The most common mechanism is blunt or penetrating trauma directly to the scapula. The physical exam and history can give the physician pertinent information and help rule out associated injuries that can be life-threatening. In a high energy trauma situation, depending on the patient's mental status this is not always possible. The physical exam of the shoulder and upper extremity should be performed in a matter that allows examination of the posterior forequarter. This can be difficult when the patient has multiple injuries and is supine in bed. Asymmetry of displacement of the shoulder or humeral head can be obvious or subtle. Palpation and visual examination of the bony landmarks should be performed followed by a thorough neurovascular examination of the upper extremity. Brachial plexus injuries can be associated with scapula fractures in 5-13 percent of patients. [10] Motor function can be difficult to assess secondary to pain associated with these injuries. A full assessment of the skin to look for open fractures is prudent because open fractures of the scapula require immediate irrigation and debridement in addition to antibiotics.

Because of the high energy needed to fracture the scapula, most patients found to have fractures of the scapula will have multiple other injuries. The patient should undergo evaluation as a trauma patient. However, there are specific potentially life-threatening injuries associated with scapular fractures that require assessment. For example, thoraco-scapular dissociations with disruptions of the subclavian vein and axillary vessels can lead to life-threatening hemorrhage.[11]

Diagnostic imaging should be performed to evaluate both scapular fractures and associated trauma. While conventional radiographs including an anterior-posterior, lateral, and axillary views are sufficient for evaluation of most scapular fractures, conventional radiography often misses associated injuries. Therefore, the recommendation is that a CT scan is performed in the evaluation of scapular fractures.[12] If there is a concern for the involvement of a joint, MRI may be needed to evaluate for ligamentous injury. 3D reconstruction of CT imaging may be helpful in determining management approaches and the need for surgical intervention. 

Most scapular fractures are managed effectively with closed treatment and medical management. In minimally displaced fractures, which account for more than 90% of scapular fractures, management is with short-term immobilization in a sling and swath.[13] Patients should progress as quickly as possible to begin early range of motion exercises to prevent frozen shoulder as tolerated. 

Scapular fractures themselves are rarely surgical emergencies, except for cases with thoracic penetration or dislocation causing rupture of nearby vascular structures. Fractures with significant displacement can cause long-term morbidity and poor outcomes of the shoulder which would be strong candidates for surgical techniques. Therefore, all scapular fracture should undergo evaluation for operative treatment. 

 Surgery is always recommended if there is a relevant alteration to the following: 

1. Scapula suspensory systems (SSSC; C4 linkage), "Floating Shoulder"
2. Open Fracture
3. Position integrity of the glenoid 
4. Lateral column displacement is present 

Indications for open reduction and internal fixation are based on locations of fracture, displacement, angulation, and articular step-off.[14]

Intraarticular surgical indications:

1. Articular step-off >5mm
2. Associated glenohumeral instability
3. Anterior rim fracture (>25% articular surface)
4. Posterior rim fractures (>33% articular surface)

Extraarticular body and neck fractures surgical indications:

1. Angular deformity (>40 degrees angulation)
2. Lateral border offset (>15mm plus angular deformity >35 degrees)
3. Lateral border offset (>20mm)
4. Glenopolar angle (<22 degrees) on true Grashay AP

However, since scapular fractures are often associated with other high-energy trauma, any operative management of scapular fracture should be delayed until the patient is stable. 

• Abdominal Pain in Elderly Persons

• Acromioclavicular Injury

• Fractures of Clavicle

• Mechanical Back Pain

• Pneumothorax

• Rib Fracture

• Shoulder Dislocation

Fractures found to be non-operative and managed conservatively have been shown to have good to excellent functional outcomes 86% of the time. Less than 1% of fractures require operative treatment, but studies demonstrate that operative patients have excellent functional outcomes.[15] Rehabilitation typically involves six weeks of the active and active-assisted range of motion; strength training begins approximately 3-4 months post injury or surgery. Patients can often expect virtually no functional deficits for non-operative fractures and good to excellent results in fractures requiring surgical intervention. 

1. Scapular fractures are usually the result of a significant force. Because of this, they often carry an association with other injuries.  

Associated injuries include:

• Rib fractures 
• Hips lateral lung injuries 
• Injuries to the shoulder girdle complex 
• Neurovascular injuries 
• Suprascapular nerve injuries 
• Vertebral compression fractures 

2. The evaluation should include radiographic imaging and CT scan. 

3. All scapular fractures should undergo evaluation by an orthopedic or trauma surgeon.

Since 1978, interprofessional teams have been identified by the World Health Organization as essential to high-quality care.[16] Given that scapular fractures typically occur in association with other traumatic injuries, highly competent, professional trauma teams deliver the needed care. Trauma teams will often comprise trauma surgeons, orthopedic traumatologists, emergency physicians, nurse practitioners, physician assistants, nurses, physical therapy, occupational therapy, social work, and other specialized personnel. Effective communication and utilization of the skills of each of the members of the team result and higher quality care and better patient outcomes.[17]