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© 1997 The Journal of Bone and Joint Surgery, Inc.
Fracture of the Scapula with Intrathoracic Penetration. A Case Report* , COLUMBIA, MISSOURIInvestigation performed at the Orthopaedic Trauma Service, University of Missouri Hospitals and Clinics, Columbia
Fracture of the scapula is a rare injury in adolescents. The most common etiology is a motor-vehicle accident or another type of high-velocity blunt trauma. There is a high prevalence of associated injuries, many of which may be life-threatening. Operative treatment has been recommended only in the case of a displaced fracture of the glenoid neck or step-off within the glenohumeral joint. We report an additional operative indication: a fracture of the body of the scapula with penetration of the thoracic cavity by a fracture fragment. Our search of the literature did not reveal any previous report of this injury.
A thirteen-year-old boy was struck by a dump truck while riding a bicycle. He lost consciousness and was hypotensive at the scene of the accident. A pneumothorax was diagnosed on arrival to the hospital. After endotracheal intubation and placement of a chest tube, the patient was transferred to the University of Missouri Hospitals and Clinics for definitive care. Physical examination revealed bilateral subcutaneous emphysema palpated over the anterior chest wall, multiple abrasions, and contusions about the thorax and the left upper extremity. A large hematoma was noted in the area of the symphysis pubis. Blood was noted at the external meatus. Orthopaedic examination revealed swelling and contusion about the posterior part of the left shoulder with no palpable osseous instability. There was a smooth range of motion, without crepitus, to 90 degrees of abduction. A full passive range of motion of the shoulder was not attempted, but the elbow and the wrist had a full, smooth passive range of motion and the vascular status of the extremity was intact. As the patient had been pharmacologically paralyzed at the referring hospital, a full motor and sensory examination was not initially possible at our institution. The records from the initial examination did not address clearly the neurological findings in the limb. Plain radiographs revealed bilateral hemopneumothorax and pulmonary contusion, multiple bilateral fractures of the ribs, a right non-displaced fracture of the anterior wall of the acetabulum, a disruption of the pelvic ring including the right sacral ala anteriorly and bilateral fracture of the inferior pubic ramus, a nasal fracture, and a fracture of the left scapula (Fig. 1). A radiograph of the chest, which had been made at an outside institution, revealed a fragment of bone projecting over the interspace between the fifth and sixth ribs; this was initially interpreted as a fragment of rib. Penetration of the thorax was not suspected. A retrograde urethrogram showed a urethral disruption. Computerized axial tomography of the abdomen and chest revealed a splenic laceration and thoracic penetration by the fractured left scapula. A computerized axial tomographic scan of the head revealed no intracranial lesions necessitating operative treatment. A three-dimensional computerized axial tomographic reconstruction of the left shoulder showed a fracture fragment impaled into the left lung (Fig. 2).
After evaluation, the patient was taken to the pediatric intensive-care unit, where he needed jet ventilation to maintain oxygenation. Upward-gaze paralysis developed as a result of the head injury, and a mild coagulopathy was also noted. Because of concerns about the severe pulmonary injury, the uncertainty regarding the neurological status, the coagulopathy, and the need to observe the splenic laceration, the pediatric trauma team delayed the open reduction until the condition of the patient had stabilized, on the fifth day in the hospital. The patient received three units of packed red blood cells and two units of fresh-frozen plasma before the operation. An open reduction of the scapular fracture was performed through a posterior approach. With the patient in the lateral decubitus position, an incision was made parallel to the lateral border of the scapula, midway between the lateral border and the posterior processes of the spine. A portion of the origin of the deltoid muscle was released from the spine of the scapula, and the interval between the teres major and the infraspinatus was developed, reflecting the infraspinatus superiorly and medially off the lateral border of the scapula. The scapular fracture fragment was hinged on the inferior portion of the lateral border, which was twisted but not broken. The lateral border was stuck between the ribs and was manually extracted with some difficulty. The lung was not seen. The intercostal muscles were repaired with sutures. Cancellous interdigitation of the fractured edge of the scapula with the main part of the scapular body was obtained, and internal fixation was not necessary (Fig. 3).
Postoperative management consisted of use of a simple sling and early motion. The recovery was unremarkable, and the patient was instructed to resume full activity at the two-month follow-up visit. At the most recent follow-up examination, five months after the injury, the patient reported no pain or functional limitation of the shoulder. Radiographs revealed a healed scapular fracture. Physical examination revealed a full, painless range of motion and grade-5 (of 5) motor strength in all planes, symmetrical with the contralateral extremity. The pulmonary and head injuries had healed without sequelae.
Fracture of the scapula was apparently originally described by Desault in 180510. It is an uncommon injury in adults and even more rare in children and adolescents2. In a review of more than 1600 shoulder girdle injuries, Rowe found that only 3 per cent involved a fracture of the scapula. The few series of patients with scapular fracture reported in the literature consisted primarily of adults1,5,6,8-10. McGahan et al. reported that one of 121 scapular fractures was in a three-year-old child. The youngest patient, to our knowledge, in any other series was fifteen years old (mean age, thirty-five years old)1,5,6,8-10. Because the scapula is protected by the surrounding muscles and chest wall, high-energy trauma is required to cause fracture2. An accident involving the driver or passenger of an automobile is the most common mechanism of injury, followed by motorcycle accidents, falls, and accidents involving an automobile and a pedestrian. Scapular fractures are frequently overlooked on the initial examination of a patient who has sustained multiple injuries. In a review of 100 consecutive scapular fractures, only fifty-seven were identified on the initial radiographs of the chest3. More than half (thirty-one of fifty-eight9, thirty of fifty-two10 and thirty-five of sixty-four1) of these fractures occur in the scapular body. Fracture of the scapula is rarely an isolated event and occurs most commonly in a patient who has sustained multiple injuries. The prevalence of associated injuries with scapular fractures has been reported to be as high as 98 per cent (fifty-seven of fifty-eight)9. Because of the high energy level involved, these injuries are frequently multiple and may be life-threatening. Fracture of the ipsilateral ribs with resulting hemopneumothorax is the most common associated injury, with a prevalence ranging from 27 per cent (fourteen of fifty-two)4 to 54 per cent (thirty of fifty-six)9. Other frequently reported injuries include clavicular fractures, with a prevalence ranging from 17 per cent (seven of forty-one)10 to 38 per cent (twenty-four of sixty-four)1; closed head injuries, with a prevalence ranging from 11 per cent (seven of sixty-four)1 to 57 per cent (thirty-two of fifty-six)9; injuries of the face and skull, with a prevalence ranging from 10 per cent (six of sixty-two)1 to 24 per cent (thirty-three of 137)5; and disruptions of the brachial plexus, with a prevalence ranging from 3 per cent (one of forty)10 to 8 per cent (four of fifty-two)4. Concomitant fracture of the first rib is highly associated with injury of the brachial plexus or the subclavian vessels, or both. This triad of injury has a poor prognosis. The mortality rate ranges from 2 per cent (two of 121)5 to 14 per cent (eight of fifty-six)9, mostly because of the severity of the concomitant injuries. Pneumothorax associated with fracture of the scapula was reported in sixteen of thirty patients followed by McLennan and Ungersma. A delayed pneumothorax developed, one to three days after injury, in ten of those patients and all required tube thoracostomy. None had actual penetration of the thoracic cavity by fracture fragments. Those authors noted a higher prevalence of pneumothorax in association with fractures of the left scapular body, which they postulated to be due to the decreased mobility of the parietal pleura on that side. They recommended daily radiographs of the chest for three days after a fracture of the left scapula. Intrathoracic dislocation of the inferior angle of the scapula was reported in 1972 by Nettrour et al. This injury was not associated with a fracture, and the authors postulated that this dislocation would not have occurred if a fracture of the scapula had been present. In our review of the literature, we found no reports of fracture of the scapula complicated by intrathoracic penetration. At the time of the operation in our patient, the fracture fragment was found to be hinged inferiorly on a flexible segment of the lateral border. This fragment was wedged between two ribs, and the elastic nature of the greenstick fragment made it somewhat difficult to extract it from the thoracic cavity. Once extracted, the hinge of bone was plastically deformed but it could be bent back to the original shape and fit securely with the body fragment. It is unlikely that this injury could occur in the more brittle adult scapula. The operative extraction of the scapular fracture fragment from the chest cavity was delayed for five days, despite the fact that thoracic penetration was noted on the computerized axial tomographic image of the chest made after admission. The delay was mandated by the pediatric trauma team because of the severity of the pulmonary injury, the uncertainty regarding the neurological status, the development of a coagulopathy, and the need to observe a splenic laceration. Ideally, intrathoracic fragments of bone should be removed as soon as possible to allow recovery of the lung.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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