01Approach to the Critical Patient/attcp46

Immediate life threats

›Cannot-miss diagnoses

›Scapulothoracic dissociation

›Lateral scapular displacement with massive shoulder swelling and pulselessness

›Vascular injury in up to 88% of cases

›Neurologic injury in up to 94% of cases

›Orthopedic and vascular emergency requiring emergent surgical consultation

›Subclavian or axillary artery injury

›Absent or diminished radial pulse

›Expanding supraclavicular hematoma

›Upper extremity ischemia

›Hemodynamic instability from polytrauma hemorrhage

›SBP <90 mmHg

›HR >120 beats/min as surrogate hemorrhage marker

Initial stabilization

›ATLS primary survey priorities

›Airway and breathing

›Pneumothorax in 55-58% of high-energy pediatric series; similar in adults

›Immediate decompression for tension physiology

›Supplemental oxygen for SpO2 <94%

›Circulation

›Two large-bore IV access

›Type and screen in all high-energy mechanisms

›Crystalloid resuscitation 1-2 L if hemodynamically unstable

›Disability and exposure

›GCS documentation

›Full spine precautions until cleared

›Complete exposure for associated injury survey

02History/hx46

Mechanism and presentation

›Mechanism of injury

›Motor vehicle collision

›Speed, restraint use, airbag deployment, ejection

›Motorcycle collision

›Most common mechanism for displaced fractures

›Fall from height

›Height, surface, landing position

›Direct blow or crush

›Industrial accident or contact sport

›Same-level fall in elderly

›Increasingly common mechanism for glenoid rim fractures

›Pain characterization

›Posterior shoulder or periscapular pain

›Onset, severity, radiation

›Inability to move the arm

›Chest pain or pleuritic component

›Suggests associated rib fracture, pneumothorax, or hemothorax

Associated symptoms

›Neurologic symptoms

›Ipsilateral arm numbness, tingling, or weakness

›Brachial plexus injury concern

›Loss of consciousness or confusion

›Concomitant TBI

›Neck pain

›Cervical spine fracture until proven otherwise

›Cardiorespiratory symptoms

›Dyspnea or shortness of breath

03Physical Exam/exam44

Vital signs and general

›Hemodynamic snapshot

›SBP <90 mmHg suggesting hemorrhage from associated injuries

›Tachycardia HR >100 beats/min

›Respiratory rate and oxygen saturation

›Temperature for sepsis if delayed presentation

Shoulder and upper extremity exam

›Inspection

›Posterior shoulder swelling or ecchymosis

›Massive swelling raises immediate concern for scapulothoracic dissociation

›Abrasions over posterior shoulder

›Deformity of clavicle or AC joint

›Concomitant clavicle fracture in up to 21% of cases

›Palpation

›Scapular body, spine, acromion, and coracoid tenderness

›Clavicle and AC joint palpation

›Supraclavicular fossa for expanding hematoma

›Neurovascular exam

›Radial, ulnar, and brachial pulses bilaterally

›Absent or diminished pulse triggers emergent vascular evaluation

›Capillary refill and skin perfusion

›Sensation in all dermatomes

›Axillary nerve (deltoid patch)

›Musculocutaneous, median, ulnar, radial nerve distributions

›Motor testing

›Deltoid, biceps, wrist extensors, grip strength, and intrinsics

›Range of motion

›Typically severely limited by pain; do not force

04Differential Diagnosis/ddx44

Life-threatening diagnoses

›Scapulothoracic dissociation

›ICD-10 S43.00 (shoulder dislocation, unspecified)

›Lateral scapular displacement on chest radiograph

›Massive shoulder swelling with neurovascular compromise

›Mortality rate significant; vascular repair required emergently

›Traumatic subclavian or axillary artery injury

›ICD-10 S25.1 (injury of innominate or subclavian artery)

›Absent radial pulse, expanding hematoma

›Clavicle fracture is independent risk factor

›Tension pneumothorax

›ICD-10 S27.0 (traumatic pneumothorax)

›Tracheal deviation, absent breath sounds, hemodynamic collapse

›Massive hemothorax

›ICD-10 S27.1 (traumatic hemothorax)

›Dullness to percussion, hypotension

Shoulder girdle injuries

›Clavicle fracture

›ICD-10 S42.00

›Palpable deformity and tenderness along clavicle

›Proximal humerus fracture

›ICD-10 S42.20

›Tenderness over proximal humerus; ecchymosis tracking to arm

›AC joint separation

›ICD-10 S43.10

›Step-off deformity at AC joint

›Glenohumeral dislocation

›ICD-10 S43.00

05Laboratory Tests/lt33

Core trauma labs

›Hematologic assessment

›Complete blood count

›Baseline hemoglobin for hemorrhage monitoring

›Repeat at 4-6 hours if suspected ongoing blood loss

›Type and screen

›Mandatory in all high-energy mechanisms

›Crossmatch if surgical intervention anticipated

›Coagulation profile

›PT/INR and aPTT

›Anticoagulant use or surgical preparation

›Abnormal coagulation in massive hemorrhage

›Fibrinogen if massive transfusion protocol activated

›Metabolic panel

›Electrolytes and creatinine

›Renal function for NSAID use and contrast administration

›Potassium for rhabdomyolysis in crush injuries

›Glucose

›Stress hyperglycemia marker

Perfusion and organ injury markers

›Lactate

›Marker of tissue hypoperfusion in polytrauma

›Lactate >2 mmol/l suggests hypoperfusion

›Repeat at 2 hours if elevated to assess clearance

›Troponin

›Indication in high-energy blunt chest trauma

›Myocardial contusion screening

›Elevated troponin with ECG changes requires cardiology input

06Diagnostic Tests/dt75

Scoring Systems

›Scapula fracture severity parameters (CT-based surgical indications)

›Glenopolar angle (GPA)

›Normal GPA 30-45 degrees

›GPA <20 degrees indicates surgical consideration for neck/body fractures

›Lateral border offset (medialization)

›>10 mm medialization is surgical indication

›Sagittal angulation

›>40 degrees is surgical indication

›Glenoid articular displacement

›>4 mm displacement is surgical indication

›>30% joint surface involvement is surgical indication

›Spike sign (plain radiograph)

›Lateral border displacement beyond the glenoid on AP shoulder

›100% positive predictive value for meeting surgical indications in extra-articular fractures

›Can be used as radiographic proxy before CT is available

›Scapular index

›Ratio of distances from midline to medial scapular border bilaterally on AP chest radiograph

›Asymmetry (ratio >1.29) suggests scapulothoracic dissociation

›Non-rotated AP chest radiograph required for accuracy

›ISS (Injury Severity Score)

›Scapula fractures with high ISS drive admission decision

›High-energy mechanisms associated with ISS often >16

›1-year mortality approximately 4%, driven by associated injuries

MRI

›Indications for MRI in scapula fracture

›Brachial plexus injury evaluation

›MRI plexus protocol when neurologic deficit present without obvious bony explanation

›Nerve root avulsion vs. stretch injury differentiation

›Rotator cuff assessment

›When surgical planning requires soft tissue evaluation

›Preferred over CT for tendon and labral pathology

›Glenoid labrum evaluation

›When associated instability suspected after acute phase

›Limitations

›Not first-line in acute polytrauma setting

›Prolonged acquisition time limits utility in unstable patients

›CT remains gold standard for bony characterization

CT

›CT shoulder without contrast

›Gold standard for fracture characterization

›Scapula fractures missed on plain radiographs in 60-73% of cases

›Evaluates intra-articular extension, GPA, angulation, and lateral border offset

›ACR Appropriateness Criteria rates CT as best modality for scapula fracture characterization

›Protocol

›Thin slice (1-2 mm) axial acquisition with coronal and sagittal reformats

›3D reconstruction for surgical planning

›CT chest (trauma pan-scan)

›Evaluates pneumothorax, hemothorax, pulmonary contusion

›Rib fractures frequently identified on CT not seen on CXR

›Spine fractures present in 42% of high-energy cases

›Typically obtained as part of standard trauma workup

›CT angiography chest and upper extremity

›Indications

›Absent or asymmetric distal pulse

›Expanding supraclavicular hematoma

›Suspected scapulothoracic dissociation

›Clavicle fracture with vascular concern

›Sensitivity and specificity for arterial injury

›CT angiography sensitivity approaches 100% for major arterial injury

›ACEP Level B recommendation for vascular injury evaluation in trauma

Ultrasound

›Extended FAST (E-FAST)

›Initial screening modality in unstable patients

›Pneumothorax detection at anterior thorax (absent lung sliding)

›Hemothorax detection at costophrenic angles

›Pericardial effusion at subxiphoid view

›Intra-abdominal hemorrhage in polytrauma

›Sensitivity for pneumothorax 78-90% vs CT as gold standard

›Suprascapular nerve block guidance

›Ultrasound-guided suprascapular nerve block for severe pain

›Reduces pain scores from mean 8.9 to 2.9 within 30 minutes

›Performed by emergency physicians at bedside

›Landmark: supraspinous fossa above scapular spine

›Vascular Doppler assessment

›Arterial Doppler of subclavian, axillary, brachial arteries

›Ankle-brachial index equivalent (arm index) for vascular injury screening

›Abnormal index <0.9 compared to contralateral limb

›Adjunct to CT angiography; not a substitute in suspected major vascular injury

07Disposition/dispo40

Admission criteria

›Indications for admission

›High-energy mechanism with associated injuries

›Pneumothorax or hemothorax requiring intervention

›Pulmonary contusion with hypoxia

›Vascular injury requiring surgical or endovascular repair

›TBI with intracranial hemorrhage

›Spine fractures requiring stabilization

›Hemodynamic instability

›SBP <90 mmHg not corrected with initial resuscitation

›Scapulothoracic dissociation

›Direct admission to OR or ICU

›Surgical scapula fracture requiring operative planning

›Displaced fractures meeting CT-based surgical criteria

›Inadequate pain control

ICU-level care criteria

›ICU indications

›Vascular injury post-repair

›Limb viability monitoring

›Pulmonary contusion with progressive hypoxia

›High-flow oxygen or mechanical ventilation

›Polytrauma with ISS >15 or shock requiring vasopressors

›TBI with GCS <13

Discharge criteria

›Safe discharge parameters

›Isolated, nondisplaced scapula fracture

›No intra-articular extension

›Adequate pain control with oral analgesics

08Treatment/t61

Initial ED management

›Immobilization

›Sling or shoulder immobilizer for comfort

›Position of comfort; do not force external rotation

›Ice application for swelling reduction

›Duration of immobilization 2-4 weeks until acute pain resolves

Analgesia

›Multimodal analgesia (first-line)

›Oral NSAIDs

›Ibuprofen 400-600 mg orally every 6-8 hours with food

›Ketorolac 15-30 mg IV in ED for acute severe pain

›ACP/AAFP guideline recommends NSAIDs as first-line for acute musculoskeletal pain

›No conclusive clinical evidence NSAIDs impair fracture healing per Orthopaedic Trauma Association

›Acetaminophen

›500-1000 mg orally every 6 hours

›Maximum 4000 mg/24 hours (3000 mg in elderly or hepatic disease)

›Topical NSAIDs

›Diclofenac gel applied to posterior shoulder

›Fewer systemic side effects than oral NSAIDs

›Regional anesthesia

›Ultrasound-guided suprascapular nerve block

›Highly effective; reduces pain from mean 8.9 to 2.9 within 30 minutes

›Bupivacaine 0.25-0.5% or ropivacaine 0.5% 10-15 mL

›Landmarks: supraspinous fossa under real-time ultrasound guidance

›Consider for patients with inadequate oral analgesia or contraindications to NSAIDs

›Opioid analgesia (second-line)

›Reserved for severe or refractory pain

›Morphine 2-4 mg IV titrated to effect

09Special Populations/sp74

Pregnancy

›Physiologic considerations

›Scapula fractures from high-energy trauma in pregnancy represent polytrauma

›Fetal assessment mandatory: fetal heart rate monitoring minimum 4-6 hours after blunt trauma

›Obstetrics consultation for all pregnant trauma patients beyond 20 weeks

›Hemodynamic assessment modified by pregnancy

›Physiologic hypotension in second trimester (SBP may be 10-15 mmHg lower than baseline)

›Left lateral decubitus positioning to avoid aortocaval compression

›Imaging considerations

›CT imaging indicated when injury warrants it; fetal radiation exposure acceptable in maternal trauma

›Uterine shielding where possible without compromising diagnostic quality

›MRI for brachial plexus evaluation preferred over CT when timing allows

›Analgesia in pregnancy

›Acetaminophen safe in all trimesters

›First-line analgesic in pregnancy

›NSAIDs relatively contraindicated after 20 weeks gestation

›Risk of premature ductus arteriosus closure

›Avoid in third trimester

›Short-term opioids acceptable for severe acute pain

›Neonatal monitoring for withdrawal if near-term use

›Suprascapular nerve block with bupivacaine generally safe in pregnancy

Geriatric

›Epidemiologic considerations

›Increasing incidence in 60-80+ age group from same-level falls

›Glenoid rim fractures most common in elderly low-energy falls

›Osteoporosis enables fracture without high-energy mechanism

›1-year mortality approximately 4%, driven by associated injuries; higher in elderly frail patients

›Assessment modifications

›Baseline cognitive function and functional status

›Pre-existing dementia complicates pain assessment

›Polypharmacy review

›Anticoagulant use increases hemorrhage risk with associated injuries

›ACE inhibitors and diuretics affect hemodynamic reserve

›Bone density and fall risk assessment

›DEXA scan referral for low-energy fracture mechanisms

›Analgesia modifications

›Acetaminophen preferred first-line

›500-1000 mg orally every 6-8 hours; maximum 3000 mg/24 hours in elderly

›NSAIDs used with caution

›Increased renal impairment risk

›GI bleeding risk; co-prescribe PPI if used

›Avoid in eGFR <30 mL/min/1.73m2

›Opioids with caution

›Start at 25-50% of standard adult dose

›Delirium and fall risk increase with opioids

›Constipation prophylaxis mandatory

›Disposition considerations

›Lower threshold for admission given comorbidities and limited home support

›Functional assessment before discharge

›Sling compliance and self-care ability

›Home safety evaluation

Pediatrics

›Epidemiologic considerations

›Scapula fractures rare in children; represent high-energy trauma

›Associated pneumothorax in 55-58%, pulmonary contusion in 63%, rib fractures in 40%

›Spine fractures in 42% and intracranial hemorrhage in 32% of high-energy pediatric series

›Child maltreatment must be considered in scapula fractures in young children without adequate mechanism

›Imaging and assessment

›Skeletal survey if non-accidental trauma suspected

›CT chest and shoulder with dose-modulated technique

›Minimize radiation exposure with pediatric CT protocols

›Growth plate involvement assessment

›Salter-Harris classification if physeal injury suspected

›Analgesia in children

›Acetaminophen 15 mg/kg orally or rectally every 4-6 hours

›Maximum 75 mg/kg/day or 4000 mg/day

›Ibuprofen 10 mg/kg orally every 6-8 hours

›Maximum 40 mg/kg/day; use with food

›Avoid in infants under 6 months

›Intranasal fentanyl 1.5 mcg/kg for rapid analgesia in ED

›Maximum single dose 100 mcg

›Opioids (morphine 0.1 mg/kg IV, maximum 2-4 mg per dose) for severe pain

›Suprascapular nerve block can be performed in cooperative children under ultrasound guidance

›Disposition

›All pediatric scapula fractures from high-energy trauma require admission

›Orthopedic consultation mandatory

›Child protection team involvement if maltreatment suspected

10Background/b77

Epidemiology

›Incidence and distribution

›Scapula fractures account for <1% of all fractures

›Approximately 3-5% of shoulder girdle fractures

›High-energy mechanisms account for approximately 22% of cases

›Motor vehicle and motorcycle collisions most common

›Male predominance (64% of cases)

›Mean age 58 years

›Increasing incidence in 60-80+ age group from falls

›Fracture type distribution

›Glenoid rim fractures most common (32%)

›Scapular body fractures (28%)

›Combined patterns common with high-energy mechanisms

›Intra-articular fractures require surgical consideration in approximately 30%

›Associated injury burden

›21% have at least one associated fracture

›Clavicle and proximal humerus most common co-fractures

›Pneumothorax present in 55-58% of high-energy cases

›Pulmonary contusion in 63%

›Rib fractures in 40%, spine fractures in 42%

›Intracranial hemorrhage in 32% of high-energy pediatric cases; similar pattern in adults

›Outcomes

›1-year mortality approximately 4%

›Mortality driven by associated injuries rather than the scapula fracture itself

›81% managed nonoperatively with good outcomes

›Scapulothoracic dissociation carries high morbidity and mortality

Pathophysiology

›Fracture mechanisms

›Direct blow to posterior shoulder

›High-energy transfer required due to thick muscle coverage

›Periscapular muscles (trapezius, rhomboids, serratus anterior, rotator cuff) provide protection

›Indirect force transmission

›Axial loading through outstretched arm

›Avulsion from muscular attachments (coracoid, acromion)

›Low-energy mechanism in osteoporotic bone

›Same-level falls in elderly

›Pathologic fractures in metabolic bone disease

›Scapulothoracic dissociation mechanism

›Forceful lateral distraction of the shoulder girdle

›Disruption of sternoclavicular joint or clavicle fracture plus AC disruption

›Complete disruption of scapulothoracic articulation

›Brachial plexus traction injury in 94%

›Severity ranges from neurapraxia to root avulsion

›Subclavian or axillary artery rupture or thrombosis in up to 88%

›Fracture classification

›Zdravkovic and Damholt classification (anatomic)

›Type I: scapular body

›Type II: apophyseal (acromion, coracoid)

›Type III: superior angle, glenoid neck, glenoid fossa

›Extra-articular vs intra-articular distinction drives operative decision-making

›Superior shoulder suspensory complex (SSSC) concept

›Bony and soft tissue ring: glenoid, coracoid, coracoclavicular ligaments, distal clavicle, AC joint, acromion

›Double disruption of SSSC creates unstable shoulder girdle requiring surgical stabilization

Therapeutic Considerations

›Nonoperative treatment evidence

›Nonoperative management successful in approximately 81% of scapula fractures

›Good to excellent outcomes with sling immobilization and early rehabilitation

›Most extra-articular fractures without displacement do not require surgery

›Early mobilization reduces shoulder stiffness

›Pendulum exercises begin at 2-4 weeks when acute pain resolves

›Progressive strengthening from 6-8 weeks

›Surgical treatment evidence

›Surgical indications based on CT criteria are well-validated

›GPA <20 degrees, medialization >10 mm, angulation >40 degrees, glenoid displacement >4 mm

›Spike sign on AP radiograph has 100% PPV for surgical indication in extra-articular fractures

›Useful early triage tool before CT availability

›Intra-articular glenoid fractures with >4 mm displacement have worse outcomes with nonoperative treatment

›Analgesia evidence

›NSAIDs and acetaminophen recommended as first-line per ACP/AAFP guidelines

›Level A recommendation for acute musculoskeletal pain management

›Ultrasound-guided suprascapular nerve block is highly effective in ED

›Pain reduction from mean 8.9 to 2.9 at 30 minutes

›Emerging as standard adjunct in ED management

›Opioids reserved for refractory pain; prescriptions >7 days increase chronic use risk

›Vascular injury management

›Emergent repair required for limb-threatening ischemia

›Endovascular repair increasingly preferred where anatomy allows

›Open repair for complex or failed endovascular cases

›Brachial plexus injury prognosis poor with complete avulsion injuries

›Neurapraxia may recover; axonotmesis has variable prognosis

11Patient Discharge Instructions/pdi38

copy discharge instructions

›Diagnosis and general information

›You have been diagnosed with a scapula (shoulder blade) fracture

›This bone is well protected by muscles and heals well in most cases

›Full recovery typically takes 3-6 months

›Wear your sling at all times for the first 2-4 weeks, including during sleep

›Remove only for gentle range-of-motion exercises as directed

›Activity restrictions

›No lifting, pushing, or pulling with the injured arm

›No lifting anything heavier than a cup of water for 6 weeks

›No overhead activity until cleared by your orthopedic surgeon

›Avoid driving until cleared; pain or sling use impairs driving safety

›You may perform gentle pendulum exercises after 2-4 weeks as pain allows

›Lean forward, let arm hang freely, move in small circles

›Pain management at home

›Ibuprofen as directed with food for pain (if no allergy or contraindication)

›Acetaminophen every 6-8 hours as needed, do not exceed 4 tablets (500 mg each) per day

›Ice pack wrapped in cloth applied for 20 minutes several times daily for first 48-72 hours

›Take opioid pain medication only if prescribed; do not drive or operate machinery

›Follow-up instructions

›Orthopedic surgery follow-up within 1-2 weeks for repeat imaging and assessment

›Do not miss this appointment; fracture alignment may need re-evaluation with CT

›If CT scan was not done in the Emergency Department, your orthopedic surgeon will arrange it

›Physical therapy referral will be made by your orthopedic surgeon at appropriate time

›Return to Emergency Department immediately for

›Increasing shortness of breath or chest pain

›May indicate delayed pneumothorax or hemothorax

›New numbness, tingling, or weakness in the arm or hand

12References/r56

Guidelines and key sources

›Schmidt V, Mukka S, Bergdahl C, et al.

›Epidemiology, Treatment, and Mortality of 3973 Scapula Fractures From the Swedish Fracture Register

›Journal of Shoulder and Elbow Surgery, 2025

›https://pubmed.ncbi.nlm.nih.gov/38688421

›Villatte G, Antoni M, Girard M, Marcheix PS

›Articular and Extra-Articular Scapula Fracture

›Orthopaedics and Traumatology Surgery and Research, 2025

›https://pubmed.ncbi.nlm.nih.gov/40998115

›Brahme IS, Shaikh H, Bober K, et al.

›Could the Scapular Spike Sign Be Used as a Radiographic Proxy for Surgical Indications

›Clinical Orthopaedics and Related Research, 2026

›https://pubmed.ncbi.nlm.nih.gov/41677170

›Tatro JM, Schroder LK, Molitor BA, Parker ED, Cole PA

›Injury Mechanism, Epidemiology, and Hospital Trends of Scapula Fractures: A 10-Year Retrospective Study of the National Trauma Data Bank

›Injury, 2019

›https://pubmed.ncbi.nlm.nih.gov/30661668

›Choo AM, Schottel PC, Burgess AR

›Scapulothoracic Dissociation: Evaluation and Management

›Journal of the American Academy of Orthopaedic Surgeons, 2017

›https://pubmed.ncbi.nlm.nih.gov/28406877

›Heiman EM, Jankowski JM, Yoon RS, Feldman JJ

›Scapulothoracic Dissociation: A Review of an Orthopedic Emergency

›Orthopedic Clinics of North America, 2022

›https://pubmed.ncbi.nlm.nih.gov/34799025

›Laur O, Ha AS, Bartolotta RJ, et al.

›ACR Appropriateness Criteria Acute Shoulder Pain: 2024 Update

›Journal of the American College of Radiology, 2025

Evidence & Review

Evidence & Review