S - Fractures of The Scapula - RI

Textbook Reading of David Sutton
Textbook of Radiology and Imaging

7th Edition, Volume 2, Chapter 44, Page 1404
FRACTURES OF THE
SCAPULA
Presented by: Karimah Amalia
Consultant: dr. Amri Wicaksono Pribadi, Sp.Rad
Section 5: Skeletal System: Soft Tissue
Chapter 44: Skeletal Trauma: Regional
• The Skull
• The Facial Bones
• The Spine
• The Pelvic and Hip
• The Shoulder and Upper Arm
❑ The Clavicle
❑ The Scapula
❑ Dislocations
❑ Humerus
• Rotator Cuff and Labra
Outline
INTRODUCTION SCAPULAR FRACTURES
1. ANATOMY: 1. EPIDEMIOLOGY
• THE SCAPULA
2. MECHANISM OF INJURY
• SHOULDER GIRDLE
• TOPOGRAPHY
3. CLINICAL PRESENTATION
4. RADIOLOGICAL ASPECT:
2. PHYSIOLOGY • RADIOGRAPH
• CT
• CLASSIFICATION
• RADIOGRAPHIC AND CT FINDINGS
5. DIFFERENTIAL DIAGNOSIS
6. QUIZ
7. REFERENCES
INTRODUCTION
1. Anatomy: The Scapula
Putz R, Pabst R. Sobotta: Atlas of Human Anatomy 14th Ed Vol. 1. Elsevier: Munich, Germany
1. Anatomy: Shoulder Girdle
Putz R, Pabst R. Sobotta: Atlas of Human Anatomy. 14th Ed Vol. 1. 2006. Elsevier: Munich, Germany
Spratt JD, et al. Weir & Abraham’s: Imaging Atlas of Human Anatomy. 6th Ed. 2021. UK
1.
Anatomy:
Topography
2.
Physiology
2.
Physiology
Thompson JC. Netter’s concise orthopaedic anatomy. 2nd Ed. 2010. Saunders, US
SCAPULAR FRACTURES
1. Epidemiology
Fractures of scapula are uncommon:
• < 1% of all fractures

• 3-5% of shoulder girdle 80% to 95%:
fractures associated with
Mortality:
additional
>>: 10-15% traumatic injuries
male, ± 36 y.o other concomitant
injuries involving the
pulmonary system, cervical
spine, or cranial region
Berritto D, et al. Scapular fractures: a common diagnostic pitfall. Acta Biomed. 2018; 89(Suppl 1): 102–110
Salimi J, Khaji A, Karbakhsh M, Saadat S, Eftekhar B. Scapular fracture: lower severity and mortality. Sao Paulo Med J. 2008 May 1;126(3):186-9
Noguchi T, Mautner JF, Duncan SFM. Dorsal Plate Fixation of Scapular Fracture. J Hand Surg Am. 2017 Oct;42(10):843.e1-843.e5
Voleti PB, Namdari S, Mehta S. Fractures of the Scapula. Adv Orthop. 2012; 2012: 903850
2. Mechanism of Injury
HIGH ENERGY Direct Fractures in all regions of

Frequently
TRAUMA: Force the scapula associated with
other acute
• Road traffic Indirect injuries:
accident Force • Rib fractures
• Fall from Glenoid and scapular • Lung injury
great height (via impaction of • Head injury
• Blunt object the humeral neck fractures • Spinal fracture
head into
• Clavicle fracture
• Cutting the glenoid
fossa)
Suedkamp N, Izadpanah K. Fractures of the Scapula. European Surgical Orthopaedics and Traumatology pp 943-968
Ropp AM, Davis DL. Scapular Fractures: What Radiologists Need to Know. American Journal of Roentgenology. 2015;205: 491-501
Kannan S, Singh HP, Pandey R. A systematic review of management of scapular fractures. Acta Orthop Belg. 2018 Dec;84(4):497-508
3. Clinical Presentation
Predilection: Simptom: Sign:

• Scapular body 45 % • Upper extremity adducted
• Glenoid neck 25 % Local pain or • Upper extremity protected from
movement
• Glenoid fossa 10 % tenderness (part. • Limited ROM (part. with abduction)
• Acromion 8%
• Coracoid process 7%
during abduction) • Crepitus
• Swelling
• Scapular spin 5% • Skin abration
Limb D. Fractures of the scapula. Mini-symposium: less common shoulder problems. 2012; 26(6): p374-379
Cole PA, Gauger EM, Schroder LK. Management of scapular fractures. J Am Acad Orthop Surg. 2012; 20: 130-141
4. Radiological Aspects: Radiograph
• Imaging → key role in identifying and classifying scapular

fractures → guides clinical decision-making
• The earliest opportunity to diagnose a scapular fracture may be
on the initial routine supine anteroposterior (AP) chest
radiograph taken in most trauma patients
• > 43% of scapular fractures → not recognized on the initial chest
radiograph
• All patients with suspected scapular fractures should have
dedicated scapular projections radiographs
SCAPULA AP VIEW
DEMONSTRATED STRUCTURES:
• Scapular parts (including acromion, coracoid

process, spine, as double almost parallel lines, and
body)
• Lateral distal third of the clavicle
• Scapulo-humeral joint
• Proximal third of the humerus
• Acromion-clavicular joint
Cole PA, Freeman G, Dubin JR. Scapula fractures. Curr Rev Musculoskelet Med (2013) 6:79–87
Ropp AM, Davis DL. Scapular Fractures: What Radiologists Need to Know. American Journal of Roentgenology. 2015; 205: 491-501
AP OBLIQUE (GRASHEY VIEW)
• Glenohumeral joint space

• The glenopolar angle
• Medial displacement of the proximal
fragment, relative to the distal fragment at
the lateral border (lateral border offset)
SCAPULA LATERAL (Y VIEW)
TECHNIQUES:
• The PA approach (erect position)
• The AP approach (supine)
• The acromion and coracoid form a “Y” or “peace sign” shape with
the body of the scapula
• The head of the humerus should be normally centered to the
middle of the “Y” shape
• The acromion and distal end of the clavicle form a “roof ”over the
shoulder joint
TRUE AXILLARY VIEW
• This view allows measuring the glenohumeral joint
space
• Lesser tuberosity is seen anteriorly as a small
inverted V on anterior surface of the humeral head
• When properly done, it is possible to assess the
anterior and posterior glenoid rim → this allows
identifying glenoid rim lesions
• A proper true axillary view should have an
“eye”(figure) created by the acromion and posterior
glenoid → absence of this “eye” indicates that we are
not viewing the true anterior and posterior edges of
the glenoid
4. Radiological Aspects: CT
• Recommended for:
✓ Complex fractures
✓ Fractures with significant displacement
• Allow clinicians:
✓ To evaluate the size, location, and degree of displacement of
fracture lines
✓ To confirm the position of the humeral head in relation to the
glenoid fossa
• 3D reconstructions of the CT scan can be extremely helpful in:
✓ Visualizing complex fracture patterns
✓ Planning for operative treatment
4. Radiological Aspects: CT
4. Radiological Aspect: Classification
A. Intra-articular Scapular Fractures

• 10-30% of all scapular fractures
• Location: glenoid fossa fractures → as
consequences of an impact between
humeral head and glenoid fossa
• The Ideberg Classification (modified by
Goss) → 6 types:
Gilbert F, et al. Intra- and interobserver reliability of glenoid fracture classifications by Ideberg, Euler and AO. BMC Musculoskelet Disord. 2018; 19: 89
Suedkamp N, Izadpanah K. Fractures of the Scapula. European Surgical Orthopaedics and Traumatology pp 943-
B. Extra-articular Scapular Fractures
• Majority
• Location: body, spine, neck, coracoid
process and acromion process
1. Scapular body and spine fractures The isolated spine fracture:

✓ The most frequent (50% of the cases)
✓ The rim fracture could be transversal • Rare (6-11% of the cases)
or vertical • Stable fracture
✓ Transversal rim: involving the
supraspinatus or infraspinatus fossa • Fast consolidating
✓ Vertical rim: trans-spinal fracture
2. Scapular neck
✓ The second most common site (26-29%)
✓ Classification according to Blauth, Suedcamp and
Hass → 2 types:
3. Coracoid process
✓ 3-7% of the cases
✓ Ogawa Classification → 2 types:
4. Acromion fractures
✓ 8-16% 0f scapular fractures
✓ Kuhn Classification → 3 types:
AO/OTA Fracture and Dislocation Classification Compendium 2018
Meinberg E, Agel J, Roberts C, et al. Fracture and Dislocation Classification Compendium. 2018; Journal of Orthopaedic Trauma. 32(1)
4. Radiological Aspects: Radiographic & CT
Findings
Bencardino JT. The shoulder: Imaging diagnosis and clinical implications. 2019: Springer Nature: Switzerland
Findings
Bencardino JT. The shoulder: Imaging diagnosis and clinical implications. 2019: Springer Nature: Switzerland
Ström P. Glenoid fractures of the shoulder. EFFORT Opern Rev. 2020; 5(10):620-623
Findings
Frich LH, Larsen MS. How to deal with a glenoid fracture. EFORT Open Rev. 2017; 2(5):151–157
Findings
Findings
Findings
Findings
5. Differential Diagnosis
Scapular Fracture Clavicle Fracture Acromioclavicular Injury
Mechanism of • Direct force Fall onto the lateral shoulder Direct trauma to the lateral aspect of the shoulder
injury • Indirect force (via impaction of the humeral or acromion process with the arm in adduction
head into the glenoid fossa
Modality/imaging • Radiograph: • Radiograph: • Radiograph:
technique ✓ Scapula AP view ✓ AP view ✓ Bilateral Zanca
✓ AP oblique (Grashey view) ✓ Second 45-degree cephalic tilt view ✓ Axillary view
✓ Scapula lateral (Y view) • CT scan ✓ Dynamic axillary view
✓ True axillary view • USG
• CT & 3D reconstruction CT • MRI
Clinical presentation Pain during abduction Pain, crepitus, and sometimes motion with gentle • Typically present with anterosuperior shoulder
palpation of the fracture pain
• Pain radiating to the neck or shoulder, which is
often worse with movement or when they try
to sleep on the affected shoulder
Radiologic finding
Jong B, Goel DP. Managing type-III acromioclavicular joint injury. BCMJ. 2018; 60(3): 164-165
Fanter NJ, Kenny RM, Baker CL III, Baker CL Jr. Surgical Treatment of Clavicle Fractures in the Adolescent Athlete. Sports Health. 2015; 7(2): 137–141
Kiel J, Kaiser K. Acromioclavicular Joint Injury. [Updated 2020 Aug 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493188/
Pujalte GGA, Housner JA. Management of Clavicle Fractures. Current Sports Medicine Reports. 2008; 7(5): p275-280
Bentley TP, Hosseinzadeh S. Clavicle Fractures. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507892/
Pogorzelski J, et al.The acutely injured acromioclavicular joint – which imaging modalities should be used for accurate diagnosis? A systematic review. BMC Musculoskelet Disord. 2017; 18: 515
6. Quiz
A 31-year-old woman was taken to the
emergency department after experiencing
a motor vehicle collision. The arm feels
painful when it is moved outward.
a. Glenoid fracture type Ia

b. Glenoid fracture type IIb
c. Glenoid fracture type III
d. Glenoid fracture type IV
e. Glenoid fracture type V
7. References
• Cole PA, Freeman G, Dubin JR. Scapula fractures. Curr Rev Musculoskelet Med (2013)
• Putz R, Pabst R. Sobotta: Atlas of Human Anatomy. 14th Ed Vol. 1. 2006. Elsevier: Munich, 6:79–87
Germany
• Meinberg E, Agel J, Roberts C, et al. Fracture and Dislocation Classification Compendium.
• Thompson JC. Netter’s concise orthopaedic anatomy. 2nd Ed. 2010. Saunders, US
• Spratt JD, et al. Weir & Abraham’s: Imaging Atlas of Human Anatomy 6th Ed. 2021. UK 2018; Journal of Orthopaedic Trauma. 32(1)
• Berritto D, et al. Scapular fractures: a common diagnostic pitfall. Acta Biomed. 2018; • Bencardino JT. The shoulder: Imaging diagnosis and clinical implications. 2019: Springer
89(Suppl 1): 102–110 Nature: Switzerland
• Salimi J, Khaji A, Karbakhsh M, Saadat S, Eftekhar B. Scapular fracture: lower severity and • Ström P. Glenoid fractures of the shoulder. EFFORT Opern Rev. 2020; 5(10):620-623
mortality. Sao Paulo Med J. 2008 May 1;126(3):186-9 • Frich LH, Larsen MS. How to deal with a glenoid fracture. EFORT Open Rev. 2017;
• Noguchi T, Mautner JF, Duncan SFM. Dorsal Plate Fixation of Scapular Fracture. J Hand Surg 2(5):151–157
Am. 2017 Oct;42(10):843.e1-843.e5 • Jong B, Goel DP. Managing type-III acromioclavicular joint injury. BCMJ. 2018; 60(3): 164-
• Voleti PB, Namdari S, Mehta S. Fractures of the Scapula. Adv Orthop. 2012; 2012: 903850 165
• Suedkamp N, Izadpanah K. Fractures of the Scapula. European Surgical Orthopaedics and • Fanter NJ, Kenny RM, Baker CL III, Baker CL Jr. Surgical Treatment of Clavicle Fractures in
Traumatology pp 943-968 the Adolescent Athlete. Sports Health. 2015; 7(2): 137–141
• Gilbert F, et al. Intra- and interobserver reliability of glenoid fracture classifications by • Kiel J, Kaiser K. Acromioclavicular Joint Injury. [Updated 2020 Aug 31]. In: StatPearls
Ideberg, Euler and AO. BMC Musculoskelet Disord. 2018; 19: 89 [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
• Ropp AM, Davis DL. Scapular Fractures: What Radiologists Need to Know. American Journal https://www.ncbi.nlm.nih.gov/books/NBK493188/
of Roentgenology. 2015;205: 491-501 • Pujalte GGA, Housner JA. Management of Clavicle Fractures. Current Sports Medicine
• Kannan S, Singh HP, Pandey R. A systematic review of management of scapular fractures. Reports. 2008; 7(5): p275-280
Acta Orthop Belg. 2018 Dec;84(4):497-508 • Bentley TP, Hosseinzadeh S. Clavicle Fractures. [Updated 2020 Aug 8]. In: StatPearls
• Limb D. Fractures of the scapula. Mini-symposium: less common shoulder problems. 2012; [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
26(6): p374-379 https://www.ncbi.nlm.nih.gov/books/NBK507892/
• Cole PA, Gauger EM, Schroder LK. Management of scapular fractures. J Am Acad Orthop • Pogorzelski J, et al.The acutely injured acromioclavicular joint – which imaging modalities
Surg. 2012; 20: 130-141 should be used for accurate diagnosis? A systematic review. BMC Musculoskelet Disord.
2017; 18: 515
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Textbook Reading of David Sutton

Textbook of Radiology and Imaging

• < 1% of all fractures

HIGH ENERGY Direct Fractures in all regions of

Predilection: Simptom: Sign:

• Imaging → key role in identifying and classifying scapular

• Scapular parts (including acromion, coracoid

• Glenohumeral joint space

A. Intra-articular Scapular Fractures

1. Scapular body and spine fractures The isolated spine fracture:

a. Glenoid fracture type Ia

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