December 08, 2017
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A 16-year-old hockey player with posterior shoulder pain, scapular winging

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A 16-year-old male hockey player was checked into the boards and sustained an isolated left scapula injury. He had no past medical history and no prior injury, deformity or pain to the left shoulder or scapula. On examination, he was noted to have significant deformity of the left scapula with prominence of the inferior angle, which resulted in the clinical appearance of winging of the scapula. There was associated ecchymosis and tenderness to palpation of the scapular body. The left shoulder had mild to moderate discomfort with active and passive motion, which was full. He had no concomitant injury and was neurovascularly intact to the left upper extremity.

Radiographs including anteroposterior (AP), lateral and axillary views of the left shoulder were obtained for further evaluation (Figure 1).

Radiographs of the left shoulder
Figure 1. Radiographs of the left shoulder revealed an extra-articular scapular body greenstick fracture with apex-volar angulation of 45°. AP (a), scapular Y lateral (b) and axillary lateral (c) views are shown. The fracture is best seen on the scapular Y view.

Source: Jeffrey S. Earhart, MD

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Scapular body fracture with significant angulation causing clinical appearance of scapular winging

Radiographs demonstrated scapular body fracture with 45° apex-volar angulation (Figure 1). CT scan with 3-D reconstructions (Figure 2) confirmed the diagnosis of an extra-articular transverse scapular body fracture with 45° apex-volar angulation and intact dorsal cortex consistent with a greenstick fracture. The patient noted difficulty wearing his shoulder pads for hockey because of the dorsal prominence from the angulated fracture. Therefore, after discussion of risks and benefits with the patient and his parents, the patient elected to undergo closed reduction under anesthesia 1 week after the injury.

Technique

The patient was positioned in the lateral decubitus position using a bean-bag and axillary roll on a radiolucent operating table, taking care to pad all extremities. The acromion and scapular spine were secured with one hand and the scapula was maximally retracted. Then, the inferior angle of the scapula was manipulated with volarly directed pressure using the other hand (Figure 3). A palpable and audible crack was encountered during manipulation and improvement of the deformity was noted. Intraoperative fluoroscopic radiographs were then obtained and showed improvement of the scapular body angulation.

Following the closed reduction, the patient was discharged home on the day of surgery and wore a sling. He was allowed immediate passive and active-assisted shoulder range of motion (ROM), but was restricted from active shoulder motion and made non-weight-bearing to the left upper extremity. After 2 weeks, he was allowed to return to full unrestricted active ROM and weightbearing as tolerated, and therapy was initiated. At 6 weeks from injury, the patient had radiographs showing progressive healing of the fracture with no residual angulation (Figure 4), no pain, full active ROM and no clinical deformity of the scapula. It was recommended that he return to hockey drills at this time, but continue to avoid contact drills and games. At 10 weeks from injury, he fully returned to competitive hockey. One year after the injury, he has no restriction to the left shoulder, continues to play hockey and has not suffered a reinjury.

scapular body greenstick fracture
Figure 2. CT of the left scapula with 3-D reconstructions showed left scapular body greenstick fracture with significant apex-volar angulation and no intra-articular involvement.Figure 3. The patient was positioned in the lateral decubitus position. The surgeon used one hand to grasp the acromion and spine of the scapula to retract the scapula. A second hand applied pressure to the inferior angle in a volar direction to achieve closed reduction. The area of erythema at the inferior scapular angle marks the site where pressure was applied.Figure 4. Radiographs obtained 6 weeks following manipulation revealed correction of the greenstick fracture angulation with full bony healing. AP (a) and scapular Y lateral (b) views are shown.

Discussion

Scapular fractures are uncommon injuries generally resulting from high-energy blunt trauma to the scapula. Although most of these injuries are treated nonoperatively, patients with these injuries may benefit from surgical management for indications including displaced intra-articular glenoid fractures, fractures resulting in significant glenoid medialization greater than 2 cm, glenoid neck fractures with significant angulation greater than 45°, glenopolar angle less than 22° and open fractures. Scapular body fractures are the most common scapula fracture pattern, and nonoperative treatment results in high rates of union and satisfactory outcomes.

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Greenstick fractures of the scapular body requiring intervention in the pediatric and adolescent population have shown up in only a few case reports. This report describes the case of a 16-year-old male hockey player who sustained an angulated greenstick fracture of the scapular body resulting in a clinical deformity similar to scapular winging. In this patient’s case, he found the deformity interfered with his ability to wear hockey shoulder pads. He and his parents therefore elected treatment with closed reduction under anesthesia. The patient achieved bony union without deformity and went on to full return to hockey activities without subsequent injury. Shin and colleagues reported a greenstick fracture of the scapular body in a 6-year-old boy resulting in a lung injury. It was treated with open reduction and chest tube insertion. Bowen and colleagues reported an angulated greenstick fracture that mimicked scapular winging in a 12-year-old boy who was treated satisfactorily with closed reduction. Our patient was 16-years-old, which indicates this injury can occur in an older adolescent compared to the prior reports of scapular body greenstick fractures. Typically, the growth plates that involve the scapula body and inferior corner will be fused by age 16 years. It is possible younger patients would have some ability to remodel these injuries if malunion occurs, although in our patient of age 16 years, there was likely minimal remodeling potential.

In this case, the patient was concerned the deformity would interfere specifically with his ability to wear shoulder pads, which was the primary indication for closed reduction. This differs from prior reports that describe associated lung injury and cosmetic deformity as the reasons for intervention. Indications for open and closed reduction of greenstick scapular body fractures are not defined in the literature since this injury has only been reported in several cases to date. We do not know to what extent this injury would interfere with shoulder and scapular function if treated without closed reduction. Although shoulder function would be unlikely to be affected, the scapular winging deformity would likely persist if the fracture was allowed to heal in a malunited position. We postulate that a young, athletic patient, such as ours, would have subjective complaints and scapular dysfunction from this deformity, which could necessitate a corrective osteotomy. The surgeon should honestly discuss the risks and benefits with the patient and family when considering closed reduction vs. no intervention for this injury.

In summary, this case suggests that an angulated greenstick fracture of the scapular body may result in a clinical deformity similar to scapular winging and that treatment with closed reduction can yield satisfactory results and improve deformity.

Disclosures: Trenhaile reports he is a consultant for and has a royalty agreement with Smith & Nephew; and is a consultant for Exactech Inc. and Rotation Medical Inc. Cvetanovich and Earhart report no relevant financial disclosures.