Journal of Orthopaedic Science 23 (2018) 845e848
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Journal of Orthopaedic Science
journal homepage: http://www.elsevier.com/locate/jos
Case Report
Bilateral isolated symmetrical avulsion fractures of the superior
scapular angles
Norihiko Nakata*, Yasuhito Tajiri, Satoru Sasaki
Department of Orthopedic Surgery, Tokyo Metropolitan Hiroo Hospital, 34-10, Ebisu 2chome, Shibuya-ku, Tokyo 150-0013, Japan
a r t i c l e i n f o
Article history:
Received 21 February 2016
Received in revised form
15 August 2016
Accepted 22 August 2016
Available online 12 September 2016
1. Introduction
Isolated avulsion fractures of the scapula are exceedingly
rare. With respect to isolated avulsion fractures of the scapula,
there are some case reports about fractures affecting the
coracoid process, superior border, infraglenoid tubercle, acro-
mion, medial spine, inferior angle, and the lateral border.
Avulsion fractures of the superior border and superior angle of
the scapula are usually combined with a fracture of the cora-
coid process [1e3], clavicle fracture [4e6], rib fracture [6],
acromioclavicular dislocation [1,3e5], or more extensive scap-
ular fractures [5]. An extremely rare case of isolated bilateral
symmetrical avulsion fractures of the superior angles is re-
ported, and these fractures were highly likely to have been
induced by the levator scapulae muscles. The patient gave
informed consent for his data to be presented in this article
and to be submitted for publication.
2. Report of the case
A 36-year-old stunt man suffered indirect trauma to both
shoulders. He had been traveling along a public road on a motor-
bike wearing a full-face helmet when he collided with the side of a
car turning right from the opposite lane. He was catapulted into the
air over the roof of the car while spinning forward a full 540
and
* Corresponding author. Fax: þ81 03 3444 3196.
E-mail address: nnakata1300@yahoo.co.jp (N. Nakata).
http://dx.doi.org/10.1016/j.jos.2016.08.011
0949-2658/© 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
landed 5 m away on his shoulder with his neck flexed (Fig. 1). His
developmental history was normal, and there was no history of
trauma or previous surgery. When carried into the emergency
room of our hospital, he had a normal level of consciousness with
no evidence of any neurovascular deficits. He could recall the ac-
cident clearly. The longitudinal direction of the approximately 10-
cm-long fracture engraved into the occipital midline of the hel-
met supported the patient's statement of the aforementioned
landing mechanism. He complained of bilateral pain at the medial
parts of the superior scapular borders, with tenderness at those
points. On X-ray, bilateral superior scapular border fractures were
suspected (Fig. 2A,B). Computed tomography showed bilateral
symmetrical avulsion fractures of the supraspinatus fossae
including the superior angles (Fig. 3A,B). The fracture parts were
identified as the insertions of the levator scapulae muscles. Because
both avulsions of the levator scapulae muscles were partial and
isolated, treatment was conservative. The patients' symptoms
improved within 6 weeks, and the patient returned to work
without any limitation in the range of motion or pain three months
after the injury.
3. Discussion
The only muscle attached to the superior border of the
scapula is the omohyoid muscle and the only muscle attached
to the superior angle of the scapula is the levator scapulae
muscle (Fig. 4). The omohyoid muscle inserts onto the central
part at the suprascapular notch and transverse scapular liga-
ment. On the other hand, the levator scapulae muscle originates
from the posterior tuberculum of the transverse processes
(cervical vertebra IeIV) and inserts into the superior angle and
medial border of the scapula. When it contracts, it pulls the
scapula in the supramedial direction. In this case, the fracture
parts were identified as the insertions of the levator scapulae
muscles.
Three mechanisms of avulsion fracture have been described:
repetitive muscular contractions (stress fracture), single violent
muscular or ligamentous contraction (traumatic avulsion frac-
ture), and violent uncoordinated muscular contractions (fractures
related to electrical shock, electroconvulsive therapy, or epileptic
seizures) [7,8]. Avulsion fracture of the scapula is usually part of a
846 N. Nakata et al. / Journal of Orthopaedic Science 23 (2018) 845e848

Fig. 1. The manner of the injury.

Fig. 2. Plane X-ray at injury. A: right, B: left. The bilateral superior scapular border fractures are unclear but suspected.

Fig. 3. The 3 dimensional reconstructed computed tomography at injury. A: right, B: left. The computed tomography show the bilateral symmetrical avulsion fractures of the
superior angles.

more serious shoulder trauma. Isolated avulsion fractures of the
scapula that result from the violent pulling of the muscles, the
ligaments, or both on their bony insertion are exceedingly rare,
especially at the superior angle; only a few cases have been re-
ported (Table 1).
Ogawa stated that a horizontal shearing force occurring be-
tween the scapula and clavicle produces a fracture of the base of
the coracoid, including a type III glenoid fracture extending into
the superior border [2]. Isolated avulsion fractures of the superior
border or superior angle have rarely been reported (Table 1).
 N. Nakata et al. / Journal of Orthopaedic Science 23 (2018) 845e848 847

stretched. In addition, there was strong stress in the distal di-

Fig. 4. Diagram of the insertion point of the omohyoid and levator scapulae muscles.
The levator scapulae muscle inserts into the superior angle and medial border of the
scapula. In this case, the fracture parts were identified as the insertions of the levator
scapulae muscles.
rection to bilateral scapulae at crash time. As a result, hyper-
stretched bilateral levator scapulae muscles caused the avulsion
fractures at their insertion points.
Due to the complex anatomy in the area, X-ray examination
alone is insufficient to evaluate the injury around the superior
border and superior angle of the scapula, and CT scanning and/or
MR imaging is necessary to detect and accurately define the de-
tails of the injuries to determine whether there is partial avulsion
of the muscle fibers with a bony fragment or there is complete
rupture with avulsion fracture of the insertion point. In the pre-
sent case, there was only partial avulsion, and the treatment was
conservative, but surgical treatment, such as suturing, might be
considered if the injury involved complete rupture with other
fractures.
From the viewpoint of isolated bilateral symmetrical avulsion
fractures, only two cases, infraglenoid tubercle avulsion fractures
induced by the long head of the triceps muscle in a 26-year-old
parachutist [11], and avulsion fractures of the neck of the acromion
induced by the deltoid muscle in severe tetanus neonatorum [12]
were reported. To the best of our knowledge, no cases of isolated
bilateral symmetrical avulsion fractures of the superior angle with
no other injuries have been reported.
In conclusion, a rare case of bilateral isolated symmetrical
scapular avulsion fractures was presented. These fractures were
likely the result of a single violent contraction of the levator
scapulae muscles. The avulsion fractures in the isolated upper
corners of the levator scapulae insertion sites were thought to
have occurred when the scapulae were pulled distally in the
longitudinal direction, primarily by the levator scapulae
muscles.

Table 1
The past reported superior border and superior angle avulsion fractures include our own. The avulsion fractures of the superior angle had been discussed in the category of the
avulsion fractures of the superior border. Considering of the main trigger muscle, the avulsion fractures of the superior angle are separately categorized in Table 1.

Site of fracture Age Sex Type of accident Trigger muscle or ligament Author Bilateral Symmetrical Isolated Complicated injury
injury fracture fracture

Superior border 33 M Fall ? Debrunner, 1940 No No No Fracture of glenoid cavity

? ? Traffic accident Omohyoid and levator scapulae Bezold case 1, 1956 No No No Clavicula fracture
30 M Traffic accident Omohyoid and levator scapulae Houghton case 1, 1979 No No No Subluxation of CA joint,
fracture of glenoid cavity
29 M Traffic accident Omohyoid and levator scapulae Houghton case 2, 1979 No No No Clavicula fracture
17 ? Traffic accident Omohyoid and levator scapulae Scholz, 1980 Yes No No Fracture of glenoid cavity
41 M Traffic accident Omohyoid Ishizuki case 5, 1981 No No Yes e
17 M Traffic accident Omohyoid Williamson, 1988 Yes No Yes e
23 M Traffic accident Omohyoid Arenas case 1, 1993 No No No 1st rib fracture
32 F Traffic accident Omohyoid Arenas case 2, 1993 Yes Yes No Right clavicule fracture
Superior angle ? M Posterior blow ? Imatani, 1975 No No ? ?
when ejected
from plane
? ? ? Levator scapulae Goss, 1996 No No No Dislocation of CA joint
36 M Traffic accident Levator scapulae Nakata, 2016 Yes Yes Yes e

Abbreviations: M: male, F: female, ?: not recorded in the report, CA: coracoacromial.

Isolated avulsion fractures of the superior border had been Conflict of interest
considered to result from single violent muscular contraction of
the omohyoid alone or both the omohyoid and levator scapulae None.
muscles, especially the former [4,5,7,9,10]. However the mecha-
nism of the avulsion fractures of the superior angle had not been
Disclosure
carefully verified because these fractures had been discussed in
the category of the avulsion fractures of the superior border. From
We have no sources of support that require acknowledgment.
the viewpoint of trigger muscle, isolated avulsion fractures of the
superior angle should be independently categorized. In the pre-
sent case, the mechanism of bilateral symmetrical fractures of the References
superior angles was thought to have been as follows. When the
patient dropped onto the street, his neck was in the full-flexion [1] Wolf AW, Shoji H, Chuinard RG. Unusual fracture of the coracoid process: a
case report and review of the literature. J Bone Jt Surg Am 1976 Apr;58(3):
position, that is, bilateral levator scapulae muscles were fully 423e4.
848 N. Nakata et al. / Journal of Orthopaedic Science 23 (2018) 845e848
[2] Ogawa K, Yoshida A. Fracture of the superior border of the scapula. Int Orthop
1997;21(6):371e3.
[3] Ishizuki M, Yamaura I, Isobe Y, Furuya K, Tanabe K, Nagatsuka Y. Avulsion
fracture of the superior border of the scapula. Report of five cases. J Bone Jt
Surg Am 1981 Jun;63(5):820e2.
[4] von Bezold K. Die Abrissfraktur der Margo cranialis scapulae. Fortschr Geb
Roentgenstr Nukl 1956;85(4):423e6 [in German].
[5] Houghton GR. Avulsion of the cranial margin of the scapula: a report of two
cases. Injury 1979 Aug;11(1):45e6.
[6] Arenas AJ, Pampliega T. An unusual kind of fracture. Acta Orthop Belg
1993;59(4):398e400.
[7] Heyse-Moore GH, Stoker DJ. Avulsion fractures of the scapula. Skelet Radiol
1982;9(1):27e32.
[8] Mathews RE, Cocke TB, D'Ambrosia RD. Scapular fractures secondary to sei-
zures in patients with osteodystrophy. J Bone Jt Surg Am 1983 Jul;65(6):
850e3.
[9] Debrunner H. Mit Bruch der freien Apophyse des Margo Superior. Z Unfallmed
Berufskr 1940 Jul-Sep;34(3):153e6 [in German].
[10] Williamson DM, Wilson-MacDonald J. Bilateral avulsion fractures of the cra-
nial margin of the scapula. J Trauma 1988 May;28(5):713e4.
[11] Binazzi R, Assiso J, Vaccari V, Felli L. Avulsion fractures of the scapula: report of
eight cases. J Trauma 1992 Nov;33(5):785e9.
[12] Kalideen JM, Satyapal KS. Fractures of the acromion in tetanus neonatorum.
Clin Radiol 1994 Aug;49(8):563e5.