Review Article

Management of Scapular
Fractures

Abstract
Peter A. Cole, MD With the exception of displaced articular glenoid fractures,
Erich M. Gauger, MD management of scapular fractures has largely consisted of benign
neglect, with an emphasis on motion as allowed by the patient’s
Lisa K. Schroder, BS, MBA
pain. Better understanding of this injury has resulted in greater
acceptance of surgical management of highly displaced variants.
However, little agreement exists on indications for surgery, and
there is no clear comparative evidence on outcomes for surgically
versus nonsurgically managed fractures. Scapular fractures are the
result of high-energy mechanisms of injury, and they often occur in
conjunction with other traumatic injuries. In addition to performing
meticulous physical and neurologic examination, the surgeon
should obtain plain radiographs, including AP shoulder, axillary, and
scapular Y views. Three-dimensional CT is used to determine
accurate measurements in surgical candidates. Surgical approach,
technique, and timing are individualized based on fracture type and
other patient-related factors.

From the Department of

Orthopaedic Surgery, University of
Minnesota, Regions Hospital,
St. Paul, MN.
Dr. Cole or an immediate family
member serves as a paid consultant
to Synthes and has received
research or institutional support from
Zimmer, Synthes, DePuy, Smith &
Nephew, Stryker, and Acumed.
Neither of the following authors nor
any immediate family member has
received anything of value from or
owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article: Dr. Gauger and Ms.
Schroder.
J Am Acad Orthop Surg 2012;20:
130-141
http://dx.doi.org/10.5435/
JAAOS-20-03-130
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
W ith regard to documenting
and surgically managing scap-
ula fractures, the French have histor-
ically dominated the field, with im-
portant contributions by Paré, Petit,
Desault, Du Verney, Lenormant, Du-
jarier, Malgaigne, Basset, Dupont,
Judet, and Evrard, among others.1
The first depiction of a scapula frac-
ture was published in 1579 by Am-
broise Paré2 in a description of a bat-
tle injury: “When the fracture
involves the neck of the scapula, the
prognosis is almost always fatal.”
Perhaps the fatality resulted from
what we now know to be commonly
associated injuries such as pneumo-
thorax or head and neck injury.
The first classification of scapula
fractures was developed by Jean-
Louis Petit,3 who divided scapula
fractures into body, neck, and pro-
cess. He further subdivided fracture
of the scapular body into longitudi-
nal, transverse, and oblique.
In 1913, Albin Lambotte4 of Bel-
gium was the first to describe inter-
nal fixation of the scapula. He
included preoperative and postoper-
ative radiographs as documentation.
However, it was Grune5 and Plage-
mann6 who, in 1911, presented the
first radiographic series detailing
fracture characteristics in 13 and 19
cases, respectively. Several docu-
mented cases of surgical manage-
ment of scapula fractures existed by
the early 1900s. In 1916, Hitzrot
and Bolling7 published a history of
treatment in the latter half of the
1800s and reported on eight cases of
their own, which was the largest sur-
gical series to date. The first docu-
mented scapula fracture operation in
the United States was performed by
Longabaugh8 in 1924. In 1938 and
1939, respectively, Reggio9 and Fis-
cher10 were the first and second per-

130 Journal of the American Academy of Orthopaedic Surgeons


sons to document surgical manage-
ment of intra-articular fractures.
Dupont and Evrard11 introduced
the term “pilier” in the context of a
primary strategy to stabilize the criti-
cal fractured lateral scapular border
(ie, pillar) with a plate. The 1950s
and 1960s were characterized largely
by nonsurgical management of scap-
ula fractures as espoused by influen-
tial thought leaders such as Rowe12
and Schnepp et al,13 despite critically
documented larger surgical series by
Decoulx et al14 (26 patients) and
Tondeur15 (38 patients), as well as
Judet,16 who described the well-
known extensile posterior approach
for internal fixation of scapula neck
fractures.
The management of scapular frac-
tures has changed based on greater
understanding of the injury, peri-
scapular anatomy, surgical ap-
proaches, and fracture fixation
strategies.17-25 Additionally, there is
new recognition of dysfunction asso-
ciated with scapula malunion, and
diagnostic strategies have been devel-
oped to better understand fracture
morphology and deformity.21,22,26-29
Although there is increased recog-
nition that certain scapular fractures
warrant fixation, controversy exists
regarding surgical indications. This
controversy stems from the recogni-
tion that most extra-articular scapu-
lar fractures heal with nonsurgical
management, with little measurable
dysfunction, in part because most are
moderately displaced, at most, and
because the shoulder has a great ca-
pacity for compensatory motion. Ad-
ditionally, there are no clear
evidence-based guidelines for surgi-
cal indications, and the decision
when to operate must be based on
expert opinion. Only recently have
accepted definitions of displacement
with validated criteria for measuring
deformity become available in the lit-
erature.29
March 2012, Vol 20, No 3
Patient Evaluation
Scapular fracture is a rare injury.
However, these high-energy injuries
are being seen more often likely be-
cause of improved emergency re-
sponse and trauma resuscitation.
Two recent reports on the subject
found the mean age of patients with
scapular fractures to be 42 years30
and 35 years.31
Scapular fracture occurs in the set-
ting of high-energy trauma, and pa-
tients must be carefully examined for
other injuries. In most cases, the vec-
tor of energy is directed from lateral
to medial, often from a position
cephalad to the plane of the shoul-
der.30 This mechanism of injury is as-
sociated with high rates of injury, in-
cluding concomitant injury in
approximately 90% of patients,30,31
ipsilateral extremity injury in 50%,31
thoracic injury in 80%,17 and associ-
ated head injuries and spinal frac-
tures in 48% and 26%, respec-
tively.31 A retrospective review of the
National Trauma Database found
scapula fractures to be an important
marker for ipsilateral upper extrem-
ity injuries, pelvic ring injuries, and
thoracic injuries even after adjusting
for injury severity.32 It has been spec-
ulated that although there is a high
injury association rate between tho-
racic injury and scapula fracture,
the energy of trauma is absorbed
through the thorax, where often
multiple rib fractures occur, which
may explain why associated mortal-
ity is approximately 10% lower in
multiply injured patients with scapu-
lar fracture than in patients with
similar injury severity but without
scapular fractures.17
The rate of thoracic injury and the
severity of injury may also under-
score the reason for missed or de-
layed diagnosis of scapula fractures,
which was noted to be 12.5% in one
study.33 Because life-threatening inju-
Peter A. Cole, MD, et al
Figure 1
Initial AP shoulder radiograph of a
patient who was injured in a
motorcycle collision. Multiple rib
fractures resulted in a caved-in
appearance of the chest. The
complex fracture pattern consists of
a superior glenoid fracture
extending through the coracoid
base, with involvement of the
scapular body and glenoid neck.
The glenoid neck fracture and
diaphyseal clavicle fracture
constitute a double disruption of
the superior shoulder suspensory
complex (ie, floating shoulder).
ries are typically prioritized over up-
per extremity fractures and because
the scapula is enveloped in an abun-
dant soft-tissue envelope, scapular
fractures are often detected late, typi-
cally after the patient has been extu-
bated and can respond to a tertiary
injury survey. The examiner should
specifically look for scapular frac-
tures in the setting of hemopneumo-
thorax and multiple rib fractures
(Figure 1).
Identifying the mechanism of in-
jury is helpful in determining other
possible injuries. The examiner also
should document pain in the pa-
tient’s neck or back as well as numb-
ness and tingling in the upper ex-
tremity. Cervical spine injuries and
brachial plexus lesions occur in 7%
of patients with scapular fracture,
and these injuries can greatly influ-
ence overall outcome.34 The physical
131
Management of Scapular Fractures
Figure 2
Clinical photograph of a patient
prior to open reduction and internal
fixation of a scapular and clavicular
fracture that had occurred 46 days
prior. In part, surgery was delayed
to allow healing of severe skin
abrasions over the anterolateral
shoulder (arrow).
examination should include a de-
tailed neurologic examination of the
ipsilateral upper extremity, and sym-
metricity of pulses should be as-
sessed. The patient should be dis-
robed for skin inspection because
severe abrasions are common, most
frequently over the acromion (Figure
2). The presence of severe abrasions
influences the timing of surgery. To
mitigate the risk of infection, shoul-
ders with abrasions or scabs should
be cleansed daily until they have
completely reepithelialized. This pro-
cess may take a few weeks. Herrera
et al35 reported excellent outcomes in
badly displaced scapula fractures
even when surgery was not per-
formed until ≥3 weeks after injury.
A standard chest radiograph
should be obtained to evaluate for
pneumothorax, and a trauma lateral
cervical spine radiograph should be
obtained to assess the patient for as-
sociated spinal fractures. Addition-
ally, the radiographic workup should
include AP shoulder, axillary, and
scapula Y views. If marked displace-
ment has occurred, such that there is
a possibility of meeting surgical indi-
cations, a three-dimensional (3D) CT
scan should be obtained.27 The 3D
CT can be rotated to the optimal AP
plane and to the lateral plane (ie,
scapula Y) for more accurate mea-
132
Figure 3
Three-dimensional CT scans of the scapula. A, AP view demonstrating the
fracture line extending from the inferior glenoid neck to the medial border
immediately caudal to the acromial spine. This view is important in
determining fracture characteristics, including medial and lateral
displacement and the glenopolar angle. B, The scapular Y view is helpful in
determining anterior-posterior displacement and angulation.
surement of displacement and angu-
lar deformity (Figure 3). Management
Prior to the use of 3D CT, it was
Many authors have suggested surgi-
difficult to comprehend the common
cal criteria for scapula fractures
variations of scapula fracture pat-
based on personal experience and
terns and specific fragment defor-
case series outcomes.36-39 Commonly
mity. Armitage et al27 evaluated 90
used terms to describe the radio-
3D CT scans of fractured scapulae
graphic characteristics of scapula
with neck and/or body involvement
fractures include displacement, medi-
and reported that, in more than two
alization, angulation, and shortening
thirds of patients, the fracture line
(Figure 4). Only recently have explic-
entered or exited just inferior to the
itly defined and validated measures
glenoid and through the vertebral of these fracture characteristics been
border just caudad to the base of the published.29 Historically, these mea-
acromial spine. Seventeen percent of sures were seldom clearly reported.
fractures had articular involvement, Historical recommendations, such
and 22% entered the spinoglenoid as those of Hardegger et al,36 Ada
notch. The articular fractures in this and Miller,37 Nordqvist and Peters-
study did not follow predictable pat- son,38 and Romero et al,39 inform the
terns. Instead, they demonstrated the surgical indications cited in the re-
highest variability in trajectory, with cent literature. These authors based
a wide distribution of exit points their surgical recommendations on
along the vertebral border. findings that indicated a significant
Journal of the American Academy of Orthopaedic Surgeons
 Peter A. Cole, MD, et al

Figure 4

Use of three-dimensional CT to measure scapular fracture characteristics. A, In the AP scapula view, the glenopolar
angle (Θ) is the angle created at the intersection of a line drawn from the inferior glenoid fossa to the superior apex of
the glenoid fossa and a line drawn from the superior apex of the glenoid fossa to the inferior angle of the scapula.
B, In the scapular Y view, angulation (Θ) is measured by drawing a line parallel to the proximal fragment and a line
parallel to the distal fragment. C, AP scapula view illustrating the components used to measure medial and/or lateral
displacement. 1 = lateral-most point of the distal fragment, 2 = lateral-most point of the proximal fragment, 3 = medial-
most point on the scapula at the level of the fracture, line A = medial/lateral displacement, line B = width of the scapula
at the level of the fracture

relationship between persistent
shoulder disability and residual ra-
diographic deformity (ie, significant
displacement and glenoid neck mal-
alignment). Patients with the most
severe injuries were most likely to
have outcomes such as residual pain
and functional complaints following
nonsurgical treatment.37
Contemporary series with defined
surgical indications are listed in Ta-
ble 1.22,34,35,37,40-51 Four studies report
the use of radiologic criteria to mea-
sure displacement and angulation to
guide surgical management of iso-
lated extra-articular fractures as
well as combined injury of the supe-
rior shoulder suspensory complex
(SSSC).22,35,37,40 In contrast, most
studies report surgical indications
only as “unstable” or “displaced.”
Goss52 coined the term “superior
shoulder suspensory complex” to de-
scribe the osseoligamentous ring
made up of the glenoid, coracoid,
clavicle, and acromion process, as
well as the connecting soft tissues
between these structures, the coraco-
clavicular ligament, and the acro-
mioclavicular joint capsule. Accord-
ing to Goss,52 the interruption of two
structures in this ring constitutes a
“double disruption,” resulting in an
interruption in the suspension be-
tween the axial and appendicular
skeleton.
The most explicit recent surgical
indications include medial displace-
ment of the lateral border >25 mm,
shortening >25 mm, angular de-
formity >45°, concomitant intra-
articular step-off >3 mm, or dis-
placed double disruption of the
SSSC.22 Indications for surgery are
based on type of scapula fracture (ie,
intra-articular, extra-articular, dou-
ble lesions of the SSSC process). Al-
though 3D CT has recently been ad-
vocated to identify displacement,
angulation, and fracture pattern,
techniques for capturing these data
points have only recently been de-
fined.21,22,29,35
With the exception of unstable and
displaced glenoid fossa fractures, all
surgical indications should be con-
sidered relative given the lack of de-
finitive proof regarding the benefits
of surgery. Management must be in-
dividualized for each patient (Figures
5 and 6).
Nonsurgical
The minimally or moderately dis-
placed scapular fracture that does
not meet surgical criteria should be
managed with a sling for 2 to 3
weeks until the fracture begins to
consolidate and the pain subsides.
Patients often experience pseudopa-
ralysis during healing and report that

March 2012, Vol 20, No 3 133

Management of Scapular Fractures

Table 1
Surgical Indications for Three Types of Scapular Fracture
No. of
Fracture Type Study Patients Explicit Surgical Indications

Extra-articular Ada and Miller37 8 Medial displacement >1 cm or angular deformity >40°
Khallaf et al40 14 Medial displacement >1 cm, angular deformity >40°
Herrera et al35 22 Medial displacement >15 mm, angular deformity >25°, articular
step-off >4 mm, or double lesion of the SSSC
Jones et al22 37 Medial displacement >25 mm, shortening >25 mm, angular de-
formity >45°, articular step-off >3 mm, or double lesion of the
SSSC
Double lesions of the SSSC Leung and Lam41 15 Unstable shoulder girdle
Rikli et al42 12 Unstable shoulder girdle
Egol et al43 7 Displaced double lesion of the SSSC
van Noort et al44 4 Significant clavicular displacement and a displaced scapular
neck
Oh et al45 10 Unstable shoulder girdle
Hashiguchi and Ito46 5 Unstable shoulder girdle
Labler et al47 17 Displaced neck fracture >25 mm and/or reduction of glenopolar
angle <30°
Intra-articular Kavanagh et al48 10 Displacement >2 mm
Leung et al49 14 Displaced fracture of the glenoid
Mayo et al34 27 Displacement >5 mm or displacement associated with sublux-
ation
Adam50 10 Displaced fracture of the glenoid
Schandelmaier 22 Displaced fracture of the glenoid
et al51

SSSC = superior shoulder suspensory complex

their injured shoulders do not work
or that they have no control over
them.
Progressive deformity of the scapu-
lar fracture during the early postin-
jury phase is a concern,53 and serial
radiographs should be obtained on a
weekly basis for up to 3 weeks. Such
deformity likely is the result of the
combination of fracture instability
and gravitational stress when pa-
tients are upright and mobile. Some
patients may require surgery to re-
pair displacement and/or angular de-
formity.53 It seems likely that frac-
tures more at risk for progressive
displacement in the early postinjury
phase are those with instability, such
as scapular fractures associated with
multiple consecutive rib fractures,
which thus do not have the underly-
ing support of the thorax, or scapu-
lar fractures associated with double
lesions of the SSSC.
In the absence of fracture displace-
ment, subsiding pain corresponds
with clinical healing. Once pain has
subsided, progressive, full, passive
range of motion is allowed. A physi-
cal therapist should demonstrate
techniques with pulleys, partners,
and/or opposite handheld guide
sticks. At 1 month after injury, full
active range of motion can be initi-
ated for the next 4 weeks (through
postinjury week 8). This is followed
by a progressive strengthening pro-
gram, starting with 3-lb weights and
resistive bands, with the goal of no
restrictions at 3 months after injury.
Endurance training is begun, empha-
sizing rotator cuff strength to avoid
long-term weakness in external rota-
tion, forward elevation, abduction,
and internal rotation.
Surgical
Isolated Process Fracture
Little has been published on frac-
tures of the scapula processes (ie,
acromion, coracoid). Prior to rela-
tively recent surgical series by
Ogawa and Naniwa54 (acromion),
Ogawa et al55 (coracoid), and Ana-
vian et al56 (acromion and coracoid),
only small case reports could be
found. In his own practice, the senior
author (P.A.C.) has established the
following surgical indications for
scapular process fractures: painful
nonunion, concomitant ipsilateral
operative scapula fracture requiring

134 Journal of the American Academy of Orthopaedic Surgeons

 Peter A. Cole, MD, et al

Figure 5

Algorithm for diagnosis and management of scapula fracture. Relative surgical indications are listed, as well.
3D = three-dimensional, ORIF = open reduction and internal fixation
a
Surgical indication reduced to 10 mm for double disruptions and to 15 mm when combined with 30° angulation in the
practice of the senior author (P.A.C.).
b
Surgical indications reduced to ≥30° in the presence of 15 mm of medialization in the practice of the senior author.

surgery, displacement ≥1 cm as seen
radiographically, or two or more dis-
ruptions of the SSSC.56
Anavian et al56 reported on 13 ac-
romion fractures and 14 coracoid
fractures managed with open reduc-
tion and internal fixation (ORIF)
using 2.7- or 3.5-mm compression
screws with and without bone plates.
Fracture locations were analyzed on
3D CT scans, and the authors rec-
ommended the use of 3D CT to as-
sess fracture characteristics and es-
tablish whether surgical criteria have
been met. At a mean follow-up of 11
months (range, 2 to 42 months), all
fractures had united, and all patients
recovered full motion with no pain.
Three patients underwent hardware
removal because of prominence and
irritation.
Two separate retrospective studies
reported on 35 coracoid fractures
managed with bone screws55 and 8
acromion fractures managed with
Kirschner wires or tension band wir-
ing.54 All fractures united. In a sys-
tematic review of surgically managed
scapula fractures, Lantry et al57 de-
scribed as apophyseal 20 fractures
(8.2%), including acromial, coracoid
and/or scapular spine fractures, of
the 243 cases studied. These apophy-
seal fractures were surgically man-
aged in 13 cases, with screws alone
in 5 (38.5%), plates and screws in 4
(30.8%), tension band wiring in 2
(15.4%), and Kirschner wires in 2
(15.4%).
Painful nonunion of the acromion
and the coracoid has been reported.
Impingement syndrome (in acromion
fracture) and neurologic compres-
sion (in coracoid fracture) have been
reported, as well. However, we rec-
ommend surgery for displaced frac-
tures (Figure 7).
Intra-articular Glenoid Fracture
Management of intra-articular gle-
noid fractures (Figure 8) is less con-
troversial than that of extra-articular
fractures. However, few authors
have reported explicit, measurable

March 2012, Vol 20, No 3 135

Management of Scapular Fractures

Figure 6

CT scans and plain radiographs demonstrating relative surgical indications and measurement techniques and those of
the senior author (P.A.C.) for scapular fracture. Scapular Y three-dimensional (3D) CT scan (A) and two-dimensional
axial CT scan (B) demonstrating measurement of intra-articular gap/step-off (surgical indications: relative, ≥3–10 mm
and 20%–30% glenoid involvement; senior author, ≥4 mm and 25% glenoid involvement). PA 3D CT scan (C) and
Grashey radiograph (D) demonstrating measurement of medialization (surgical indications: relative, ≥10–20 mm; senior
author, 20 mm). In the practice of the senior author, the surgical indication is reduced to 10 mm for double disruptions
and to 15 mm when combined with 30° angulation. PA 3D CT scan (E) and Grashey radiograph (F) demonstrating
measurement of the glenopolar angle (surgical indications: relative, ≤20°–22°; senior author, <22°). Scapular Y 3D CT
scan (G) and scapular Y (lateral) radiograph (H) demonstrating measurement of angulation (surgical indications:
relative, ≥30°–45°; senior author, >45°). In the practice of the senior author, the surgical indication is reduced to ≥30°
in the presence of 15 mm of medialization. Line A = displacement of the proximal fragment relative to the distal
fragment at the lateral border, line B = full width of the scapula at the level of the fracture

surgical indications (Table 1). Ka-
vanagh et al48 reported the outcomes
following surgical management of
intra-articular fractures displaced >2
mm. Later, Mayo et al34 reported
follow-up on 27 patients from a se-
ries of 31 surgically treated patients
in which displacement of the articu-
lar fragments was defined as being
>5 mm. Currently, there are no
agreed-on surgical indications for
intra-articular glenoid fractures.
Reports regarding long-term out-
comes following surgical and non-
surgical management are limited,
and they typically consist of level IV
evidence and use subjective sur-
geon outcome assessment. Kavanagh
et al48 reported on nine patients
treated surgically for intra-articular
fractures with displacement >2 mm.
All patients were pain free, and seven
regained normal strength. Mayo
et al34 reported good to excellent
outcomes in 22 of 27 patients at an
average follow-up of 43 months
(range, 25 to 75 months). These out-
comes were assessed using a subjec-
tive surgeon rating system that took
into account pain, strength, and mo-
tion. Complications included hard-
ware removal in three patients,
marked infraspinatus weakness in
two, and wound dehiscence in one.
In both studies, poor outcomes were
attributable to associated brachial
plexus injuries.34,48
In the past decade, only two pub-
lished series have reported on out-
comes in patients with intra-articular
glenoid injuries.50,51 Surgical manage-
ment led to good outcomes in these

136 Journal of the American Academy of Orthopaedic Surgeons

 Peter A. Cole, MD, et al

Figure 7 series of 1050 and 2251 patients.

Schandelmaier et al51 reported a
mean shoulder Constant score of
79% (reported as a percentage of the
contralateral uninjured shoulder) at
a mean follow-up of 10 years.

Double Lesions of the Superior

Shoulder Suspensory Complex
Double lesions of the SSSC are re-
ferred to as “floating shoulder” inju-
ries when the double disruption in-
volves a fractured scapular neck and
concomitant ipsilateral clavicular
fracture. Ipsilateral acromioclavicu-
lar dislocation and coracoid fracture
is a less common double disruption
A, Preoperative posterior three-dimensional CT scan of an isolated displaced
fracture at the base of the acromion. The displacement is better appreciated of the SSSC. Although several case
on the superior view of the scapula (inset). B, AP scapula radiograph studies have been published on surgi-
obtained 5 weeks after open reduction and internal fixation demonstrating cal and nonsurgical management of
anatomic alignment that was achieved with a 2.7-mm reconstruction plate these injuries, no study provides
and a small-fragment T-plate.
measurable surgical indications be-
yond the simple presence of the dou-
ble lesion. This is often referred to as
Figure 8 an unstable shoulder girdle (Table 1).
The largest series to report func-
tional outcomes following surgical
management of double lesions of the
SSSC was published in 1993 by
Leung and Lam.41 They performed
ORIF on 15 patients with scapular
and clavicular fractures. At a mean
follow-up of 25 months (range, 14 to
47 months), 14 patients had good to
excellent results according to the
scoring system of Rowe.
Since the publication of that initial
series, disagreement has arisen re-
garding whether to fix both fractures
or only the clavicle fracture, or
whether nonsurgical management is
most appropriate for satisfactory
outcomes. In several studies, only the
clavicle was repaired.42,44,46,58 Nota-
A, Preoperative scapular Y three-dimensional CT reconstructions of an intra- bly, three studies reported scapular
articular glenoid fracture involving the base of the coracoid and extending malunion and drooping in some pa-
into the scapular body (top inset). Bottom inset, Two-dimensional axial CT
scan demonstrating 9 mm of articular step-off. B, Postoperative AP tients, as well as conversion to surgi-
radiograph of a different patient treated surgically to manage intra-articular cal treatment in patients with unsat-
glenoid fracture. A combined anterior/posterior approach was required to isfactory nonsurgical outcomes.44,46,58
address the many fractures. Open reduction and intramedullary fixation with
Other series combined results of
intramedullary implants was performed on ribs six through eight to address
the considerable displacement of the thorax. ORIF of the clavicle only with ORIF
of both clavicular and scapular frac-

March 2012, Vol 20, No 3 137

Management of Scapular Fractures
Figure 9
AP radiographs of a patient who presented with chronic pain, weakness, and
a drooping shoulder 4 months after sustaining a scapular fracture. A, The
uninjured right shoulder. B, View of the injured shoulder demonstrating
significant medial and/or lateral displacement. The dashed lines outline the
articular glenoid surface as well as the lateral scapular border, which is
malunited with severe deformity.
tures, thereby making it difficult to
assess differential outcomes with or
without a concomitant clavicle frac-
ture.43,45,47
Currently, no evidence exists to
suggest that fixation of the clavicle
fracture alone reduces the scapula
and glenohumeral joint. Fixation of
both the clavicular and scapular frac-
tures does restore stability, thereby
allowing for potentially faster reha-
bilitation and a reduction in the
number and magnitude of symptoms
related to malunion. However, fixa-
tion of either or both bones is indi-
cated only when both are signifi-
cantly displaced. There appears to be
no role for surgical fixation of mini-
mally or nondisplaced fractures of
double lesions.
Isolated Extra-articular
Fractures of the Scapular
Neck or Body
Management of isolated fractures of
the scapular neck and body remains
controversial. In most cases, union is
achieved with nonsurgical manage-
ment; the shoulder has tremendous
capability for compensatory motion.
However, whether this compensation
leads to increased dysfunction or
138
symptoms is not well understood.
Few studies stratify outcomes by
degree of displacement or deformity.
However, Bozkurt et al59 demon-
strated a strong positive correlation
between a decreased glenopolar an-
gle (GPA) (Figure 4) and Constant
scores in 18 extra-articular scapula
fractures that were managed nonsur-
gically (P < 0.05). Romero et al39
demonstrated significantly poorer
outcomes in patients who healed
with a GPA <20° (P < 0.05). In a
small study, Kim et al60 demonstrated
statistically significant improvements
in Constant score in patients with a
GPA >30° compared with patients
with a GPA <30° (P < 0.05). Not all
scapular malunions are asymptom-
atic. Not all patients treated nonsur-
gically do well, regardless whether
there are associated brachial plexus
lesions (Figure 9).
In the most rigorous study to date
assessing function in surgically man-
aged extra-articular fractures, Her-
rera et al35 recorded a mean Disabili-
ties of the Arm, Shoulder and Hand
score of 14 at 26-month follow-up,
as well as symmetric motion and
near-complete recovery of strength.
Journal of the American Academy of Orthopaedic Surgeons
Other surgical series report good
outcomes based on less rigorous out-
come assessments.37,40 Additionally,
Jones et al22 reported mean forward
flexion of 158° in 37 patients follow-
ing ORIF to manage medialization
>25 mm or angular deformity of the
scapula measuring 45°.
Surgical Approaches and
Postoperative
Rehabilitation
It is important to choose the correct
operation for the specific fracture
pattern (Figure 10). For example, an
anterior deltopectoral approach
should be used to address glenoid
fossa fractures involving the anterior
and inferior glenoid. In general, it is
best to manage such injuries with
minifragment fixation with 2.0-mm
screws and a plate used in a buttress
mode.61
Wiedemann62 described a lateral
approach through the midaxial re-
gion of the upper thorax just caudal
to the axilla for inferior glenoid frac-
tures. This approach eases the pro-
cess of hardware fixation along the
scapular neck. Another common
fracture pattern is the superior gle-
noid fracture, which extends into the
coracoid process and causes dis-
placement of it. In this scenario, the
deltopectoral approach should be ex-
tended proximally to the clavicle to
allow access to the coracoid and
coracoclavicular ligaments. Typi-
cally, coracoid fractures can be fixed
with 2.7- or 3.5-mm screws; a one-
quarter tubular plate may be needed,
as well, depending where the fracture
extends in relation to the base.56
Fractures involving the neck and
body of the scapula make up ap-
proximately 80% to 90% of surgi-
cal injury patterns.63,64 They are
addressed through a posterior ap-
proach. A straight posterior ap-
proach overlying the glenohumeral
 Peter A. Cole, MD, et al

Figure 10

Algorithm demonstrating surgical approaches to scapular fracture as well as postoperative rehabilitation protocols.
AC = acromioclavicular, AROM = active range of motion, ORIF = open reduction and internal fixation, PROM = passive
range of motion

joint is warranted for fracture dis-
placement that is isolated to the pos-
terior glenoid, scapula neck, and/or
lateral border. However, a Judet inci-
sion should be used if the surgeon
wishes to access multiple scapula
borders, such as the acromial and
vertebral spines, in addition to the
lateral border.16 The Judet incision
courses along the spine of the scap-
ula, beginning at the acromion and
angling down along the vertebral
border as far distal as necessary to
address the fracture pattern. With
the Judet incision, either the infraspi-
natus muscle can be elevated along
with the teres minor off the infraspi-
natus fossa, or intermuscular inter-
vals can be developed to specific
access sites along the scapular perim-
eter where fixation and reduction
can be obtained. Several posterior
approaches have been described for
accessing the posterior glenoid and
the posterior scapular neck and
body.20-22,25,44,61,65 In general, the trend
is toward use of smaller plates (eg,
2.7-mm rather than 3.5-mm) for fix-
ation of the scapular neck and body
through a posterior approach. Lock-
ing plates are advantageous given the
thin bone available for fixation, es-
pecially along the vertebral border.
Locked plates are particularly help-
ful in circumstances in which there is
little per-screw purchase in bone, es-
pecially along the thin vertebral bor-
der.
Postoperative care should proceed

March 2012, Vol 20, No 3 139

Management of Scapular Fractures
as described for nonsurgical manage-
ment, with one exception. If the sur-
geon feels that adequate stability has
been achieved, immediate and full
passive and active-assisted range of
motion should be emphasized. In the
clinical experience of the senior au-
thor (P.A.C.), this rehabilitation pro-
tocol allows for immediate range of
motion. Strengthening and resistance
with 3- to 5-lb weights is begun 5
weeks postoperatively, followed by
strength and endurance training be-
ginning in week 9. At week 13, all
restrictions are lifted, and the patient
may return to normal activities.
Summary
Indications for surgical management
of scapular fractures continue to
change with greater understanding
of symptomatic malunions, im-
proved technology, and higher num-
bers of patients who survive high-
energy trauma with highly displaced
scapular fractures. Surgical indica-
tions for scapular fracture typically
are based on angular deformity and
displacement. In some cases, surgical
indications are based on associated
lesions in the upper extremity. These
indications should be considered to
be relative until comparative func-
tional outcome data emerge to clar-
ify surgical criteria. Indications for
surgery often include such parame-
ters as medialization (≤25 mm), 25°
to 45° angulation on a lateral radio-
graph, GPA <20°, and displaced
double lesions of the SSSC. Three-
dimensional CT has advanced our
understanding of fracture morphol-
ogy and allows accurate measure-
ment of such displacement and angu-
lation.
No rigorous studies have com-
pared surgical and nonsurgical co-
horts, and controversy persists re-
garding which patients are best
managed surgically. Suspected and
140
confirmed scapular fractures warrant
meticulous evaluation and manage-
ment. Orthopaedic surgeons should
proceed to surgery only after careful
practice and preparation.
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