Clinical Significance

The scapula is a strong bone and protects the posterior upper chest. Scapular fractures are rare and indicate severe trauma. Winging of the scapula may occur after injury to the long thoracic or the spinal accessory nerves. The long thoracic nerve may be injured during axillary dissection, trauma, or a thoracotomy.[6] The spinal accessory nerve may be injured during a procedure or with trauma to the posterior neck. In the case of a winged scapula, a pertinent physical exam finding would be the scapula on the affected side protruding posteriorly when a posterior force is applied to the extended upper extremity, such as in pushing on a wall with an arm flexed to 90 degrees. The thoracodorsal nerve may also be iatrogenically injured when performing surgery on the breast or axilla as it courses close to the anterior surface of the scapula. A sign of injury to the thoracodorsal nerve is paralysis of the ipsilateral latissimus dorsi muscle, leading to an inability to actively depress the shoulder. Injury to the dorsal scapular nerve should be suspected if the scapula on one side of the body is located more lateral from the midline when compared with the contralateral side. This injury causes paralysis of the ipsilateral rhomboid muscles.[7]

In shoulder impingement syndrome, there may be an abnormal scapular function. Dysfunctional movements of the scapula can lead to dyskinesis and abnormal motion of the shoulder. In rare cases after a high thoracotomy, the scapula may become impinged between the ribs.[8] In such cases, the base of the scapula may need to be revised.

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The scapula also provides an attachment point for the ligaments connecting the acromion to the clavicle and the coracoid process to the clavicle. These ligaments, the acromioclavicular and coracoclavicular ligaments, may become injured during a fall directly onto or with other traumatic impacts to the shoulder leading to a shoulder separation. This is a common injury with several grades of severity, depending on how badly the ligaments are injured.[9]

A case study was performed on a patient who presented with a triad of humeral fracture, scapular fracture, and traumatic anterior dislocation of the humerus. It is rare for these three injuries to occur together. The case report demonstrated that open reduction and internal fixation of the fracture before reducing the dislocation should be performed to reduce the risk of neurovascular compromise.[10]

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