Pediatric Scapula Fractures: Causes, Symptoms, and Treatment Options
Pediatric scapula fractures are uncommon but can occur due to trauma or child abuse. Learn about the causes, symptoms, and treatment options for scapula fractures in children.
Epidemiology
These are less common in children than in adults where they constitute only 1% of all fractures and 5% of shoulder fractures in the general population.
Anatomy
The scapula forms from intramembranous ossification. The body and spine are ossified at birth.
| Structure | Ossification Time |
|---|---|
| Coracoid center | 1 year |
| Base of coracoid and upper 1/4 of glenoid | 10 years |
| Tip of coracoid | Variable time |
| All three structures | 15-16 years |
| Acromion | 22 years |
| Vertebral border and inferior angle | Puberty to 22 years |
| Lower 3/4 of glenoid | Puberty to 22 years |
The suprascapular nerve traverses the suprascapular notch on the superior aspect of the scapula, medial to the base of the coracoid process, thus rendering it vulnerable when fractures occur in this region.
Isolated scapula fractures are extremely uncommon, particularly in children; child abuse should be suspected unless a clear and consistent mechanism of injury exists.
Clinical Evaluation
Full trauma evaluation, with attention to airway, breathing, circulation, disability, and exposure should be performed, if indicated.
Patients typically present with the upper extremity supported by the contralateral hand in an adducted and immobile position, with painful range of shoulder motion, especially with abduction.
Radiographic Evaluation
Initial radiographs should include a trauma series of the shoulder, consisting of true AP, axillary, and scapular-Y (true scapular lateral) views; these generally are able to demonstrate most glenoid, neck, body, and acromion fractures.
The axillary view may be used to further delineate acromial and glenoid rim fractures.
Classification
| Location | Fractures |
|---|---|
| Body (35%) and Neck (27%) Fractures | Isolated versus associated disruption of the clavicle Displaced versus nondisplaced |
| Glenoid Fractures | IA: Anterior avulsion fracture IB: Posterior rim avulsion II: Transverse with inferior free fragment III: Upper third including coracoid IV Horizontal fracture extending through body V: Combined II, III, and IV VI: Extensively comminuted |
Treatment
Scapula body fractures in children are treated nonoperatively, with the surrounding musculature maintaining reasonable proximity of fracture fragments. Operative treatment is indicated for fractures that fail to unite, which may benefit from partial body excision.
Scapula neck fractures that are nondisplaced and not associated with clavicle fractures may be treated nonoperatively. Significantly displaced fractures may be treated in a thoracobrachial cast. Associated clavicular disruption, either by fracture or ligamentous instability (i.e., multiple disruptions in the SSSC), is generally treated operatively with open reduction and internal fixation of the clavicle alone or open reduction and internal fixation of the scapula fracture through a separate incision.
Coracoid fractures that are nondisplaced may be treated with sling immobilization. Displaced fractures are usually accompanied by acromioclavicular dislocation or lateral clavicular injury and should be treated with open reduction and internal fixation.
Acromial fractures that are nondisplaced may be treated with sling immobilization. Displaced acromial fractures with associated subacromial impingement should be reduced and stabilized with screw or plate fixation.
Glenoid fractures in children, if not associated with glenohumeral instability, are rarely symptomatic when healed and can generally be treated nonoperatively if they are nondisplaced.
- Type I: Fractures involving greater than one-fourth of the glenoid fossa that result in instability may be amenable to open reduction and lag screw fixation.
- Type II: Inferior subluxation of the humeral head may result, necessitating open reduction, especially when associated with a greater than 5-mm articular step-off. An anterior approach usually provides adequate exposure.
- Type III: Reduction may be difficult; fractures occur through the junction between the ossification centers of the glenoid and are often accompanied by a fractured acromion or clavicle, or an acromioclavicular separation. Open reduction and internal fixation followed by early range of motion are indicated.
- Types IV to VI: These are difficult to reduce, with little bone stock for adequate fixation in pediatric patients. A posterior approach is generally utilized for open reduction and internal fixation with Kirschner wire, plate, suture, or screw fixation for displaced fractures.