fracture, suspect other traumatic injuries such as the following [1,2].
- Upper torso: rib fractures, clavicular fractures, sternal fractures
- Cardiopulmonary: myocardial contusion, aortic dissection, pulmonary contusion, pneumothorax
- Spinal: thoracic spine > cervical spine > lumbar spin
By obtaining a shoulder trauma x-ray series
- True anteroposterior view
- Superior-inferior axillary view – looking inferiorly at the shoulder with the arm abducted (Figure 3)
Figure 3. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 7505. Annotations by author
- Scapular Y view (Image 4)
Image 4. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 48080. Annotations by author
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Pearl: CT can be used to further characterize the fracture if there is a concern for intra-articular extension, significant displacement, or high suspicion for concurrent injuries (Image 5).
Figure 5. Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 28072
This patient can be placed in a sling and follow up with orthopedics and/or sports medicine in 1-2 weeks. Most isolated scapular fractures are minimally displaced and require a sling for 2 weeks, followed by early shoulder mobility.
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Pearl: Indications for operative management include the following [2]
- Open fractures or neurovascular compromise
- Glenoid: displaced intra-articular fracture
- Scapular neck: fracture with significant angulation
- Scapular spine: comminuted fracture
- Acromion: fracture with subacromial space impingement
- Coracoid process: fracture with > 1cm displacement or third-degree acromioclavicular separation
Resources & References:
Consider brushing up on the radiologic approach to the traumatic shoulder and other can’t miss shoulder injuries.
- Cole PA, Freeman G, Dubin JR. Scapula fractures. Curr Rev Musculoskelet Med. 2013;6(1):79-87. PMID: 23341034.
- Egol K, Koval, KJ, Zuckerman JD. Handbook of Fractures. Lippincott Williams & Wilkins. 2010 ISBN: 160547760.
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