- Email: [email protected]
Scapular fracture in a professional boxer
Scapular fracture in a professional boxer R. Bradley Wyrsch, MD, Kurt P. Spindler, MD, and Paul R. Stricker, MD, Nashville, Tenn.
Scapular fractures typically result from high-energy direct trauma such as motor vehicle accidents, direct blows, falls, or crushing injuries. As a result of these injury mechanisms scapular fractures are often associated with other far more serious injuries. In contrast, only a paucity of literature exists describing less violent causes of scapular fractures. We report a rare scapular body fracture in a professional boxer resulting from muscle contraction. CASE HISTORY The patient was a 25-year-old, left-hand dominant, highly ranked featherweight professional boxer who had no history of shoulder pain. During a title match he attempted to knock out his opponent with a full-powered, left-handed punch, which completely missed his opponent. The patient had immediate severe pain in the left shoulder girdle area. He struggled but completed the round, although he was unable to lift his left arm to punch or defend himself. The fight was stopped before the next round as a result of the injury. He was evaluated and treated in the emergency department of a local hospital. Routine radiographs were taken but did not include axillary or Westpoint views. The patient was diagnosed with a posterior shoulder subluxation. His arm was placed in a sling and swathe, and he was directed to undergo orthopaedic follow-up evaluation. Two days later he was seen in our clinic for evaluation and further treatment. Qn presentation to our facility the patient continued to report severe pain in the left shoulder, especially with motion, and loss of function. He From Vanderbill Sports Medicine Center, Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville. Reprint requests: Kurt P. Spindler, MD, Director, Vanderbilt Sports Medicine Center, 2601 Jess Neely Dr., Nashville, TN 37212. J SHOULDERELBOWSURG1995;4:395-8. Copyright 9 1995 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/95/$5.00 + 0
32141623OO
denied neck pain, tingling, numbness, or paresthesias in his left arm. Physical examination revealed severely limited range of motion of the left shoulder in all planes; motion was limited because of pain. When the patient attempted to abduct his arm, a sharp pain at approximately 50 ~ caused him to drop his arm. His motion with passive internal and external rotation at 0 ~ abduction and with passive forward flexion and abduction to 90 ~ was much less painful. Local swelling and direct tenderness was present over the scapular body. Cervical motion was normal. Neurologic examination including motor, sensory, and reflex function was entirely normal. Peripheral pulses were symmetrically palpable. Radiographs from the emergency department were inconclusive, but views obtained at our clinic documented a minimally comminuted, slightly displaced, extraarticular fracture of the scapular body just proximal to the glenoid (Figure 1). The patient's arm was immobilized in a sling and swathe. Repeat radiographs of the arm in the sling showed acceptable alignment of the fracture with a reduced inferior tilt. 9 A magnetic resonance imaging scan (Figure 2) was also obtained to better assess the complexity of the fracture, including the degree of anteversion of the glenoid and the possibility of a stress fracture or a neoplastic process. The magnetic resonance imaging scan revealed an extraarticular fracture with a slight increase in anteversion of the glenoid and an extension of the fracture into the coracoid process that had not been seen on the plain radiographs. Furthermore, the rotator cuff and glenohumeral ligaments were intact. The patient was immobilized for 3 weeks. Repeat radiographs continued to show acceptable alignment of the fracture with early callus formation. Examination at 3 weeks revealed no swelling, minimal tenderness, active abduction of the shoulder to 150 ~, and forward flexion to 170 ~. A rehabilitation program was initiated. At 4 weeks the patient had return of full active range of motion, and the shoulder pain had resolved.
395
396
Wyrsch, Spindler, and Stricker
J. ShoulderElbow Surg. September~October 1995
Figure 1 Anteroposterior (A) and axillary lateral (B) view of left shodder demonstrate minimally comminuted and slightly displaced extraarticularfracture of scapula just proximal to glenoid,
Figure 2 Magnetic resonance image was also obtained. This image demonstrated extension of fracture into coracoid process. In addition, no evidence of any other pathologic process was found. At 6 weeks callus was present on radiographs. Light workouts were initiated. At 10 weeks both clinical and radiographic evaluations (Figure 3) showed that the fracture was healed, and the patient was allowed to resume sparring and work-
outs: At 12 weeks the patient had regained full range of motion, had no loss in his power, and continued to be free from pain. At 14 weeks after injury he fought a rematch against the same opponent and won the professional title. At last fol-
J. Shoulder Elbow Surg. Volume 4, Number 5
Wyrsch, Spindler, and Stricker
397
Figure 3 Anteroposterior (A) and axillary (B) views 2 months after injury demonstrate heated fracture with bridging callus. low-up evaluation (5 months after the injury) he had successfully defended his title and reported no shoulder weakness or pain.
DISCUSSION Scapular fractures have been caused by many types of forces. These include motor vehicle accidents, i, 12, 14, 16, 17 falls,17 crush injuries, direct blows, ~ electrical shock, 4' 15 skiing accidents, 2 and seizures.8, 13 Certainly high-speed motor vehicle trauma accounts for most of these fractures, often with associated injuries to the chest wall, lung, shoulder girdle, and ipsilateral subclavian, axillary, or brachial arteries. 1~
A few reports exist in the literature regarding scapular fractures from indirect or less violent trauma. In his series on scapular fractures in 1932 Bloch mentioned a fracture of the scapula from "muscular action. ''5 No other details were given. Deltoff and Bressler7 reported a fracture of the scapula occurring in a nonathletic man who was performing pushups. Benton and Nelson 3 reported on an avulsion fracture of the coracoid process in a tennis player; the fracture was treated successfully by excision of coracoid fragment and reattachment of the conjoined tendon. Heyse-Moore and Stoker 11 proposed a classification of avulsion fractures of the scapula. In addition to avulsion
398
J. Shoulder Elbaw Surg. September~October 1995
Wyrsch, Spindler, and Stricker
fractures, stress fractures of the coracoid have been reported in trapshooters and in patients who do vigorous weight training/These fractures were believed to be caused by repetitive stress or minor trauma. One other series reported on scapular fractures in professional athletes. Cain and Hamilton r reviewed five cases of scapular fractures in professional football players in high-impact positions. The mechanism of injury in all instances was a direct blow to the scapula. All players were treated conservatively with early active range of motion, and fractures in four out of five athletes healed by 6 weeks with no resultant limitations. The players had a full return to competition. We report another unusual scapular body fracture from muscular action in a young professional boxer occurring as a result of a missed punch during a title boxing match. This is the third reported case in the literature and the first in a professional athlete of a scapular fracture caused by voluntary muscle contraction. As in other lowenergy and extraarticular fractures of the scapula, this patient was treated successfully by nonoperarive means with progressive active range of motion and physical therapy. Fractures from voluntary muscle contracture are infrequent. Gregerson 1~ reviewed four cases of humeral shaft fractures that occurred from throwing activities. It was hypothesized that these fractures were caused by violent torsional forces from poorly coordinated and imbalanced voluntary muscle contraction. The mechanisms of indirect scapular fractures from presumed voluntary muscle contraction are also poorly understood; Eighteen different muscles attach to the scapula, providing a multitude of diverse forces of different magnitude and direction. It is conceivable that a force generated by a violent muscle contraction could overcome the structural integrity of the scapula, leading to fracture. Certainly repetitive forces on a bone that is unaccustomed to such stresses can result in a stress fracture. In this case, however, no history of scapular pain or evidence of stress fracture on radiographs or magnetic resonance imaging was noted; the only indication of a fracture was a sudden onset of debilitating pain occurring immediately after a missed punch. Absence of direct violent trauma about the shoulder girdle in the patient's history should not exclude the possibility of a scapular fracture, as
demonstrated in this particular case. Scapular fractures can usually be diagnosed on physical examination with localized pain and tenderness on palpation with hematoma formation and swelling. Confirmation should be made by an axillary or Westpoint radiograph, which provides excellent visualization of the entire scapular body and glenoid in addition to revealing posterior or anterior dislocation. Although uncommon, a fracture of the scapula should be considered in the differential diagnosis of shoulder pain in the setting of a direct blow, repetitive stresses, or a violent voluntary muscle contraction. The authors thank Holly Quick for editorial assistance with this manuscript. REFERENCES
1. ArmstrongCP, Van Der SpuyJ. The fractured scapula: importance and management based on a series of 62 patients. Injury 1984;15:324-9. 2. BanerjeeAK, Field S. An unusualscapularfracture caused by a water skiing accident. Br J Radial 1985;58:465-7. 3. BentonJ, Nelson C. Avulsion of the coracoid process in an athlete. J BoneJoint Surg Am 1971 ;53A:356-8. 4. Beswick DR, Morse SO, BarnesAU. Bilateral scapular fracture from low voltage electrical injury. Ann Emerg Med 1982;11:676-7. 5. BIoch E. Fracture of scapula. New Orleans Med Surg J 1923;75:704-10. 6. Cain TE, Hamilton WP. Scapular fractures in professional football players. Am J Sports Med 1992;20:363-5. 7. Deltoff MN, Bressler HB. Alypical scapular fracture. Am J Sports Med 1989;17:292-5. 8. DiRaimondoCR, PowersTA, DiRaimondoCV, et ah Scapular fractures resulting from grand mal seizuresin chronic hemodialysis patients. J Tenn Med Assoc 1986;79:411-4. 9. rink-BennettDM, BensonMT. Unusualexercise-relatedstress fractures: ~o case reports. Clin Nuc Med 198419:430-4. 10. Gregerson HN. Fracture of the humerusfrom muscularviolence. Acta Orthop Scand 1971 ;42:506-12. 11. Heyse-Moore GH, Stoker DJ. Avulsion fractures of the scapula. Skeletal Radial 1982;9:27-32. 12. Imatani RJ. Fracturesof the scapulae: a review of 53 fractures. J Trauma 1975;15:473-8. 13. Matthews RE, Cocke TB, D'Ambrosia RD. Scapular fractures secondary to seizuresin patientswith osteodystrophy.J Bone Joint Surg Am 1983;65A:850-3. 14. McGahan JP, Rab GT, Dublin A. Fracturesof the scapula. J Trauma 1980;20:880-3. 15. Tarquino 1-, Weinstein ME, VirgiJio RW. Bilateral scapubr fractures from accidental electric shock. J Trauma 1979; 19: 1324. 16. ThompsonDA, FlynnTC, Miller PW, et ah The significance of scapular fractures. J Trauma 1985;25:974-7. 17. Wilber MC, Evans EB. Fracturesof the scapula. J BoneJoint Surg Am 1977;59A:358-62.
Scapular fractures typically result from high-energy direct trauma such as motor vehicle accidents, direct blows, falls, or crushing injuries. As a result of these injury mechanisms scapular fractures are often associated with other far more serious injuries. In contrast, only a paucity of literature exists describing less violent causes of scapular fractures. We report a rare scapular body fracture in a professional boxer resulting from muscle contraction. CASE HISTORY The patient was a 25-year-old, left-hand dominant, highly ranked featherweight professional boxer who had no history of shoulder pain. During a title match he attempted to knock out his opponent with a full-powered, left-handed punch, which completely missed his opponent. The patient had immediate severe pain in the left shoulder girdle area. He struggled but completed the round, although he was unable to lift his left arm to punch or defend himself. The fight was stopped before the next round as a result of the injury. He was evaluated and treated in the emergency department of a local hospital. Routine radiographs were taken but did not include axillary or Westpoint views. The patient was diagnosed with a posterior shoulder subluxation. His arm was placed in a sling and swathe, and he was directed to undergo orthopaedic follow-up evaluation. Two days later he was seen in our clinic for evaluation and further treatment. Qn presentation to our facility the patient continued to report severe pain in the left shoulder, especially with motion, and loss of function. He From Vanderbill Sports Medicine Center, Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville. Reprint requests: Kurt P. Spindler, MD, Director, Vanderbilt Sports Medicine Center, 2601 Jess Neely Dr., Nashville, TN 37212. J SHOULDERELBOWSURG1995;4:395-8. Copyright 9 1995 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/95/$5.00 + 0
32141623OO
denied neck pain, tingling, numbness, or paresthesias in his left arm. Physical examination revealed severely limited range of motion of the left shoulder in all planes; motion was limited because of pain. When the patient attempted to abduct his arm, a sharp pain at approximately 50 ~ caused him to drop his arm. His motion with passive internal and external rotation at 0 ~ abduction and with passive forward flexion and abduction to 90 ~ was much less painful. Local swelling and direct tenderness was present over the scapular body. Cervical motion was normal. Neurologic examination including motor, sensory, and reflex function was entirely normal. Peripheral pulses were symmetrically palpable. Radiographs from the emergency department were inconclusive, but views obtained at our clinic documented a minimally comminuted, slightly displaced, extraarticular fracture of the scapular body just proximal to the glenoid (Figure 1). The patient's arm was immobilized in a sling and swathe. Repeat radiographs of the arm in the sling showed acceptable alignment of the fracture with a reduced inferior tilt. 9 A magnetic resonance imaging scan (Figure 2) was also obtained to better assess the complexity of the fracture, including the degree of anteversion of the glenoid and the possibility of a stress fracture or a neoplastic process. The magnetic resonance imaging scan revealed an extraarticular fracture with a slight increase in anteversion of the glenoid and an extension of the fracture into the coracoid process that had not been seen on the plain radiographs. Furthermore, the rotator cuff and glenohumeral ligaments were intact. The patient was immobilized for 3 weeks. Repeat radiographs continued to show acceptable alignment of the fracture with early callus formation. Examination at 3 weeks revealed no swelling, minimal tenderness, active abduction of the shoulder to 150 ~, and forward flexion to 170 ~. A rehabilitation program was initiated. At 4 weeks the patient had return of full active range of motion, and the shoulder pain had resolved.
395
396
Wyrsch, Spindler, and Stricker
J. ShoulderElbow Surg. September~October 1995
Figure 1 Anteroposterior (A) and axillary lateral (B) view of left shodder demonstrate minimally comminuted and slightly displaced extraarticularfracture of scapula just proximal to glenoid,
Figure 2 Magnetic resonance image was also obtained. This image demonstrated extension of fracture into coracoid process. In addition, no evidence of any other pathologic process was found. At 6 weeks callus was present on radiographs. Light workouts were initiated. At 10 weeks both clinical and radiographic evaluations (Figure 3) showed that the fracture was healed, and the patient was allowed to resume sparring and work-
outs: At 12 weeks the patient had regained full range of motion, had no loss in his power, and continued to be free from pain. At 14 weeks after injury he fought a rematch against the same opponent and won the professional title. At last fol-
J. Shoulder Elbow Surg. Volume 4, Number 5
Wyrsch, Spindler, and Stricker
397
Figure 3 Anteroposterior (A) and axillary (B) views 2 months after injury demonstrate heated fracture with bridging callus. low-up evaluation (5 months after the injury) he had successfully defended his title and reported no shoulder weakness or pain.
DISCUSSION Scapular fractures have been caused by many types of forces. These include motor vehicle accidents, i, 12, 14, 16, 17 falls,17 crush injuries, direct blows, ~ electrical shock, 4' 15 skiing accidents, 2 and seizures.8, 13 Certainly high-speed motor vehicle trauma accounts for most of these fractures, often with associated injuries to the chest wall, lung, shoulder girdle, and ipsilateral subclavian, axillary, or brachial arteries. 1~
A few reports exist in the literature regarding scapular fractures from indirect or less violent trauma. In his series on scapular fractures in 1932 Bloch mentioned a fracture of the scapula from "muscular action. ''5 No other details were given. Deltoff and Bressler7 reported a fracture of the scapula occurring in a nonathletic man who was performing pushups. Benton and Nelson 3 reported on an avulsion fracture of the coracoid process in a tennis player; the fracture was treated successfully by excision of coracoid fragment and reattachment of the conjoined tendon. Heyse-Moore and Stoker 11 proposed a classification of avulsion fractures of the scapula. In addition to avulsion
398
J. Shoulder Elbaw Surg. September~October 1995
Wyrsch, Spindler, and Stricker
fractures, stress fractures of the coracoid have been reported in trapshooters and in patients who do vigorous weight training/These fractures were believed to be caused by repetitive stress or minor trauma. One other series reported on scapular fractures in professional athletes. Cain and Hamilton r reviewed five cases of scapular fractures in professional football players in high-impact positions. The mechanism of injury in all instances was a direct blow to the scapula. All players were treated conservatively with early active range of motion, and fractures in four out of five athletes healed by 6 weeks with no resultant limitations. The players had a full return to competition. We report another unusual scapular body fracture from muscular action in a young professional boxer occurring as a result of a missed punch during a title boxing match. This is the third reported case in the literature and the first in a professional athlete of a scapular fracture caused by voluntary muscle contraction. As in other lowenergy and extraarticular fractures of the scapula, this patient was treated successfully by nonoperarive means with progressive active range of motion and physical therapy. Fractures from voluntary muscle contracture are infrequent. Gregerson 1~ reviewed four cases of humeral shaft fractures that occurred from throwing activities. It was hypothesized that these fractures were caused by violent torsional forces from poorly coordinated and imbalanced voluntary muscle contraction. The mechanisms of indirect scapular fractures from presumed voluntary muscle contraction are also poorly understood; Eighteen different muscles attach to the scapula, providing a multitude of diverse forces of different magnitude and direction. It is conceivable that a force generated by a violent muscle contraction could overcome the structural integrity of the scapula, leading to fracture. Certainly repetitive forces on a bone that is unaccustomed to such stresses can result in a stress fracture. In this case, however, no history of scapular pain or evidence of stress fracture on radiographs or magnetic resonance imaging was noted; the only indication of a fracture was a sudden onset of debilitating pain occurring immediately after a missed punch. Absence of direct violent trauma about the shoulder girdle in the patient's history should not exclude the possibility of a scapular fracture, as
demonstrated in this particular case. Scapular fractures can usually be diagnosed on physical examination with localized pain and tenderness on palpation with hematoma formation and swelling. Confirmation should be made by an axillary or Westpoint radiograph, which provides excellent visualization of the entire scapular body and glenoid in addition to revealing posterior or anterior dislocation. Although uncommon, a fracture of the scapula should be considered in the differential diagnosis of shoulder pain in the setting of a direct blow, repetitive stresses, or a violent voluntary muscle contraction. The authors thank Holly Quick for editorial assistance with this manuscript. REFERENCES
1. ArmstrongCP, Van Der SpuyJ. The fractured scapula: importance and management based on a series of 62 patients. Injury 1984;15:324-9. 2. BanerjeeAK, Field S. An unusualscapularfracture caused by a water skiing accident. Br J Radial 1985;58:465-7. 3. BentonJ, Nelson C. Avulsion of the coracoid process in an athlete. J BoneJoint Surg Am 1971 ;53A:356-8. 4. Beswick DR, Morse SO, BarnesAU. Bilateral scapular fracture from low voltage electrical injury. Ann Emerg Med 1982;11:676-7. 5. BIoch E. Fracture of scapula. New Orleans Med Surg J 1923;75:704-10. 6. Cain TE, Hamilton WP. Scapular fractures in professional football players. Am J Sports Med 1992;20:363-5. 7. Deltoff MN, Bressler HB. Alypical scapular fracture. Am J Sports Med 1989;17:292-5. 8. DiRaimondoCR, PowersTA, DiRaimondoCV, et ah Scapular fractures resulting from grand mal seizuresin chronic hemodialysis patients. J Tenn Med Assoc 1986;79:411-4. 9. rink-BennettDM, BensonMT. Unusualexercise-relatedstress fractures: ~o case reports. Clin Nuc Med 198419:430-4. 10. Gregerson HN. Fracture of the humerusfrom muscularviolence. Acta Orthop Scand 1971 ;42:506-12. 11. Heyse-Moore GH, Stoker DJ. Avulsion fractures of the scapula. Skeletal Radial 1982;9:27-32. 12. Imatani RJ. Fracturesof the scapulae: a review of 53 fractures. J Trauma 1975;15:473-8. 13. Matthews RE, Cocke TB, D'Ambrosia RD. Scapular fractures secondary to seizuresin patientswith osteodystrophy.J Bone Joint Surg Am 1983;65A:850-3. 14. McGahan JP, Rab GT, Dublin A. Fracturesof the scapula. J Trauma 1980;20:880-3. 15. Tarquino 1-, Weinstein ME, VirgiJio RW. Bilateral scapubr fractures from accidental electric shock. J Trauma 1979; 19: 1324. 16. ThompsonDA, FlynnTC, Miller PW, et ah The significance of scapular fractures. J Trauma 1985;25:974-7. 17. Wilber MC, Evans EB. Fracturesof the scapula. J BoneJoint Surg Am 1977;59A:358-62.