01Approach to the Critical Patient/attcp43

Immediate priorities

›Scapular fracture high-energy context

›ATLS primary survey

›Hemorrhage and shock triggers

›Concurrent head and chest injury suspicion

›Limb threat screening

›Radial pulse

›Ulnar pulse

›Capillary refill

›Doppler signal if pulses equivocal

›Neurovascular documentation before and after immobilization

›Axillary nerve sensation

›Deltoid motor function

›Suprascapular nerve function

›Radial nerve motor and sensation

›Median nerve motor and sensation

›Ulnar nerve motor and sensation

›Chest injury linkage

›Pneumothorax concern

›Hemothorax concern

›Pulmonary contusion concern

›Rib fracture concern

›Scapulothoracic dissociation concern

›Open fracture pathway when skin breach possible

›Antibiotics within 60 minutes goal

›Tetanus status

›Sterile moist dressing

›Immediate orthopedics escalation

02History/hx24

Mechanism and risk mapping

›History elements

›High-energy mechanism

›Motor vehicle collision

›Fall from height

›Crush injury

›Direct blow to scapula

›Traction mechanism

›Time since injury

›Prior shoulder instability

›Prior shoulder surgery or hardware

›Hand dominance

›Baseline shoulder function

›Anticoagulants and bleeding risk

›Bone health risks

›Osteoporosis

›Chronic steroid use

›Malignancy history

›Symptom red flags

›Dyspnea

›Chest pain

›Paresthesia or weakness

›Cold or pale limb

›Pain out of proportion

›Inability to elevate arm

03Physical Exam/exam40

Shoulder girdle and chest focused exam

›Exam domains

›Skin integrity

›Open wound

›Tenting

›Blanching

›Expanding hematoma

›Scapular region tenderness

›Crepitus

›Visible deformity

›Glenohumeral alignment

›AC joint tenderness

›SC joint tenderness

›Clavicle tenderness

›Rib tenderness

›Respiratory effort and symmetry

›Neurovascular exam

›Axillary nerve

›Lateral deltoid sensation

›Deltoid contraction

›Suprascapular nerve

›External rotation strength

›Abduction initiation strength

›Distal upper limb nerves

›Radial motor and sensation

›Median motor and sensation

›Ulnar motor and sensation

›Distal perfusion

04Differential Diagnosis/ddx14

Traumatic shoulder and chest mimics

›Differential clusters

›Glenohumeral dislocation

›Anterior dislocation

›Posterior dislocation

›Proximal humerus fracture

›Clavicle fracture

›AC separation

›SC dislocation

›Rib fracture

›Pneumothorax

›Pulmonary contusion

›Rotator cuff tear

›Brachial plexus injury

›Axillary artery injury

05Laboratory Tests/lt15

Labs by scenario

›Laboratory strategy

›No routine labs for isolated stable closed fracture

›Polytrauma set

›Complete blood count for bleeding concern

›Electrolytes and creatinine for trauma resuscitation context

›Venous blood gas for shock concern

›Lactate for hypoperfusion concern

›Coagulation studies for anticoagulants or major trauma

›Type and screen for operative or hemorrhage concern

›Open fracture set

›Complete blood count baseline

›Coagulation studies if operative likely

›Pitfalls and limitations

›Normal hemoglobin early after hemorrhage possible

›Lactate nonspecific for hypoperfusion source

06Diagnostic Tests/dt52

Scoring Systems

›Classification systems

›Glenoid fractures

›Ideberg classification

›Intra-articular involvement and instability risk linkage

›Scapular neck and body

›AO OTA scapula classification

›Glenopolar angle assessment

›Lateral border offset assessment

›Superior shoulder suspensory complex

›Double disruption concept

›Floating shoulder definition

›Coracoid fractures

›Ogawa classification

›Base fractures association with SSSC disruption

›Acromion fractures

›Kuhn classification

›Subacromial space compromise linkage

Radiographs

›Radiograph approach

›Trauma series context

›Chest radiograph for thoracic injury screening

›Shoulder imaging

›AP shoulder view

›Scapular Y view

›Axillary view if tolerated

›Grashey view if concern for glenoid involvement

›Dedicated scapula views

07Disposition/dispo22

Site of care and follow-up

›Disposition decisions

›Discharge criteria

›Hemodynamic stability

›Controlled pain with oral regimen

›Normal distal perfusion

›No evolving neurologic deficit

›No associated injuries requiring admission

›Admission criteria

›Polytrauma

›Significant chest injury

›Uncontrolled pain

›Neurovascular compromise

›Open fracture

›Transfer criteria

›Vascular injury concern

›Scapulothoracic dissociation concern

›Floating shoulder pattern with instability concern

›Operative glenoid fracture pattern without local capability

›Follow-up timing

›Orthopedics within 7 days for displaced patterns

›Orthopedics within 7 to 14 days for nondisplaced patterns

›Earlier reassessment for worsening pain or neurologic symptoms

08Treatment/t66

Immediate life-saving interventions

›Life threats first

›ATLS stabilization for polytrauma

›Pneumothorax treatment when present

›Hemothorax treatment when present

›Massive hemorrhage protocol when shock and bleeding present

›Vascular injury immediate escalation

›Scapulothoracic dissociation immediate escalation

Immobilization and Splinting

›Immobilization plan

›Sling and swathe

›Comfort position

›Short duration to limit stiffness

›Shoulder immobilizer option

›High pain or poor control

›Early elbow and hand motion

›Stiffness prevention

›Neurovascular recheck after immobilization

›Axillary nerve documentation

›Distal pulse documentation

Reduction

›Reduction context

›No routine reduction for scapular fractures

›If associated glenohumeral dislocation present

›Analgesia and anesthesia options

›Non-opioid analgesia

›Acetaminophen PO 1000 mg

›Ibuprofen PO 400 mg

09Special Populations/sp25

Pregnancy

›Pregnancy considerations

›Imaging strategy

›Shielding for radiographs when feasible

›CT when maternal benefit outweighs fetal risk

›Analgesia

›Acetaminophen preferred

›NSAID avoidance in later gestation per obstetric guidance

›Trauma escalation

›Obstetric consultation for significant mechanism

›Fetal assessment when viable gestation and major trauma

Geriatric

›Geriatric considerations

›Lower energy mechanisms possible

›Higher baseline stiffness risk

›Early mobilization emphasis

›Opioid adverse effects risk

›Delirium risk

›Falls risk

›Osteoporosis evaluation pathway linkage

Pediatrics

›Pediatric considerations

›Growth and remodeling context

›Nonaccidental trauma consideration when mechanism inconsistent

›Weight-based analgesia

›Acetaminophen PO 15 mg per kg

›Ibuprofen PO 10 mg per kg

›Follow-up earlier when displacement present

10Background/b27

Epidemiology

›Epidemiology highlights

›Rare injury pattern among fractures

›High-energy mechanism predominance

›High association with thoracic trauma

›Body fractures most common subtype

Pathophysiology

›Pathophysiology concepts

›Scapula protected by thoracic cage and musculature

›Body fractures from direct blow and high energy

›Neck fractures alter glenoid position relative to thorax

›Glenoid fractures disrupt articular congruity

›Acromion fractures compromise subacromial space

›Coracoid fractures disrupt SSSC ring stability

Therapeutic Considerations

›Treatment rationale

›Most fractures stable and heal with sling and early motion

›Operative indications based on instability and displacement

›Glenoid incongruity increases post-traumatic arthritis risk

›SSSC double disruption increases nonunion and dysfunction risk

›Operative consideration triggers

›Glenoid articular step-off greater than 2 to 5 mm

›Glenoid surface involvement greater than 20 to 25 percent

›Glenohumeral instability or subluxation

›Scapular neck displacement greater than 10 mm

›Scapular neck angulation greater than 40 degrees

›Glenopolar angle less than 20 degrees

›Floating shoulder with instability concern

11Patient Discharge Instructions/pdi24

Copy discharge instructions

›Discharge instructions

›Sling use for comfort

›Hand and elbow motion several times daily

›Shoulder motion plan per orthopedics timeline

›Ice 15 minutes at a time

›Elevation when resting

›Pain control plan

›Acetaminophen dosing per label or prescription

›Ibuprofen dosing per label or prescription if safe

›Opioid only if prescribed

›Activity limits

›No lifting with injured arm

›No overhead activity

›Return to ED triggers

›Worsening shortness of breath

›Chest pain

›New numbness or weakness

›Cold or pale hand

›Increasing pain not controlled

›Fever or drainage from wound

›Splint or sling causing severe pressure

›Follow-up plan

›Orthopedics appointment timing

›Repeat imaging if directed

12References/r6

Clinical guidelines and evidence sources

›Reference set

›ATLS principles for initial trauma care

›Orthopaedic Trauma Association guidance for scapula fractures

›AAOS general fracture management principles

›Procedural sedation guidance for ED sedation

›Surgical indication thresholds supported by orthopedic trauma consensus

Evidence & Review

Evidence & Review