Intra-thoracic displacement of scapular lateral margin: a case report and literature review

Abstract

Background

Cases of scapular fractures with fragments displacing into the thoracic cavity via intercostal spaces are exceedingly rare in clinical practice. According to the literature, there have been no prior reports of distal lateral margin fractures of the scapula that displace into the thoracic cavity.

Case presentation

We reported a case of a patient who presented with right shoulder pain and limited mobility after a fall. Examination revealed fractures of the medial and lateral margins of the right scapula, with the distal end of the lateral margin having detached from the inferior angle of the scapula and penetrating the thoracic cavity through the second intercostal space. Therefore, there existed the possibility of a pleural breach. We opted to perform an operation of open reduction and internal fixation via the Judet approach, during which it was confirmed that the fracture fragments were in contact but didn’t perforate the pleura, thereby avoiding complications such as pneumothorax. The use of plates on both the medial and lateral columns, together with the sturdy scapular spine, formed a triangular structure that stabilized the fracture. At the six-month postoperative follow-up, the patient demonstrated favorable clinical outcomes.

Conclusion

Surgical approaches are increasingly becoming minimally invasive. In this complex case of scapular fracture, we chose a sufficiently exposed large incision surgical approach to provide a clear view of the fracture fragment that was directed toward the pleura. The non-thoracotomy approach, avoiding the complication of pneumothorax and ensuring rigid fracture fixation, represented an alternative form of “minimally invasive” surgery.

Background

The scapula is a flat, irregular bone situated on the posterior aspect of the chest wall, with its body predominantly covered by muscles that provide robust fixation and protection. As a result, scapular fractures have a relatively low incidence, accounting for approximately 1–2.2% of all fractures [1], of which fractures of the scapular body represent around 50% [2]. Scapular body fractures typically result from high-energy trauma [3, 4], and usually accompany with injuries such as rib fractures, hemothorax, pneumothorax, clavicle fractures, pulmonary contusions, closed head injuries, and injuries to the ipsilateral upper limb [5]. However, occurrences of scapular fracture fragments displacing into the thoracic cavity are exceedingly rare. This review examines six similar cases from 1997 to the present [6,7,8,9,10,11], where fracture lines originated from the lateral margin of the scapula and extended horizontally across the scapular body or diagonally toward the inferior angle. In these cases, the fracture lines did not breach the inferior angle of the scapula, resulting in distortion of the lateral margin, which became trapped in the intercostal space and compressed the thoracic cavity. However, in the patient we reported, the lateral column of the scapula was separated from the inferior angle, with the fracture end projecting toward and contacting the pleura, which could potentially injure or aggravate injury to the pleura if not handled with caution.

Case presentation

Preoperative assessment

A 39-year-old male patient presented to our hospital on August 2, 2023, six hours after sustaining a high fall injury, complaining of pain in the right shoulder and back accompanied by limited mobility, without symptoms such as dyspnea or cyanosis. The patient’s past medical history was unremarkable with no previous trauma or surgeries. Physical examination of the chest revealed no significant crepitations or hyperresonance. A chest CT scan indicated a fracture of the second right rib, a comminuted fracture of the right scapula with displacement of the medial and lateral margins, and compression of the right thoracic cavity by the lateral margin fragment, raising concerns about possible pleural perforation (Fig. 1). The diagnoses were: (1) comminuted fracture of the right scapula, (2) possible rupture of the right pleura, and (3) fracture of the right second rib.

Fig. 1

Preoperative CT in the axial view (A) and three-dimensional reconstruction(B-D). The white arrow in (A) and (B-D) indicate the distal end of the lateral margin was compressing the right thoracic cavity through the intercostal space

Intraoperative details

Surgery was performed the day after the injury. A double-lumen endotracheal tube was utilized for anesthesia, and the patient was positioned in a lateral decubitus posture. The fracture fragments were routinely exposed through the Judet approach, revealing a comminuted fracture below the scapular spine, with both the medial and lateral margins fractured and displaced. The distal end of the lateral margin was compressing the right thoracic cavity through the intercostal space. Referring to preoperative chest X-rays and CT scans, a small amount of saline was instilled at the site of compression on the pleura caused by the distal end of the lateral margin, and the anesthesiologist was instructed to inflate the affected lung using a bag during the slow retraction of the distal end of the lateral margin. No air bubbles were observed throughout the procedure, confirming that the parietal pleura was intact preoperatively and intraoperatively, with no pneumothorax detected. Consequently, the fracture was subsequently reduced, and two locking plates were fixed between the medial and lateral borders of the scapula, achieving stable triangular fixation with the scapular spine. Intraoperative C-arm fluoroscopy demonstrated satisfactory fracture reduction and stable fixation. The procedure was completed without complications. Findings from intraoperative imaging and postoperative chest CT are as follows (Fig. 2A and B).

Fig. 2

Intraoperative imaging (A) and chest CT three-dimensional reconstruction (B) on the first postoperative day confirmed the stable fixation of the fracture with plates

Postoperative management

At 6 weeks postoperatively, the patient was instructed to gradually begin active shoulder exercises, including internal rotation, forward flexion, and abduction. Strength training was initiated at 8 weeks postoperatively. Follow-up chest CT scans were performed at regular intervals to monitor fracture fixation and healing (Fig. 3A). At the 1-year follow-up, the patient was able to resume normal weight-bearing activities, with satisfactory recovery of shoulder range of motion. Active internal rotation allowed the dorsum of the hand to reach the level of the L3 vertebral body (Fig. 3B), forward flexion reached 150° (Fig. 3C), and abduction reached 120° (Fig. 3D).

Fig. 3

Chest CT three-dimensional reconstruction (A) and shoulder joint movement (B-D) at sixth month postoperatively. Chest CT three-dimensional reconstruction demonstrates secure fixation of the scapular fracture (A). Shoulder joint movement has almost completely recovered: internal rotation (B); anterior elevation (C); abduction (D). The black box in (D) indicates the concealment of the patient’s identity

Discussion

The scapula is encircled by a complex network of muscles and ligaments and possesses a robust blood supply. General scapular fractures often heal with conservative treatment [12]. If the displacement of the scapular body fracture exceeds 1 cm, open reduction and internal fixation should be actively considered as the treatment option [13]. In this case, the patient presented with a comminuted fracture of the scapular body, characterized by the distal end of the lateral margin being displaced by more than 3 cm, which compressed the thoracic cavity and raised concerns regarding the potential for pneumothorax. Therefore, surgical intervention is warranted.

Table 1 Summarizes six similar cases from 1997 to the present, all of which exhibited comparable injury mechanisms. High-energy impacts to the posterior lateral aspect of the scapula resulted in fracture lines originating from the lateral margin And extending toward the center of the scapular body And the inferior angle of the scapula. However, the rigid inferior angle of the scapula prevents complete fractures of the lateral margin, causing it to Bend anteriorly And lodge in the intercostal space, thereby compressing the thoracic cavity. Reports by blue et al. [6]. And Shin et al. [10]. Indicated that patients underwent the removal of bone fragments through a lateral approach, which alleviated compression, with a chest drain Utilized to manage pneumothorax caused by the bone fragments. However, this surgical approach offers a limited field of view, hindering direct repair of the damaged pleura And potentially exacerbating pleural injury. Patients reported by Porte et al. [7]. And Van Schie-van der Weert [9] underwent thoracotomy through the fifth intercostal space to release bone fragments. Although thoracotomy provided an excellent field for reduction, it exacerbated pleural injury And could lead to postoperative complications such as the development of new pneumothorax, pleural effusion, empyema, or atelectasis. Park et al. [11]. Described a case in which a child’s fracture fragments were reduced through a medial approach, And a chest drain was employed for managing hemothorax And pneumothorax. During fixation, the fracture fragments were secured to the scapular body using sutures, though this method May result in inadequate fixation. Schwartzbach et al. [8]. Utilized the Judet approach to expose the fracture site. Following reduction, the fracture was securely fixed with plates, And a chest drain was placed to prevent pneumothorax And pleural effusion resulting from potential pleural rupture. We believe that prophylactic use of a chest drainage tube resulted in pleural injury, which could have been avoided.

Table 1 A review of cases of scapular fractures complicated with intra-thoracic displacement of fracture fragments from 1997 to the present

The patient we presented experienced thoracic compression due to a scapular fracture. However, this case demonstrates unique characteristics compared to previously reported similar cases. Specifically, previous cases reported that the lateral column was obliquely twisted and compressed into the intercostal space, without complete fracture or detachment from the inferior angle of the scapula. In contrast, our patient exhibited fractures of both the medial and lateral margins of the scapula, which were free-floating, along with a comminuted body fracture. The distal end of the lateral margin was completely fractured and detached from the inferior angle of the scapula, leading to compression of the right thoracic cavity through the second intercostal space. Regarding treatment approaches, previous cases have utilized small incisions or open thoracotomy for reduction and employed chest drainage tubes to manage and prevent pneumothorax. These methods have, to varying degrees, resulted in pleural injury or increased the risk of pleural damage. Although the Judet approach we chose necessitates extensive detachment of the infraspinatus muscle, it avoids the need for thoracotomy. During the reduction of the fracture fragments, adequate visualization of the surgical field and close collaboration with the anesthesiologist mitigated the risk of pleural injury and pneumothorax, thereby eliminating the need for prophylactic chest drainage postoperatively. Even in cases of intraoperative pleural injury, direct repair can be performed under visualization. Furthermore, adequate surgical exposure facilitates robust fixation of the fracture. In addition to the lateral border fracture, the patient exhibited concurrent fractures of the scapular body’s medial border and inferior angle, accompanied by significant displacement. Muscles such as the rhomboid and serratus anterior attach to the medial border and inferior angle of the scapula. Consequently, if fractures extending from the inferior angle to the medial border are not anatomically reduced and stabilized, postoperative scapular winging may occur. Speigner et al. [14]. reported a case of winged scapula caused by direct injury to the tendon-bone junction of the serratus anterior muscle at the medial border of the scapula, which led to retraction of the muscle and displacement of the scapular inferior angle fragments. Instead of excising the fragment, they reattached it to the scapula, achieved anatomic restoration of the musculotendinous insertion and preserved the tendon-bone interface. By three months postoperatively, the patient regained full strength and normal right shoulder range of motion without signs of scapular winging. Excision of avulsed fragments not only compromises scapular integrity but also hinders anatomic muscle reattachment and functional recovery. In the present case, a large displaced fracture of the scapular inferior angle required intraoperative anatomic reduction during which a plate was used to rigidly fix the inferior angle to both the medial and lateral borders, forming a triangular construct with the robust scapular spine to stabilize the fracture. At one-year postoperative follow-up, the patient demonstrated near-complete restoration of strength and right shoulder mobility.

Scapular fractures with fragments penetrating the thoracic cavity are exceptionally rare, and surgical approaches vary from distinct surgeons. Some opt for minimally invasive approaches when the lateral column remains partially intact in order to avoid dedicated fixation [6, 10, 11], while others favor extensive open approaches for cases complicated by hemopneumothorax or concurrent scapular fractures [7,8,9]. These methods, however, invariably risk pleural injury or exacerbate existing pleural compromise. In this case, severe displacement of the scapular medial and lateral columns posed a high intraoperative risk of pleural injury and pneumothorax. The Judet approach provided optimal exposure for reduction and fixation [15], with clinical evidence demonstrating its efficacy in minimizing pleural trauma and facilitating intraoperative complication management. This strategy prioritized patient’s safety and therapeutic outcomes. However, the Judet approach carries disadvantages as well, including a lengthy incision, suboptimal cosmesis, and extensive detachment of the infraspinatus muscle [16], which diverges from the strategies of contemporary minimally invasive philosophies. Paradoxically, by avoiding the greater morbidity of thoracotomy and pleural violation, the Judet approach embodies an unconventional interpretation of “minimally invasive” principles. At the 1-year postoperative evaluation, the patient exhibited no significant pain or functional limitations in shoulder mobility, with radiographic confirmation of fracture union. Follow-up outcomes suggest that the benefits of the Judet approach outweighed its inherent drawbacks in this complex scenario.

Conclusion

Integrating insights from both the previous cases and the current case presented, the surgical approach for complex scapular fractures with fragments displaced into the thoracic cavity should prioritize the complete visualization of all fracture sites and consider whether facilitate the avoidance and management of related complications, and then strive to minimize trauma and reduce incision size. It is essential to maintain a focus on fundamental surgical effectiveness and potential risks, rather than excessively pursuing superficial minimally invasive techniques.