Bilateral scapular fracture in blunt chest trauma: Report of 2 cases

Abstract

Bilateral scapular fracture (BSF) is a very rare injury, with most of the reported cases in the literature being attributed to electrical shock or epileptic seizures. The significance of scapular fractures in blunt chest trauma extends beyond the bone injury itself, as they often serve as indicators of severe associated thoracic injuries, some of which may be life-threatening. As it is rarely encountered and documented, it might go unrecognized in cases of polytrauma. The likelihood of long-term complications due to the delay in the diagnosis can be avoided by the early recognition and management of such cases. Herein, we present 2 cases of bilateral scapular fractures following severe blunt chest trauma. The CT scan allowed identification of the BSF that was missing on the initial X-ray as well as other serious thoracic and extra-thoracic injuries. Both patients needed operative intervention for severe associated injuries, however the scapular fractures were treated conservatively leading to favorable outcomes.

Introduction

Scapular fractures are uncommon in blunt trauma and usually result from high-energy impacts on the chest [1]. Bilateral scapular fracture (BSF) is a very rare injury, with most of the reported cases in the literature being attributed to electrical shock or epileptic seizures [2]. A limited number of BSF have been documented in the context of blunt chest trauma [3]. The BSF is usually associated with high-energy injury mechanisms of trauma. However, the significance of scapular fractures in blunt chest trauma extends beyond the bone injury itself, as they often serve as indicators of severe associated thoracic injuries, some of which may be life-threatening and require urgent intervention [3].

As they are rarely encountered and documented, these fractures might go unrecognized in cases of polytrauma [2]. Diagnosing scapular fractures on plain radiographs is often missed [4]. Furthermore, the likelihood of long-term complications due to the delay in the diagnosis can be avoided by the early recognition of such cases [5]. Herein, we present 2 cases BSF following severe blunt chest trauma.

To our knowledge, these cases are among the few reported cases of BSF caused by a high energy blunt trauma. The trauma resulted in serious thoracic and extra-thoracic injuries in both cases which distinguish them from other cases of BSC due to electrical shock or epileptic seizures. The presentation of these cases adds valuable insight into the clinical spectrum and management approach of such rare injuries.

Case presentation

Case 1

A 29-year-old male was involved in a motor vehicle collision. The patient was sitting in the open part of the pick-up car, unrestrained. Vehicle rolled over and he fell off the vehicle.

On arrival at the Emergency Department, he was semi-conscious with Glasgow Coma Score (GCS) 9/15, a pulse rate of 103 beats/min, blood pressure of 107/76 mmHg, and a respiratory rate of 30 breath/min. A structured trauma assessment was performed according to ATLS protocol, systematically addressing the airway, breathing and circulation. During the primary survey, on physical examination, his airway was intact with labored breathing. Air entry decreased on the right side with right-sided surgical emphysema, and bilateral chest wall contusion.

The secondary survey was conducted to identify additional injuries. A lacerated wound on the antero-medial aspect of the left thigh was noted, which was consistent with a degloving injury reaching the inguinal ligament.

Plain chest radiography revealed diffuse opacification of the entire right lung field with pneumothorax. Scapular fractures were not detected.

The patient was intubated, and a right-sided chest tube was inserted. Following initial stabilization, a subsequent trauma computerized tomography (CT) scan revealed multiple injuries including BSF, multiple rib fractures, extensive bilateral lung contusions more on the right lung, mild right-sided pneumothorax and surgical emphysema (Fig. 1). Additionally, the CT scan showed a subcapsular hematoma in the liver with multiple hepatic parenchymal contusions (Grade II liver injury) and right adrenal gland hematoma. Fractures were also noted in the left transverse processes of L1–L5 vertebrae, left acetabulum, left pubic bone, and the right iliac bone extending into the sacroiliac joint. There was also surgical emphysema of the left thigh extending to the inguinal area.

Fig. 1.

CT 3D reconstruction (A), axial (B), and coronal sections demonstrating bilateral scapular fractures (yellow arrows) associated with pulmonary contusion (arrowhead) and right sided chest tube (red arrow).

Conservative management of scapular fractures and pelvic fractures were adopted. The cardiologist was consulted due to high troponin levels and persistent tachycardia; both ECG and echocardiogram were unremarkable, and conservative management was advised. On Day 3, the chest tube was removed, and the patient was later extubated. The degloving injury of the left thigh was explored under general anesthesia, and repeated debridement sessions (seven in total) were performed, followed by a Vacuum-assisted closure (VAC) dressing.

A follow-up X-ray of both scapulae demonstrated satisfactory alignment and positioning.

On Day 50, partial-thickness skin grafting was performed. The patient’s clinical course showed continued improvement, and he was discharged on day 57 in good condition.

The patient was followed up in the outpatient clinic for repeated wound dressing until the wound healed. The patient demonstrated full shoulder joint mobility without residual pain.

Case 2

A 29-year-old male presented to the Emergency Department after sustaining significant blunt trauma when struck by a large quantity of marble plates at his workplace. The patient complained of constant, severe pain affecting the head, chest, thoracic region, and trunk. On examination, the patient was fully conscious. His GCS score was 15/15. Vital signs were normal, and oxygen saturation was 100% on room air. Following the ATLS protocol, a primary survey was conducted. A right-sided scalp laceration with moderate bleeding and a mandibular deformity consistent with mandibular fracture was noted. Chest examination showed multiple bruises and left flail chest. Additional findings included abdominal tenderness and a right lower forearm laceration extending to the wrist, with radial and ulnar pulses that were well palpable. Secondary survey identified further injuries, plain radiographs showed bilateral rib fractures, however, the scapular fractures were not detected. The trauma CT scan revealed bilateral comminuted displaced mandibular bone fractures. The CT scan also showed BSF, bilateral small pneumohemothorax, bilateral pulmonary contusions, and multiple rib fractures (Fig. 2). Liver injury was noted with a linear laceration and multiple hypodense areas with a subcapsular hematoma (Grade II liver laceration). The patient was admitted under the care of the general surgery team for observation and further management. The patient refused open reduction and internal fixation (ORIF) of the ribs. Bilateral arm slings were applied to support the scapular fractures. On the second day of admission, the patient underwent open reduction and internal fixation (ORIF) for bilateral mandibular fractures. Conservative management was continued for the bilateral scapular fractures. The patient’s clinical course showed continued improvement, and he was discharged on the 8th day in good condition.

Fig. 2.

CT 3-dimensional (3D) reconstruction of the skull (A) and thorax axial (B), and coronal sections (C) demonstrating bilateral mandibular body fractures (arrowheads) and bilateral scapular fractures (arrows).

A follow-up radiographic examination of both scapulae was performed 2 weeks later, revealing satisfactory alignment and positioning. At 2-month follow-up, the patient demonstrated full restoration of shoulder range of motion with absence of residual pain.

Discussion

Although traumatic scapular fractures are rare, they are often indicators of the severity of the trauma to the thoracic cage [3,6,7]. The scapula is protected by layers of muscles, requiring a high level of force to induce scapular fractures, which will usually result in other serious thoracic injuries such as flail chest, rib fractures, pulmonary contusions, pneumothorax, or heart and great vessels injuries [3,7]. As evident in this report, both patients sustained serious thoracic and extra thoracic injuries that required comprehensive management highlighting the complexity of their clinical course. Diagnosing BSF in polytrauma patients might be difficult due to the presence of other injuries [6,8]. The occurrence of traumatic BSF can result from 2 main mechanisms: 1 through direct trauma to the scapula, or the other indirectly through force transmitted by shared anatomical structures with the scapula, such as the humerus or clavicle [9,10]. In both cases in this report, BSF was sustained following high-energy direct trauma to the scapula and shoulder girdle. Such severe mechanism of injury explains why a strong bone like the scapula, although well protected, was fractured bilaterally.

In both patients described in our report, initial chest X-rays failed to demonstrate scapular fractures, and the definitive diagnosis was established through CT imaging. Plain X-rays often miss scapular fractures in multiple trauma patients as the fractures may be overlooked by the overlapping of nearby structures or other associated injuries. Also, it is difficult to move injured patients into the right position to use various angles of X-rays [5,11]. Therefore, distinguishing scapular fractures on standard X-rays from other injuries, such as shoulder dislocations or rib fractures, can be difficult and may result in suboptimal management of those trauma patients [1,5].

In contrast with plain X-ray, CT imaging provides superior identification of the scapular fractures as well as the details of the accompanying injuries, thereby aiding in the decision-making process regarding the treatment [4,12].

The CT scan precisely visualizes the fracture line in relation to the glenoid fossa and scapular neck [[13], [14], [15]] Hardegger et al. [16] classified the scapular fractures into 2 main distinct types focusing on their location and complexity. The first group is where there is neither glenoid involvement nor severe displacement. Conservative management in this group is usually sufficient to restore the normal function without long term complications. The second group of fractures involving the glenoid or have severe displacement where operative intervention is preferred. This classification aids in determining the fracture complexity and risk, as well as guiding the management.

Despite the severe trauma in both cases, the scapular fractures were extra-articular and involved neither the glenoid cavity nor scapular neck. Accordingly, BSF in both cases required conservative management which included administration of analgesics and immobilization followed by early rehabilitation [[17], [18], [19]].

Conclusion

Bilateral scapular fractures are rare injuries in blunt trauma patients. CT imaging enables more precise visualization of fracture patterns which helps in determining proper management. This type of injury is an indicator of severe trauma and might be accompanied by other life-threatening thoracic injuries.

Authors contributions

All authors have read and agreed to the published version of the manuscript.

SEA: Share in the idea and concept of the study, wrote the main manuscript text Data collection, literature review, repeated editing of the manuscript.

AAQ: Share in the idea and concept of the study, data collection, literature review, repeated editing of the manuscript, approved the final manuscript.

AFH: Share in the idea and concept of the study, data collection, literature review, repeated editing of the manuscript, and preparation of figures and final manuscript.

Patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have consent for images and other clinical information to be reported in the journal. They understand that names and initials will not be published, and due efforts will be made to conceal the patient identity, but anonymity cannot be guaranteed.