J Korean Orthop Assoc.  2014 Apr;49(2):165-171. 10.4055/jkoa.2014.49.2.165.

Treatment of Scapula Fractures of the Inferior Angle Causing Pseudowinging Scapula

• Min KD
• Hwang SH
• Kim JB
• Cho SH
• Lee BI

• KMID: 2185223
• DOI: http://doi.org/10.4055/jkoa.2014.49.2.165

Abstract

Nonoperative treatment of scapular body fractures has shown good clinical results. Although scapula fractures of the inferior angle, particularly with oblique lines from the medial proximal to lateral distally, are very rare, we believe that such a fracture pattern would be regarded as an avulsion fracture of the serratus anterior muscle requiring surgery. We have experienced three cases demonstrating pseudowinging of the scapula due to displacement of the inferior angle fracture of the scapula. Surgical repair or plating showed satisfactory clinical results. Through these cases, we describe the cause of winging scapula and the problems resulting from an avulsion fracture of the serratus anterior muscle with a review of the relevant literature and explain the reason that an operation is needed for this fracture pattern.

Keyword

scapula; serratus anterior muscle; winging scapula; avulsion fracture

MeSH Terms

Scapula*

Figure

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  Figure 1 (A) On physical examination, a 41-year-old driver who suffered a traffic accident; image shows right winging of the scapula at posttraumatic one year. (B) Scapula lateral view shows the bony fragment, which is separated from the inferior border of the scapula and displaced by the serratus anterior muscle. (C) Image of 3-dimensional-computed tomography can check for a blunted fracture margin, suggesting nonunion. (D) Intraoperative image shows the surgical technique used to reduce and hold the fracture with a double plate and surgical repair. (E) At postoperative six weeks, lateral radiograph of the right scapula shows a well reducted state of the bony fragment. (F) At postoperative three months, there is no winging of the scapula on elevation of the arm and no crepitus on abduction.

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  Figure 2 (A, B) Scapula lateral view and image of 3-dimensional-computed tomography show the inferior border fracture of the scapula and anterolateral displacement of the bony fragment. (C, D) At postoperative three months, lateral radiograph and image of 3-dimensional-computed tomography of the left scapula confirm good alignment of the inferior angle of the scapula.

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  Figure 3 (A) On initial examination, a 55-year-old man who fell from a height of 2 m; photography shows dominant winging of the right scapula in leaning with his arms on the wall. (B) Scapula lateral view shows anterolateral displacement of the bony fragment with the inferior border fracture of the scapula. (C) At postoperative three months, image of 3-dimensional-computed tomography of the right scapula confirms acceptable alignment of the inferior angle of the scapula.

Reference

1. Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006; 20:230–233.

2. Hayes JM, Zehr DJ. Traumatic muscle avulsion causing winging of the scapula. A case report. J Bone Joint Surg Am. 1981; 63:495–497.

3. Heyse-Moore GH, Stoker DJ. Avulsion fractures of the scapula. Skeletal Radiol. 1982; 9:27–32.

4. Brindle TJ, Coen M. Scapular avulsion fracture of a high school wrestler. J Orthop Sports Phys Ther. 1998; 27:444–447.

5. Bowen TR, Miller F. Greenstick fracture of the scapula: a cause of scapular winging. J Orthop Trauma. 2006; 20:147–149.

6. Mansha M, Middleton A, Rangan A. An unusual cause of scapular winging following trauma in an army personnel. J Shoulder Elbow Surg. 2010; 19:e24–e27.

7. Gaffney KM. Avulsion injury of the serratus anterior: a case history. Clin J Sport Med. 1997; 7:134–136.

8. Otoshi K, Itoh Y, Tsujino A, Hasegawa M, Kikuchi S. Avulsion injury of the serratus anterior muscle in a high-school underhand pitcher: a case report. J Shoulder Elbow Surg. 2007; 16:e45–e47.

9. Hamada J, Igarashi E, Akita K, Mochizuki T. A cadaveric study of the serratus anterior muscle and the long thoracic nerve. J Shoulder Elbow Surg. 2008; 17:790–794.

10. Franco M, Albano L, Blaimont A, Barrillon D, Bracco J. Spontaneous fracture of the lower angle of scapula. Possible role of cough. Joint Bone Spine. 2004; 71:580–582.