Scapular Fracture in a High School Football Player
J. P. McBryde, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 10 - OCTOBER 1997
In Brief: Scapular fractures are rare in athletes, but they have been reported in professional football players who play high-collision positions. This case report of a painful, nondisplaced scapular fracture in a 17-year-old high school offensive and defensive lineman shows that these fractures can happen even in amateur athletes. A scapular fracture may mimic a rotator cuff injury, as happened initially in this case. Conservative treatment is usually appropriate for these fractures unless there is severe displacement.
Scapular fractures are rare, representing less than 1% of all skeletal injuries. These fractures are frequently overlooked because of more severe accompanying injuries, and are usually associated with high-speed vehicular trauma (1,2). There have been few published reports of scapular fractures in athletes (3-5). This report describes such a fracture in a high school football player.
A 17-year-old high school football lineman presented for evaluation of his left shoulder. He reported that 1 week earlier he had fallen directly on the outside of his left shoulder during practice. At that time he had been unable to raise his arm because of pain that radiated to, but not below, his elbow. He did not practice for 2 to 3 days following that injury but subsequently returned to contact drills. After returning to practice, he again hit his shoulder. He had more pain with radiation to his hand, along with decreased range of motion. He was otherwise healthy with no previous shoulder injuries.
On initial examination, the patient's neck showed full range of motion and was nontender, and he had a full range of passive shoulder motion. However, he had pain and weakness with supraspinatus testing and on external rotation. He had no acromioclavicular joint tenderness, but he did have some pain over the trapezium. Motor strength and deep tendon reflexes of his forearm and hand were normal. Radiographs were read as an open physis at the greater tuberosity of the humerus with no acute fracture.
The patient's injury was diagnosed as a rotator cuff sprain. He was held out of contact sports for 10 days, and was instructed in range-of-motion exercises. On follow-up 11 days after the initial examination, he had excellent range of motion, some residual weakness on supraspinatus testing, and mild tenderness over the greater tuberosity. He was cleared to return to football as tolerated.
Ten days after returning to football, the patient reinjured his shoulder in a game. He presented with increasing pain and swelling about the left arm and shoulder. Examination at that time revealed pain on palpation of the scapula and severe pain while attempting to actively move his arm.
Radiographs revealed a scapular body fracture without displacement (figure 1). A computed tomography scan was obtained to rule out intra-articular involvement. The scan showed some mild displacement and deformity but no intra-articular involvement.
The patient was fitted with a sling and was restricted from football. Physical therapy was initiated 3 weeks later. At 6 weeks, repeat radiographs showed good healing with calcification at the fracture site (figure 2). He strongly desired to return to football, and was cleared for play with the knowledge that he might reinjure his scapula. However, he did well for the remaining 2 weeks of the football season.
Mechanisms of injury. Most literature on scapular fractures associates these injuries with non-sports-related trauma (1,2). I found only one article related to scapular fractures in football players, in which Cain and Hamilton (3) described professionals who played high-impact positions such as offensive backfield, wide receiver, defensive backfield, and quarterback. Our patient was an offensive and defensive lineman—positions considered not high impact.
Diagnosis. In Cain and Hamilton's review (3), rotator cuff injuries were initially suspected in two of four players, and complete tears were subsequently ruled out by arthrography. Similarly, rotator cuff sprain was initially suspected in our patient, and he was treated accordingly. Even on review of his initial radiographs, we cannot say for certain that he had a scapular injury at that time; but given his course it seems possible. Harris and Harris (6) found that 43% of the 100 scapular fractures in their series were missed on initial radiographs.
Additionally, in 1956 Nevaiser (7) described a condition called "pseudorupture of the rotator cuff" associated with scapular fractures. This condition involves weakness of the cuff following scapular fracture. Weakness is caused in part by intramuscular hemorrhage into the supraspinatus, infraspinatus, and subscapularis muscles.
Treatment. Treatment of scapular fractures is usually conservative regardless of the mechanism, and only with severe displacement should fixation be considered (2). Cain and Hamilton (3) found intra-articular extension in four of the five scapular fractures in their review, yet all the patients did well with conservative treatment, and no residual limitations or functional disability resulted in the long term.
Our patient had a fracture through the body of his scapula with no intra-articular involvement, and minimal displacement visible on a computerized axial tomography scan. He did extremely well with a shoulder sling for 3 weeks followed by physical therapy for 3 weeks, and was playing full-contact football at 6 weeks after diagnosis of the fracture.
Suspecting the Scapula
Although scapular fractures are rare in athletes, they should be suspected with any shoulder injury, and a full examination of the shoulder girdle must be performed.
Dr McBryde is an emergency medicine physician and a sports medicine fellow at the Carolinas Medical Center and Miller Orthopaedic Clinic in Charlotte, North Carolina. Address correspondence to J.P. McBryde, MD, Miller Orthopaedic Clinic, Sports Medicine Center, 1001 Blythe Blvd, Suite 200, Charlotte, NC 28203; e-mail to [email protected].