Overlooked Fracture of the Inferior Scapular Angle Treated Conservatively

Abstract

Isolated fracture of the inferior scapular angle is extremely rare. We present the case of a 20-year-old female with persistent periscapular pain and a winged scapula caused by delayed union of an inferior scapular angle (ISA) fracture. Ten months previously, the patient had a car accident while seated in the left rear passenger seat. The patient visited an orthopedic clinic where a surgeon diagnosed left shoulder contusion without any abnormal radiographic findings. The left arm was kept in a sling for 2 months, as left arm elevation caused severe pain in the upper back. After sling removal, the dull pain around the left scapula continued. The patient presented at our clinic because her mother had noticed the deformity of her back. Radiographs showed a small bony fragment in the ventral side of the ISA. Computed tomography revealed a narrow gap between the ISA and the fragment. The patient's symptoms resolved with conservative treatment that consisted of relative rest for 2 months and subsequent reinforcement exercises of the serratus anterior for 2 months.

Characteristics, Management, and Outcomes of Inferior Scapula Angle Fractures: A Systematic Review of the Literature

“…Of the 467 studies assessed by title and abstract, 16 papers [3,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] were extracted and their full text was screened. One case report [22] was further excluded at this stage as it did not provide relevant data, such as MOI, management, or outcomes.…”

“…Two more case reports [23,24] were included that were found in the reference list of our relevant studies. Seventeen case reports [3,[8][9][10][11][12][13][14][15][16][17][18][19][20][21]23,24] were finally included (Figure 5). There were 15 adult and seven pediatric cases (Adult:Pediatric ratio 2.1:1), with 18 years as the cutoff age for pediatric cases.…”

“…There were 15 adult and seven pediatric cases (Adult:Pediatric ratio 2.1:1), with 18 years as the cutoff age for pediatric cases. The most common MOI was high energy injuries (77%, 17 cases); more specifically falls (41%, nine cases) [3,8,[14][15][16][17]19,21], motor vehicle accident (MVA) -including toboggan accident (27%, six cases) [3,8,9,16,18,20], and direct trauma (9%, two cases) [11,12]. On the other hand, indirect trauma, such as extreme shoulder extension, prolonged cough, and extreme arm adduction (our case), was reported in 14% (three cases) [10,13].…”

“…Displacement of the ISAF fragment was found in 64% (14 cases) [3,9,11,12,[14][15][16][17][18]21,24] (Table 1). Six cases (27%) did not report displacement [8,10,13,19,20], while in two cases (9%) it was unknown [8,23]. Winging of the scapula was found in 64% (14 cases) [3,[8][9][10][11]14,16,17,20,21,24], while in 18% (four cases) it was not reported [12,15,19] and in another 18% (four cases), it was unknown [8,13,18,23].…”

“…Initial management was conservative in 77% (17 cases) [3,[8][9][10][12][13][14]16,17,[19][20][21]23,24] and surgical in 23% (five cases) [11,15,16,18] (Table 1, Figure 6). ISAF tend to be treated initially conservatively; however, displacement strongly affects outcome.…”