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Fracture of the scapular body: Functional outcome after conservative treatment
J Shoulder Elbow Surg (2009) 18, 443-448
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Fracture of the scapular body: Functional outcome after conservative treatment Taco Gosens, MD, PhD*, Bernhard Speigner, MD, Joanne Minekus, PhD Department of Orthopaedic Surgery and Traumatology, St. Elisabeth Hospital Tilburg, Tilburg, The Netherlands Background: Scapular body fractures, irrespective of the number of fragments, are usually managed nonoperatively, with favorable results. We evaluated results after non-operative management to determine the outcomes of scapular body fractures. Methods: We evaluated 22 patients following a fracture of the scapular body that had been treated nonoperatively. To assess the influence of accompanying injuries other than those of the involved limb, we used both patient-oriented general health and shoulder-based outcome measures. Results: In this series the functional outcome, reflected by the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Simple Shoulder Test (SST) score and the range-of-motion, showed a difference between multiple injured patient group and a group sustaining a isolated scapular fracture. There was no significant difference in the SF-36 scores of the overall group compared with an age-matched population control in any subcategory beside the subcategory social function. The SF-36 scores of the multitrauma patient group were significantly lower than the scores of the age-matched population controls in several subcategories. Conclusion: Whereas isolated scapular body fractures healed leading to a functional shoulder score level equal to the general population and a range of motion equal to the uninjured contralateral shoulder, the multitrauma patient group showed a less favorable outcome. Level of evidence: Level 4 retrospective case series. Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Scapula; scapular fractures; scapular body fractures; DASH score; simple shoulder test; SF-36; multitrauma patient
Because of its muscular coverage, scapular fractures are uncommon, representing 3% to 5% of all shoulder girdle injuries and 0.4% to 1% of all fractures.15,18 Patients are typically an average age of 35 years (range, 25-50 years).1,14,21,24 Fractures of the scapula usually result from major blunt trauma.1,12,14,21,24 Direct trauma leads to fractures of the scapular body, spina, or the acromion. Indirect *Reprint requests: Taco Gosens, MD, PhD, Department of Orthopaedic Surgery and Traumatology, St. Elisabeth Hospital Tilburg, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands. E-mail address: [email protected] (T. Gosens).
trauma compressing the shoulder has to proceed very rapidly to fracture the scapula because of the ‘‘recoil mechanism’’ described by Rowe,18 that allows the scapula to evade impacting force by retracting on the thorax with little resistance. Indirect trauma that pulls or levers the arm usually results in a fracture of the glenoid or scapular collum. Following the classification of Euler and Ruedi based on severity and prognosis, extra-articular fractures (type A, B, C) are distinguished from intra-articular fractures (type D) and from combination fractures with the proximal humerus (type E). Extra-articular fractures are classified as corpus fractures (type A), fractures of the spina, coracoid, or
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Table I
Characteristics of the patients
No.
Sex
Age
Dom
Trauma
M/S
Sat
Work
Elev,
Abd,
ER,
DASH
SST
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
F M M M F F M M M F M M M M M M M M M M M M
48 28 64 53 62 61 19 29 45 48 66 59 60 53 7 67 35 52 67 57 31 61
D D L D L D L L D L L D L D L D L D R D L L
RTA RTA RTA Fall Fall Fall Fall Fall RTA RTA Fall Fall Fall RTA Fall Fall RTA Fall RTA Fall Fall RTA
M M M M S S S S S M S S S M S S M S M S S S
N N Y Y Y Y N N Y N Y Y Y N Y N Y N Y N Y Y
N N Y Y Y Y Y Y Y N Y Y Y N Y Y Y Y Y Y Y Y
120 90 160 150 150 160 140 170 140 30 150 160 150 100 150 150 140 140 140 170 160 170
110 100 150 160 170 160 160 170 160 30 160 170 170 140 160 140 180 170 160 170 170 180
60 40 80 40 80 90 70 60 100 20 70 60 90 20 90 60 80 90 60 100 80 90
37 60 10 17 7 8 7 8 7 82 8 7 8 51 7 13 13 7 9 8 7 3
6 7 11 10 12 12 12 11 12 4 12 12 11 5 12 12 8 12 9 11 12 12
Remarks 2 months ICU for head injury
Brachial plexus injury
Thoracic vertebra fractures
Abd, Abduction; DASH, Disabilities of Hand, Shoulder and Elbow; Dom, dominant arm; Elev, elevation; ER, external rotation; ICU, intensive care unit; M, multiple injuries; RTA, road traffic accident; S, single injury; Sat, satisfied; SST, simple shoulder test; Work, return to previous level of work.
acromion (type B), and fractures of the collum (type C).3 Most scapular fractures involve the body, with a reported frequency of 43% to 73%. Fractures of the scapular neck are the second most common, at 15% to 33%).1,14,17,24 Scapular body fractures, irrespective of the number of fragments, usually are managed nonoperatively, with favorable results reported.1,14,24 Symptomatic and functional treatment typically includes pain medication, local ice, and sling immobilization, followed by stretching exercises, and after the fracture has healed by shoulder mobilization and shoulder girdle strengthening.2 Operative intervention is rare, and only 2 cases of scapular body fractures have been reported that were treated primarily by surgical intervention.5,8 Three cases have been reported of pseudoarthrosis after conservative treatment of scapular body fractures that required open reduction and internal fixation.4,6,16 Early passive and assisted active motion exercises are assumed to assist the muscle-induced self-reposition of fragments.11 Even in malposition, healed scapular body fractures are reported to show generally good results.14 Nordqvist and Petersen,17 in a long-term follow-up study, indicated that displacement exceeding 10 mm leads to functional deficits; therefore, they consider surgical treatment of strongly displaced fractures. Hardegger7 advises surgical intervention for burst fractures of the scapular body when the lateral margin of the body may be displaced and a sharp spike may enter the joint capsule.
This study used patient-oriented general health and shoulder-based outcome measures to evaluate a series of patients after the healing of a scapular body fracture that had been treated nonoperatively. We also assessed the influence of accompanying injuries other than those of the involved limb.
Materials and methods A review of emergency department and fracture clinic records identified 62 patients in whom a fracture of the scapula had been treated at our institution between 1998 and 2003. The radiographs and medical records of these patients were retrospectively reviewed, and 26 patients with a fracture of the scapular body (type A) who met our inclusion criteria were identified. Patients were included in the study if they had a closed fracture of the scapular body, no additional fracture of the spina, coracoid, acromion, neck or glenoid, a normal contralateral upper extremity, no additional acute or chronic pathologic condition affecting the function of either upper extremity, clinical evidence of fracture union, and the ability to complete the involved questionnaires. All patients had been treated with a sling and started active range of motion exercises as soon as the associated injuries allowed. No complications were registered during follow-up. Patients were offered formal physiotherapy as soon as they showed clinical evidence of healing, but compliance was variable. Three patients could not be located, and 1 patient died because of the injuries sustained during the accident, leaving 22 patients in this study (Table I).
Outcome of scapular body fractures
445
Figure 1 (A) Radiographs show a scapular body fracture with multiple fragments in a multiply traumatized patient (liver and spleen bleeding necessitating emergency laparotomy, stable pelvic fracture treated conservatively and contusion of the brain) after a road traffic accident with a good result after conservative treatment (patient 3 in Table 1). (B) CT scan of the same patient. All of the 22 patients (18 men, 4 women) who could be contacted were willing to participate and sent back their questionnaires. The mean patient age was 49 years (range, 7-67 years). Ten dominant and 12 nondominant limbs were involved. The mean follow-up was 63 months (range, 41-85 months). Outcome assessments were performed with the Disability of Arm, Shoulder and Hand score (DASH) and the Simple Shoulder Test (SST) for the function of the shoulder. Overall health outcome was assessed using the RAND 36-Item Short Form Health Survey (SF-36). The DASH is a responsive, validated, and reliable patient-oriented outcome measure for assessing disability of the upper extremity.9,19,22 A higher score means greater disability, with 100 points indicating a completely disabled extremity and 0 points indicating a ‘‘perfect extremity.’’ The SST is a validated and reliable patient-oriented outcome measure for evaluation of the shoulder function, consisting of 12 ‘‘yes’’ and ‘‘no’’ questions about activities of daily living.13 More ‘‘yes’’ answers indicate greater functional ability, whereas more ‘‘no’’ answers indicate greater functional shoulder disability. The SF-36 is a responsive, validated, and reliable patient-oriented outcome measure for assessing physical and mental components of overall health in 8 subcategories.23 For each subcategory, a higher score (range, 0-100) indicates a better outcome. Patients were asked if they were satisfied, partly satisfied, or dissatisfied with the outcome, and why. They were also asked about their work status before and after the fracture. The range of shoulder
flexion, abduction, and external rotation of either shoulder was selfassessed by the patients, preferably with the help of a second person. The returned questionnaires for 2 patients were not conclusive and they were visited for clinical examination. Statistical analysis was performed with SPSS 16 software (SPSS Inc, Chicago, IL). A t test was used to determine differences in continuous parameters. Comparison of rates between groups was performed with the Pearson c2 test. Analysis of variance testing was performed for ordinal parameters. A value of P .05 was considered significant.
Results In addition to the scapular body fracture, 8 of the 22 patients had at least one accompanying injury other than a contusion or laceration (Figure 1). All but 1 of these patients sustained the scapular body fracture in a road traffic accident, and their mean injury severity score (ISS), based on the abbreviated injury scale, was 17.41 points (range, 11-31 points).20 In the remaining 14 patients who had sustained a fracture of the scapular body without any associated injury other than contusion or laceration, the main trauma mechanism was a fall from different heights in 12 patients, followed by road traffic accidents in 2 patients.
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Table II Group
Results of the RAND 36-Item Short Form Survey Physical function
Social function
Physical problem
Social problem
Mental health
Vitality
Pain
General health
Change of health
Total patients 73.6 (78.1) 70.7 (85.4) 67.1 (77.6) 64.7 (83.9) 64 (75.8) 61.5 (66.9) 74.5 (79.7) 62.4 (68.5) 44.1 (51) (n ¼ 22) (controls)) Multiple injuries 61.7 (78.5) 52.1 (85) 58.3 (77.6) 50 (83.6) 58 (75.4) 52.5 (66.9) 63.3 (80.1) 57.5 (68.4) 37.5 (51) (n ¼ 8) (controls) 80 (77.9) 81.6 (85.5) 75 (77.2) 77.8 (84.6) 69.3 (76) 69.4 (66,7) 84.1 (79) 66.7 (67.7) 50 (50.7) Single injury (n ¼ 14) (controls) )
The controls were age-matched population.
The average ISS in this group was 4.18 points (range, 4-5 points), which was significantly different (P ¼ .002, t test). The mean age was not significantly different between groups (P ¼ .876, t test), nor was dexterity (P > .99) or gender (P ¼ .531 Pearson c2 test). Patients’ reasons for dissatisfaction after fracture healing included sense of weakness, pain, crepitations when moving the shoulder, or a bump. The difference in satisfaction between the groups was not significant (P ¼ .51, Pearson c2 test). All single-injury patients had returned to their preinjury levels of work and recreational activity within 6 months. In the multiple-injury group, 2 patients had returned to a less strenuous occupation. Two patients had not returned to work mainly as a result of associated injuries. The others returned to their preinjury levels of work and recreational activity within 1 year. The difference between the 2 groups was significant (P ¼ .003, Pearson c2 test). The single-injury group retained range of motion compared with the noninjured shoulder. The range of motion (mean standard error) for the injured shoulder was 156 33 of anteflexion, 165 15.5 of abduction, and 81 11 of external rotation. None of the values were significantly different from those for the normal, contralateral shoulder. In the multiple-injury group, a decrease of motion of the injured shoulder was observed compared with the noninjured contralateral limb. The range of motion for the injured shoulder was 120 52 for anteflexion (contralateral shoulder 167 18 ), 140 30 for abduction (contralateral shoulder 167 14 ), and 51 29 for external rotation (contralateral shoulder 72 21 ). The differences in motion between the injured and the noninjured contralateral limb were significant for anteflexion (P ¼ .004), abduction (P ¼ .011), and external rotation (P ¼ .001, t test). The difference in range of motion of the injured shoulder between the 2 groups was significant for abduction (P ¼ .016) and external rotation (P ¼ .002, t test). The mean DASH score ( standard deviation) of the 22 patients was 17.5 20.8 points, compared with a published normative value for the general population of 10.10 points.10 A significant difference (P ¼ .001, t test) of the
DASH score was found between the single-injury patients (7.6 14.9 points) and the multiple-injury patients (34.9 27.3 points). The overall SST score of all patients was 9.9 3.8 points. The SST score was 11.8 0.4 points in the singleinjury patients and 7.5 2.4 points in the multiple-injury patients. The difference between the 2 groups was significant (P < .001, ANOVA). The SF-36 scores of all patients did not differ significantly compared with an age-matched population control group in any subcategory aside from the social function subcategory (P ¼ .04, t test). The SF-36 scores of the multitrauma patients in the subcategories social function (P ¼ .03), vitality (P ¼ .04), and general health (P ¼ .02) were significantly lower than the scores of the age-matched population controls (Table II).27 Although the multitrauma patients tended to have lower scores in each subcategory of the SF-36 questionnaire compared with the single-injury patients, these differences were not significant (P > .05).
Discussion The severity of the force required to fracture the scapula often leads to associated thoracic injuries. In the literature, scapular fractures are shown to be a firm indicator for the severe thoracic trauma of the multiply injured patient.1,21 A retrospective study of patients with multiple injuries showed that those who sustained a scapular fracture had more severe underlying chest injuries and an overall higher ISS, but this did not correlate with a higher rate of intensive care unit admission, length of hospital stay, or death.25 More surprisingly, scapular fractures in multiple-injury patients in another study were indicated to be associated with lower mortality.26 Isolated fractures of the scapula are rare. In studies analyzing diverse types of scapular fractures, an incidence of concomitant injuries of between 75% and 88% is documented.1,12,14,18,21,24 When taking the excluded patients (peripheral nerve lesion, death of the patient) into account, the results of this study indicate that the frequency
Outcome of scapular body fractures of severe associated injuries of 45.5% in patients with scapula body fractures is lower than in patients sustaining other types of scapular fractures. This might result from different causes. In other series that studied various scapular fracture types, the predominant mechanism of injury was road traffic accidents, with a reported frequency of 64.4% to 75%.14,21,24 Scapular body fractures in this series were mainly caused by falls from different heights, and road traffic accidents were the second most common. Fractures of the scapula body have traditionally been treated nonoperatively, with the expectation of little functional loss,17 and 86% excellent or good results are reported.28 Many previous studies, however, depended on surgeon-based outcome scores that might not have been sensitive enough to detect subtle deficits. The functional outcome in this series, reflected by the DASH score, the SST score, and the range of motion, showed a difference between the multitrauma patients and those who sustained an isolated scapular fracture. Whereas isolated scapular body fractures healed, leading to a functional shoulder score level equal to the general population and a range of motion equal to the uninjured contralateral shoulder, the multitrauma patients showed a less favorable outcome. The possible causal factors are diverse. The severity of associated injuries might distract attention from the shoulder injury, resulting in delay of diagnosis of a scapular fracture and disregard of its relevance.1,21 In contrast with patients with an isolated scapular fracture, who are usually treated in the outpatient clinic and physiotherapy providing active and passive motion is started as soon as pain is tolerable, patients with multiple injuries usually are admitted to the hospital, and associated thoracic injuries often require immobilization, including the shoulder. This delayed start of motion might contribute to the reduced level of function due to adhesions developing at the thoracoscapular joint. Apart from delayed start of mobilization, the associated rib fractures that are frequently seen in the multitrauma group might influence the functional outcome by affecting the thoracoscapular joint. The fact that most of the scapular body fractures in the multitrauma patient group resulted from road traffic accidents and isolated scapular body fractures were mostly caused by falls from different heights, might indicate a different severity of force acting on the shoulder during trauma. This might be reflected in different fracture patterns of the scapular body and different associated softtissue injuries of the shoulder leading to the functional deficits in the multitrauma patient group. The absence of advanced radiologic study using magnetic resonance imaging or computed tomography (CT) scans investigating this matter is one of the limitations of this study. We were therefore unable to evaluate and determine precisely the fracture type. We did investigate for nonunion in the patients with a bad result by x-ray imaging and, when in doubt, with CT scanning. No nonunion was
447 documented in any patient. We did not routinely obtain x-ray images in those patients who were without symptoms in clinical follow-up. Three cases of nonunion of the scapular body were recently reported as rare and uncommon complications of conservatively treated scapular body fractures.4,6,16 In all 3 patients, symptoms included pain and shoulder dysfunction. Successful treatment was achieved by open reduction and internal fixation with local bone grafting. We conclude that the shoulder-related outcome measured by SST, DASH, and range of motion, as well as the general health-related outcome of scapular body fractures, is good in isolated fracture cases, but less good in patients with multiple injuries. The assumption that scapular fractures have an overall satisfying outcome is thus not reproduced in this series. Multiply injured patients with a scapular body fracture should be told that the prognosis of shoulder and general health outcome is not as good as that in patients with isolated scapular fractures. In our opinion, this is the first time that a statistical difference related to associated trauma in a selected population of fracture of the scapular body has been demonstrated.
Acknowledgment We acknowledge the relatively low number of patients and warn the reader to be cautious when drawing conclusions from these statistically different results between groups. We realize that in our series possible confounders are present, such as additional trauma causing impairment of shoulder function and lower scores in all categories of the SF-36. Whether operative treatment improves this situation remains unclear and cannot be distilled from this series.
References 1. Armstrong CP, van der Spuy J. The fractures scapula: Importance and management based on a series of 62 patients. Injury 1984;15:324-9, 62. 2. Butters KP. Fractures of the scapula. In: Buchholz RW, Heckman JD, Court-Brown CM, Tornetta P, Koval KJ, editors. Fractures in adults. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 1079-118. 3. Euler E, Ruedi T. Skapulafraktur. In: Habermayer P, Schweiberer L, editors. Schulterchirurgie. Munich: Urban & Schwarzenberg; 1996. p. 261-72. 4. Ferraz IC, Papadimitriou NG, Sotereanos DG. Scapula body nonunion: a case report. J Shoulder Elbow Surg 2002;11:98-100. 5. Fischer WR. Fracture of the scapula requiring open reduction. Report of a case. J Bone Joint Surg 1939;21:459-61. 6. Gupta R, Sher J, Williams GR, Iannotti JP. Non-union of the scapula body. A case report. J Bone Joint Surg Am 1998;80:428-30. 7. Hardegger FH, Simpson LA, Weber BG. The operative treatment of scapular fractures. J Bone Joint Surg Br 1984;66:725-31. 8. Harmon PH, Baker DR. Fracture of the scapula with displacement. J Bone Joint Surg 1943;25:834-8. 9. Hudak PL, Amadio PC, Bombardier CB. Development of an upper extremity outcome measure: the DASH (disabilities of the arm,
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10.
11.
12. 13.
14. 15. 16.
17. 18.
shoulder and hand). The Upper Extremity Collaborative Group (UECG). Am J Ind Med 29:602-8. Hunsaker FG, Cioffi AD, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcome instruments: normative values from the general population. J Bone Joint Surg Am 2002;84:208-15. Ideberg R. Fractures of the scapula involving the glenoid fossa. In: Bateman JE, Welsh RP, editors. Surgery of the shoulder. Philadelphia: Decker; 1984. p. 63-6. Imatini RJ. Fractures of the scapula: a review of 53 fractures. J Trauma 1975;15:473-8. Lippet SB, Harryman DT, Matsen FA 3rd. A practical tool for the evaluation of the function: the simple shoulder test. In: Matsen FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of stability and mobility. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1993. p. 501-18. McGahan JP, Rab GT, Dublin A. Fractures of the scapula. J Trauma 1980;20:880-3. McGinnis M, Denton JR. Fractures of the scapula: a retrospective study of 40 fractured scapulae. J Trauma 1989;29:1488-93. Michael D, Fazal MA, Cohen B. Nonunion of a fracture of the body of the scapula: case report and literature review. J Shoulder Elbow Surg 2001;10:385-6. Nordqvist A, Petersson C. Fracture of the body, neck, or spine of the scapula. A long term follow-up study. Clin Orthop Relat Res 1992;283:139-44. Rowe CR. Fractures of the scapula. Surg Clin North Am 1963;43: 1565-71.
T. Gosens et al. 19. Solway S, Beaton D, McConnell S, Bombardier C. The DASH outcome measure user’s manual. Toronto: Institute for Work and Health; 2002. 20. The abbreviated injury scale. Update 98. Barrington: Association of the Advancement of Automotive Medicine; 1998. 21. Thompson DA, Flynn TC, Miller PW, Fischer RP. The significance of scapular fractures. J Trauma 1985;25:974-7. 22. Veehof MM, Sleegers EJ, van Veldhoven NH, Schuurman AH, van Meeteren NL. Psychometric qualities of the Dutch language version of the Disability of the Arm, Shoulder and Hand questionnaire (DASHDLV). J Hand Ther 2002;15:347-54. 23. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30:473-81. 24. Wilber MC, Evans EB. Fractures of the scapula. An analysis of forty cases and a review of literature. J Bone Joint Surg Am 1977;59: 358-62. 25. Veysi VT, Mittal R, Agarwal S, Dosani A, Giannoudis PV. Multiple trauma and scapula fractures: so what? J Trauma 2003;55:1145-7. 26. Weening B, Walton C, Cole PA, Alanezi K, Hanson BP, Bhandari M. Lower mortality with scapular fractures. J Trauma 2005;59:1477-81. 27. Zee van der KI, Sanderman R. Het meten van de algemene gezondheidstoestand met de RAND-36: een handleiding. Groningen: Noordelijk Centrum voor Gezondheidsvraagstukken; 1993. 28. Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma 2006;20:230-3.
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Fracture of the scapular body: Functional outcome after conservative treatment Taco Gosens, MD, PhD*, Bernhard Speigner, MD, Joanne Minekus, PhD Department of Orthopaedic Surgery and Traumatology, St. Elisabeth Hospital Tilburg, Tilburg, The Netherlands Background: Scapular body fractures, irrespective of the number of fragments, are usually managed nonoperatively, with favorable results. We evaluated results after non-operative management to determine the outcomes of scapular body fractures. Methods: We evaluated 22 patients following a fracture of the scapular body that had been treated nonoperatively. To assess the influence of accompanying injuries other than those of the involved limb, we used both patient-oriented general health and shoulder-based outcome measures. Results: In this series the functional outcome, reflected by the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Simple Shoulder Test (SST) score and the range-of-motion, showed a difference between multiple injured patient group and a group sustaining a isolated scapular fracture. There was no significant difference in the SF-36 scores of the overall group compared with an age-matched population control in any subcategory beside the subcategory social function. The SF-36 scores of the multitrauma patient group were significantly lower than the scores of the age-matched population controls in several subcategories. Conclusion: Whereas isolated scapular body fractures healed leading to a functional shoulder score level equal to the general population and a range of motion equal to the uninjured contralateral shoulder, the multitrauma patient group showed a less favorable outcome. Level of evidence: Level 4 retrospective case series. Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Scapula; scapular fractures; scapular body fractures; DASH score; simple shoulder test; SF-36; multitrauma patient
Because of its muscular coverage, scapular fractures are uncommon, representing 3% to 5% of all shoulder girdle injuries and 0.4% to 1% of all fractures.15,18 Patients are typically an average age of 35 years (range, 25-50 years).1,14,21,24 Fractures of the scapula usually result from major blunt trauma.1,12,14,21,24 Direct trauma leads to fractures of the scapular body, spina, or the acromion. Indirect *Reprint requests: Taco Gosens, MD, PhD, Department of Orthopaedic Surgery and Traumatology, St. Elisabeth Hospital Tilburg, Hilvarenbeekseweg 60, 5022 GC Tilburg, the Netherlands. E-mail address: [email protected] (T. Gosens).
trauma compressing the shoulder has to proceed very rapidly to fracture the scapula because of the ‘‘recoil mechanism’’ described by Rowe,18 that allows the scapula to evade impacting force by retracting on the thorax with little resistance. Indirect trauma that pulls or levers the arm usually results in a fracture of the glenoid or scapular collum. Following the classification of Euler and Ruedi based on severity and prognosis, extra-articular fractures (type A, B, C) are distinguished from intra-articular fractures (type D) and from combination fractures with the proximal humerus (type E). Extra-articular fractures are classified as corpus fractures (type A), fractures of the spina, coracoid, or
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Table I
Characteristics of the patients
No.
Sex
Age
Dom
Trauma
M/S
Sat
Work
Elev,
Abd,
ER,
DASH
SST
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
F M M M F F M M M F M M M M M M M M M M M M
48 28 64 53 62 61 19 29 45 48 66 59 60 53 7 67 35 52 67 57 31 61
D D L D L D L L D L L D L D L D L D R D L L
RTA RTA RTA Fall Fall Fall Fall Fall RTA RTA Fall Fall Fall RTA Fall Fall RTA Fall RTA Fall Fall RTA
M M M M S S S S S M S S S M S S M S M S S S
N N Y Y Y Y N N Y N Y Y Y N Y N Y N Y N Y Y
N N Y Y Y Y Y Y Y N Y Y Y N Y Y Y Y Y Y Y Y
120 90 160 150 150 160 140 170 140 30 150 160 150 100 150 150 140 140 140 170 160 170
110 100 150 160 170 160 160 170 160 30 160 170 170 140 160 140 180 170 160 170 170 180
60 40 80 40 80 90 70 60 100 20 70 60 90 20 90 60 80 90 60 100 80 90
37 60 10 17 7 8 7 8 7 82 8 7 8 51 7 13 13 7 9 8 7 3
6 7 11 10 12 12 12 11 12 4 12 12 11 5 12 12 8 12 9 11 12 12
Remarks 2 months ICU for head injury
Brachial plexus injury
Thoracic vertebra fractures
Abd, Abduction; DASH, Disabilities of Hand, Shoulder and Elbow; Dom, dominant arm; Elev, elevation; ER, external rotation; ICU, intensive care unit; M, multiple injuries; RTA, road traffic accident; S, single injury; Sat, satisfied; SST, simple shoulder test; Work, return to previous level of work.
acromion (type B), and fractures of the collum (type C).3 Most scapular fractures involve the body, with a reported frequency of 43% to 73%. Fractures of the scapular neck are the second most common, at 15% to 33%).1,14,17,24 Scapular body fractures, irrespective of the number of fragments, usually are managed nonoperatively, with favorable results reported.1,14,24 Symptomatic and functional treatment typically includes pain medication, local ice, and sling immobilization, followed by stretching exercises, and after the fracture has healed by shoulder mobilization and shoulder girdle strengthening.2 Operative intervention is rare, and only 2 cases of scapular body fractures have been reported that were treated primarily by surgical intervention.5,8 Three cases have been reported of pseudoarthrosis after conservative treatment of scapular body fractures that required open reduction and internal fixation.4,6,16 Early passive and assisted active motion exercises are assumed to assist the muscle-induced self-reposition of fragments.11 Even in malposition, healed scapular body fractures are reported to show generally good results.14 Nordqvist and Petersen,17 in a long-term follow-up study, indicated that displacement exceeding 10 mm leads to functional deficits; therefore, they consider surgical treatment of strongly displaced fractures. Hardegger7 advises surgical intervention for burst fractures of the scapular body when the lateral margin of the body may be displaced and a sharp spike may enter the joint capsule.
This study used patient-oriented general health and shoulder-based outcome measures to evaluate a series of patients after the healing of a scapular body fracture that had been treated nonoperatively. We also assessed the influence of accompanying injuries other than those of the involved limb.
Materials and methods A review of emergency department and fracture clinic records identified 62 patients in whom a fracture of the scapula had been treated at our institution between 1998 and 2003. The radiographs and medical records of these patients were retrospectively reviewed, and 26 patients with a fracture of the scapular body (type A) who met our inclusion criteria were identified. Patients were included in the study if they had a closed fracture of the scapular body, no additional fracture of the spina, coracoid, acromion, neck or glenoid, a normal contralateral upper extremity, no additional acute or chronic pathologic condition affecting the function of either upper extremity, clinical evidence of fracture union, and the ability to complete the involved questionnaires. All patients had been treated with a sling and started active range of motion exercises as soon as the associated injuries allowed. No complications were registered during follow-up. Patients were offered formal physiotherapy as soon as they showed clinical evidence of healing, but compliance was variable. Three patients could not be located, and 1 patient died because of the injuries sustained during the accident, leaving 22 patients in this study (Table I).
Outcome of scapular body fractures
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Figure 1 (A) Radiographs show a scapular body fracture with multiple fragments in a multiply traumatized patient (liver and spleen bleeding necessitating emergency laparotomy, stable pelvic fracture treated conservatively and contusion of the brain) after a road traffic accident with a good result after conservative treatment (patient 3 in Table 1). (B) CT scan of the same patient. All of the 22 patients (18 men, 4 women) who could be contacted were willing to participate and sent back their questionnaires. The mean patient age was 49 years (range, 7-67 years). Ten dominant and 12 nondominant limbs were involved. The mean follow-up was 63 months (range, 41-85 months). Outcome assessments were performed with the Disability of Arm, Shoulder and Hand score (DASH) and the Simple Shoulder Test (SST) for the function of the shoulder. Overall health outcome was assessed using the RAND 36-Item Short Form Health Survey (SF-36). The DASH is a responsive, validated, and reliable patient-oriented outcome measure for assessing disability of the upper extremity.9,19,22 A higher score means greater disability, with 100 points indicating a completely disabled extremity and 0 points indicating a ‘‘perfect extremity.’’ The SST is a validated and reliable patient-oriented outcome measure for evaluation of the shoulder function, consisting of 12 ‘‘yes’’ and ‘‘no’’ questions about activities of daily living.13 More ‘‘yes’’ answers indicate greater functional ability, whereas more ‘‘no’’ answers indicate greater functional shoulder disability. The SF-36 is a responsive, validated, and reliable patient-oriented outcome measure for assessing physical and mental components of overall health in 8 subcategories.23 For each subcategory, a higher score (range, 0-100) indicates a better outcome. Patients were asked if they were satisfied, partly satisfied, or dissatisfied with the outcome, and why. They were also asked about their work status before and after the fracture. The range of shoulder
flexion, abduction, and external rotation of either shoulder was selfassessed by the patients, preferably with the help of a second person. The returned questionnaires for 2 patients were not conclusive and they were visited for clinical examination. Statistical analysis was performed with SPSS 16 software (SPSS Inc, Chicago, IL). A t test was used to determine differences in continuous parameters. Comparison of rates between groups was performed with the Pearson c2 test. Analysis of variance testing was performed for ordinal parameters. A value of P .05 was considered significant.
Results In addition to the scapular body fracture, 8 of the 22 patients had at least one accompanying injury other than a contusion or laceration (Figure 1). All but 1 of these patients sustained the scapular body fracture in a road traffic accident, and their mean injury severity score (ISS), based on the abbreviated injury scale, was 17.41 points (range, 11-31 points).20 In the remaining 14 patients who had sustained a fracture of the scapular body without any associated injury other than contusion or laceration, the main trauma mechanism was a fall from different heights in 12 patients, followed by road traffic accidents in 2 patients.
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Table II Group
Results of the RAND 36-Item Short Form Survey Physical function
Social function
Physical problem
Social problem
Mental health
Vitality
Pain
General health
Change of health
Total patients 73.6 (78.1) 70.7 (85.4) 67.1 (77.6) 64.7 (83.9) 64 (75.8) 61.5 (66.9) 74.5 (79.7) 62.4 (68.5) 44.1 (51) (n ¼ 22) (controls)) Multiple injuries 61.7 (78.5) 52.1 (85) 58.3 (77.6) 50 (83.6) 58 (75.4) 52.5 (66.9) 63.3 (80.1) 57.5 (68.4) 37.5 (51) (n ¼ 8) (controls) 80 (77.9) 81.6 (85.5) 75 (77.2) 77.8 (84.6) 69.3 (76) 69.4 (66,7) 84.1 (79) 66.7 (67.7) 50 (50.7) Single injury (n ¼ 14) (controls) )
The controls were age-matched population.
The average ISS in this group was 4.18 points (range, 4-5 points), which was significantly different (P ¼ .002, t test). The mean age was not significantly different between groups (P ¼ .876, t test), nor was dexterity (P > .99) or gender (P ¼ .531 Pearson c2 test). Patients’ reasons for dissatisfaction after fracture healing included sense of weakness, pain, crepitations when moving the shoulder, or a bump. The difference in satisfaction between the groups was not significant (P ¼ .51, Pearson c2 test). All single-injury patients had returned to their preinjury levels of work and recreational activity within 6 months. In the multiple-injury group, 2 patients had returned to a less strenuous occupation. Two patients had not returned to work mainly as a result of associated injuries. The others returned to their preinjury levels of work and recreational activity within 1 year. The difference between the 2 groups was significant (P ¼ .003, Pearson c2 test). The single-injury group retained range of motion compared with the noninjured shoulder. The range of motion (mean standard error) for the injured shoulder was 156 33 of anteflexion, 165 15.5 of abduction, and 81 11 of external rotation. None of the values were significantly different from those for the normal, contralateral shoulder. In the multiple-injury group, a decrease of motion of the injured shoulder was observed compared with the noninjured contralateral limb. The range of motion for the injured shoulder was 120 52 for anteflexion (contralateral shoulder 167 18 ), 140 30 for abduction (contralateral shoulder 167 14 ), and 51 29 for external rotation (contralateral shoulder 72 21 ). The differences in motion between the injured and the noninjured contralateral limb were significant for anteflexion (P ¼ .004), abduction (P ¼ .011), and external rotation (P ¼ .001, t test). The difference in range of motion of the injured shoulder between the 2 groups was significant for abduction (P ¼ .016) and external rotation (P ¼ .002, t test). The mean DASH score ( standard deviation) of the 22 patients was 17.5 20.8 points, compared with a published normative value for the general population of 10.10 points.10 A significant difference (P ¼ .001, t test) of the
DASH score was found between the single-injury patients (7.6 14.9 points) and the multiple-injury patients (34.9 27.3 points). The overall SST score of all patients was 9.9 3.8 points. The SST score was 11.8 0.4 points in the singleinjury patients and 7.5 2.4 points in the multiple-injury patients. The difference between the 2 groups was significant (P < .001, ANOVA). The SF-36 scores of all patients did not differ significantly compared with an age-matched population control group in any subcategory aside from the social function subcategory (P ¼ .04, t test). The SF-36 scores of the multitrauma patients in the subcategories social function (P ¼ .03), vitality (P ¼ .04), and general health (P ¼ .02) were significantly lower than the scores of the age-matched population controls (Table II).27 Although the multitrauma patients tended to have lower scores in each subcategory of the SF-36 questionnaire compared with the single-injury patients, these differences were not significant (P > .05).
Discussion The severity of the force required to fracture the scapula often leads to associated thoracic injuries. In the literature, scapular fractures are shown to be a firm indicator for the severe thoracic trauma of the multiply injured patient.1,21 A retrospective study of patients with multiple injuries showed that those who sustained a scapular fracture had more severe underlying chest injuries and an overall higher ISS, but this did not correlate with a higher rate of intensive care unit admission, length of hospital stay, or death.25 More surprisingly, scapular fractures in multiple-injury patients in another study were indicated to be associated with lower mortality.26 Isolated fractures of the scapula are rare. In studies analyzing diverse types of scapular fractures, an incidence of concomitant injuries of between 75% and 88% is documented.1,12,14,18,21,24 When taking the excluded patients (peripheral nerve lesion, death of the patient) into account, the results of this study indicate that the frequency
Outcome of scapular body fractures of severe associated injuries of 45.5% in patients with scapula body fractures is lower than in patients sustaining other types of scapular fractures. This might result from different causes. In other series that studied various scapular fracture types, the predominant mechanism of injury was road traffic accidents, with a reported frequency of 64.4% to 75%.14,21,24 Scapular body fractures in this series were mainly caused by falls from different heights, and road traffic accidents were the second most common. Fractures of the scapula body have traditionally been treated nonoperatively, with the expectation of little functional loss,17 and 86% excellent or good results are reported.28 Many previous studies, however, depended on surgeon-based outcome scores that might not have been sensitive enough to detect subtle deficits. The functional outcome in this series, reflected by the DASH score, the SST score, and the range of motion, showed a difference between the multitrauma patients and those who sustained an isolated scapular fracture. Whereas isolated scapular body fractures healed, leading to a functional shoulder score level equal to the general population and a range of motion equal to the uninjured contralateral shoulder, the multitrauma patients showed a less favorable outcome. The possible causal factors are diverse. The severity of associated injuries might distract attention from the shoulder injury, resulting in delay of diagnosis of a scapular fracture and disregard of its relevance.1,21 In contrast with patients with an isolated scapular fracture, who are usually treated in the outpatient clinic and physiotherapy providing active and passive motion is started as soon as pain is tolerable, patients with multiple injuries usually are admitted to the hospital, and associated thoracic injuries often require immobilization, including the shoulder. This delayed start of motion might contribute to the reduced level of function due to adhesions developing at the thoracoscapular joint. Apart from delayed start of mobilization, the associated rib fractures that are frequently seen in the multitrauma group might influence the functional outcome by affecting the thoracoscapular joint. The fact that most of the scapular body fractures in the multitrauma patient group resulted from road traffic accidents and isolated scapular body fractures were mostly caused by falls from different heights, might indicate a different severity of force acting on the shoulder during trauma. This might be reflected in different fracture patterns of the scapular body and different associated softtissue injuries of the shoulder leading to the functional deficits in the multitrauma patient group. The absence of advanced radiologic study using magnetic resonance imaging or computed tomography (CT) scans investigating this matter is one of the limitations of this study. We were therefore unable to evaluate and determine precisely the fracture type. We did investigate for nonunion in the patients with a bad result by x-ray imaging and, when in doubt, with CT scanning. No nonunion was
447 documented in any patient. We did not routinely obtain x-ray images in those patients who were without symptoms in clinical follow-up. Three cases of nonunion of the scapular body were recently reported as rare and uncommon complications of conservatively treated scapular body fractures.4,6,16 In all 3 patients, symptoms included pain and shoulder dysfunction. Successful treatment was achieved by open reduction and internal fixation with local bone grafting. We conclude that the shoulder-related outcome measured by SST, DASH, and range of motion, as well as the general health-related outcome of scapular body fractures, is good in isolated fracture cases, but less good in patients with multiple injuries. The assumption that scapular fractures have an overall satisfying outcome is thus not reproduced in this series. Multiply injured patients with a scapular body fracture should be told that the prognosis of shoulder and general health outcome is not as good as that in patients with isolated scapular fractures. In our opinion, this is the first time that a statistical difference related to associated trauma in a selected population of fracture of the scapular body has been demonstrated.
Acknowledgment We acknowledge the relatively low number of patients and warn the reader to be cautious when drawing conclusions from these statistically different results between groups. We realize that in our series possible confounders are present, such as additional trauma causing impairment of shoulder function and lower scores in all categories of the SF-36. Whether operative treatment improves this situation remains unclear and cannot be distilled from this series.
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