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Delayed Union of a Scapular Fracture-An Unusual Cause of Persistent Shoulder Pain

CURTIS, CHRISTINE2; SHARMA, VIVEK3; MICHELI, LYLE1,2

Medicine & Science in Sports & Exercise: December 2007 - Volume 39 - Issue 12 - p 2095-2098
doi: 10.1249/mss.0b013e318156e8ec
CLINICAL SCIENCES: Clinical Case Studies
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Introduction: Scapular fractures in athletes are rare, although they have been reported in football and baseball players. Most scapular fractures heal with nonoperative management; delayed union is rarely a problem.

Case Summary: A 15-yr-old male fell onto his posterior shoulder after he had been pushed into the boards and then fell to the ice during a hockey check. He was diagnosed with a rotator cuff injury at an outside facility. Initial radiographs were negative. The patient was not immobilized, and he continued to play hockey despite intermittent pain. Seven months later, he presented to our sports medicine clinic, complaining of an aching pain at the base of his left shoulder. Examination revealed point tenderness along the base of the scapula, restriction of shoulder abduction, rhomboid weakness, scapular winging, and anterior impingement-type shoulder pain. A new radiograph, obtained at our sports medicine clinic, was nondiagnostic. Magnetic resonance imaging revealed increased signal on T2, with bone edema at the lateral margin of the scapular neck. A computed tomography scan revealed an unhealed, left-transverse, subglenoid scapular fracture. The fracture was nondisplaced. The patient was treated with transcutaneous electrical stimulation for 6 months and a physical therapy regimen focusing on periscapular strengthening. A final computed tomography scan, 6 months after initial presentation to our clinic, revealed healing of the fracture. Examination was normal. The patient was asymptomatic and was able to fully return to sports without any complications.

Conclusions: Although scapular fractures in athletes are rare, they may occur, particularly in "contact sports" that share the energies of injury seen in high-speed motor vehicle collisions. Early identification and proper management are integral to decrease symptoms and to avoid protracted disability, particularly in athletes.

1Harvard Medical School, Boston, MA; 2Children's Hospital Boston, Department of Orthopaedics, Division of Sports Medicine, Boston, MA; and 3Cincinnati Children's Hospital Medical Center, Department of Orthopaedics, Cincinnati, OH

Address for correspondence: Lyle Micheli, M.D., F.A.C.S.M., 319 Longwood Avenue, 2nd Floor, Department of Orthopaedics, Division of Sports Medicine, Children's Hospital Boston, Boston, MA 02115; E-mail: michelilyle@aol.com.

Submitted for publication June 2007

Accepted for publication July 2007.

Scapular fractures are rare, representing fewer than 1% of all skeletal injuries and 5% of shoulder fractures (8). This may be partly because the unique anatomy of the scapula protects it from severe injury. In addition, the mobility of the scapula provides considerable dissipation of traumatic forces. Scapular fractures usually result from macro trauma to the upper shoulder or scapular region. Such injuries are most commonly reported in high-speed vehicular accidents (2). In the general population, 80-95% of patients with scapular fractures have coexisting injuries; many involve major organ systems and may be life threatening (7). Because of the accompanying severity of these injuries, scapular fractures are often diagnosed late or overlooked. The incidence of scapular fractures is even rarer in athletes, though they have been reported in both football and baseball players (4,5,7,8,12,15).

Most scapular fractures heal with nonoperative management; therefore, surgery is rarely indicated. A rich blood supply to the scapula aids in fracture healing. Therefore, union of scapular fractures is rarely a problem. In a series of 148 fractures in 116 scapulae in 113 patients, only one fracture failed to unite (1). Delayed unions or nonunions may result from a myriad of factors, including inadequate immobilization, health status, age, and anatomic location of the fracture.

In some athletes, repetitive stresses from athletic activity may result in overuse lesions of the scapula and alter the natural course of fracture healing (12). We report a scapular fracture of the lateral neck in a healthy, 15-yr-old male hockey player who presented to our sports medicine clinic. This is a rare case of an athlete with 7 months of delayed union of an extraarticular scapular fracture.

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CASE REPORT

A 15-yr-old male fell onto his posterior shoulder after he was pushed into the boards during a hockey check. The first impact was when the patient hit the glass, and the second impact occurred when he fell on the ice. Throughout the injury, the patient's arm was adducted and next to his chest. There were no associated symptoms such as respiratory distress or numbness of the upper extremity after his injury. Informed consent to use clinical data was obtained from the patient.

Past medical history was negative for tobacco use and significant for cold-induced asthma. He denied symptoms of asthma for the past year. Past medical history was negative for delayed healing of fractures and metabolic bone disorders. Two months after his injury, the patient suffered a Tillaux fracture. He was also diagnosed with a right-mallet injury 8 months after initial presentation to our sports medicine clinic. Family history was negative for metabolic bone disorders and significant for cold-induced asthma.

The patient was able to play hockey after his injury, but he began having activity-related pain in his left shoulder. The pain was intermittent and worsened with hockey activities. He sought care at an outside facility, where he was diagnosed with a rotator cuff injury. Initial radiographs were negative. The patient was not immobilized and continued to play hockey. Shoulder-strengthening exercises were prescribed, but his symptoms neither improved nor worsened with strengthening exercises.

Seven months later, the patient presented to our clinic, complaining of an aching pain at the lateral border close to the posterior aspect of the shoulder joint. He denied all other trauma. A visual analog scale of 4 of 10 at rest was given. Pain was described as deep, dull, aching, and more localized than when the patient had presented to an outside institution 7 months earlier. Examination revealed point tenderness posteriorly along the upper part of the lateral border of the scapula immediately inferior and adjacent to the glenohumeral joint. The patient was neurovascularly intact, and sensory examination was normal. Shoulder abduction beyond 90° was restricted. On active motion, there was restriction of abduction beyond 90° because of muscle weakness. The periscapular muscles were weak on examination. There was pain with terminal abduction; however, there were no indications of impingement. Weakness of the rhomboids (assessed by adducting and medially rotating the scapula while in a sitting position), scapular winging, and anterior impingement-type shoulder pain were also present.

A new radiograph obtained at our sports medicine clinic was nondiagnostic. Magnetic resonance imaging (MRI) was performed. The MRI revealed increased signal on T2 with bone edema at the lateral margin of the scapular neck. A computed tomography (CT) scan was subsequently ordered to gain better assessment of bone anatomy. The CT revealed an unhealed, left-transverse, subglenoid scapular fracture. The fracture was nondisplaced.

Transcutaneous electrical bone-growth stimulation (EBI, Parsippany, NJ) and a physical therapy regimen focusing on periscapular strengthening were prescribed. Six weeks later, a follow-up CT scan was ordered to assess bony healing. The CT scan revealed progressive healing of the fracture. The patient was still symptomatic and reported that his pain was generally improving, but worsened during throwing and overhead activities. He was instructed to continue with electrical stimulation and physical therapy and to avoid any painful maneuvers.

A final CT scan 6 months after the patient had initially presented to our clinic revealed healing of the fracture. (Fig. 1) His shoulder was nontender. He had full range of motion at his shoulder and no scapular winging. Motor strength was five of five bilaterally in his upper extremities. A visual analog scale of 1 of 10 at rest was given. He was fully participating in sports without any complications.

FIGURE 1-Fi

FIGURE 1-Fi

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DISCUSSION

Many "contact sports" share the energies of injury seen in high-speed motor vehicle collisions. This case demonstrates the importance of considering a scapular fracture in any athlete with sport-related shoulder trauma. In the athletic population, scapular fractures have been described in a number of sports, including football and baseball (4,8,12,15). Injuries most commonly associated with scapular fractures include rib fractures, hemothorax, pneumothorax, brachial plexus injuries, and vascular injuries.

There is a paucity of literature surrounding scapular fractures in the athletic population, particularly in child or adolescent athletes. Incomplete evaluation of patients presenting with shoulder problems in clinical settings may result in incorrect diagnoses. Underreporting may also be a factor. In our patient, failure to correctly diagnose, with continuation of sports-related stressors, may have resulted in delayed union of the scapula and protracted disability.

Recent studies have demonstrated the crucial role the scapula has in shoulder function. Kibler describes five important roles of the scapula (13). Failure of the scapula to perform any of these roles can result in disruption of shoulder function and injury. In athletes, abnormal function of the parascapular muscles is an important contributor to abnormal shoulder function and resultant injury (10). These muscles may be injured by direct acute trauma; strained from repetitive micro trauma, leading to weaknesses and force-couple imbalance; or inhibited by other painful conditions around the shoulder (13). In addition, injury to the axillary, suprascapular, and the upper brachial plexus nerves may result in muscle dysfunction (18).

Our patient was diagnosed with an extraarticular scapular fracture of the lateral aspect of the scapular neck. Retrospective studies have identified fractures of the neck in approximately 25% of all scapular fractures (3). These fractures are rare, and fractures of the lateral margin of the scapula are even rarer, although their true incidence has not been reported in athletes.

Scapular neck fractures typically result from an anterior or posterior force applied to the shoulder. Our patient's fracture was most likely the result of the dual impact of hitting the glass and then falling to the ice onto the glenohumeral joint.

A detailed history, physical examination, and selection of appropriate imaging modalities are important when evaluating the athlete who presents with upper-extremity trauma. Physical examination may reveal shoulder weakness and decreased range of motion as well as pain. Our patient's fracture was initially diagnosed as a rotator cuff injury at an outside facility. This may have been attributable to his shoulder weakness and pain as well as lack of radiographic evidence. Rotator cuff injuries were suspected in two other reports of scapular fractures in athletes (8,15).

Scapular fractures may be evident on anterior, posterior, and Y radiographic shoulder views (6). Although plain radiographs, particularly the Y view, may be useful when evaluating a patient with a possible scapular fracture, the three-dimensional structure of the scapula is intricate. Fractures may not be evident on plain radiographs, and more sophisticated diagnostic modalities such as MRI or CT may be required. In a retrospective study by Harris and Harris, 43 of 100 scapular fractures were undetected on plain radiographs (11).

Pertinent positives of the physical examination in this case included restricted active range of motion, rhomboid weakness, scapular winging, and anterior-type impingement shoulder pain. It is noteworthy that passive range of motion was unrestricted. The MRI revealed bony edema at the neck of the scapula.

CT is considered the gold standard for characterization of fracture; therefore, a CT was ordered to gain better assessment of osseous anatomy. The interim CT was performed to assess fracture healing and effectiveness of the bone stimulator, because the patient was still symptomatic.

Healing times of scapular fractures generally range from 6 to 8 wk. The extensive blood supply that the suprascapular artery and circumflex scapular artery provide may facilitate healing at the fracture site. Therefore, the delayed union of this fracture was atypical.

A variety of factors may delay fracture union, including inadequate immobilization, age, and previous health. Union may also be delayed in patients with diabetes mellitus, poor nutrition, and in those who use tobacco. Our patient was a healthy 15-yr-old male who was not immobilized after his injury. He continued to play hockey after his injury for 7 months. If the diagnosis had been made at the time of injury, immobilization may have resulted in early union.

Repetitive shoulder girdle motions performed during hockey may have resulted in an overuse lesion of the scapula. It is, therefore, more likely that the repetitive athletic stresses placed on the glenohumeral joint and scapula resulted in delayed union of the fracture in our patient.

Because more than 90% of scapular fractures are minimally displaced by support provided by surrounding soft tissues, surgery is rarely indicated (11). Surgical indications include greater than 1-cm medial displacement and greater than 40° angulation. Nonoperative modalities often yield good to excellent results and include ice followed by heat and immobilization for a period of 3-4 wk. A physical therapy regimen of periscapular strengthening exercises is often prescribed.

Because our patient presented with delayed union for 7 months, a more aggressive therapy, transcutaneous electrical bone growth stimulation (EBI, Parsippany, NJ) using pulsed electromagnetic field therapy, was prescribed. The unit is typically worn for 9 hours per day for a period of 3 months, or until the fracture heals.

Electrical stimulation has been shown to result in the healing of fractures, particularly in long bones such as the tibia (3,19). A number of case studies and the prospective study have reported good or excellent results with electrical stimulation, particularly in recalcitrant cases (9,16,17). Pulsed electromagnetic field therapy (PEMF), one of three types of electrical stimulation, is thought to replicate the negative potential created at fracture sites by the body's electrical impulses. PEMF stimulation has been demonstrated to decrease healing time of fractures (3,16). This is the first reported case of a scapular fracture in a child, adolescent, or adult athlete that healed when treated with electrical stimulation.

Contrary to motor vehicle accidents, sports participation is typically thought to produce injuries by low-energy mechanisms. As demonstrated in our case report, this may not always occur. Scapular fractures are an important component of differential diagnosis of shoulder pain in any athlete after upper-extremity trauma.

In conclusion, the physician should maintain a high index of suspicion for a scapular fracture when evaluating the patient who presents with shoulder pain. Examination findings (such as point tenderness along the upper part of the lateral border of the scapula inferior and adjacent to the glenohumeral joint, restricted range of motion, rhomboid weakness, scapular winging, and anterior-type impingement shoulder pain), as well as lack of response to earlier treatment, increase the likelihood of a scapular fracture.

A detailed history, thorough physical examination, and appropriate imaging are necessary to make the correct diagnosis. Fractures may behave differently depending on the altered stresses specific to sports-related injuries; therefore, they should be treated more aggressively. Early identification and proper management are integral to improve healing time of fractures and to decrease symptoms and activity limitations, particularly in athletes engaged in sports associated with this fracture.

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    Keywords:

    HOCKEY PLAYER; MANAGEMENT; RECALCITRANT HEALING; CONTACT SPORTS

    ©2007The American College of Sports Medicine