Attack by Bat

Author: BuMin Kong, MD

Peer-Reviewer: Mark Hopkins, MD

Final Editor: Alex Tomesch, MD

 

30yr old M presents to the ED with pain over the right shoulder after being assaulted by a bat. Right arm is held in adduction and has limited range of motion due to pain.

Image 1.  Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 74640

1. What is your diagnosis?

2. What other injuries are often associated with this diagnosis?

3. How can you better characterize this fracture?

4. What is your management and disposition from the ED?

-- Please see below for answers –

1. What is your diagnosis?

Nondisplaced scapular neck and spine fracture (labeled in Image 2).

Image 2.  Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 74640. Annotations by author

 

2. What other injuries are often associated with this diagnosis?

The scapula is relatively mobile and surrounded by large muscles that can absorb a significant amount of force. Therefore, in the presence of a scapular fracture, suspect other traumatic injuries such as the following [1,2].

1. Upper torso: rib fractures, clavicular fractures, sternal fractures

2. Cardiopulmonary: myocardial contusion, aortic dissection, pulmonary contusion, pneumothorax

3. Spinal: thoracic spine > cervical spine > lumbar spine

 

3. How can you better characterize this fracture?

Shoulder trauma x-ray series

1. True anteroposterior view

2. Superior-inferior axillary view (looking inferiorly at the shoulder with the arm abducted) (image 3)

Image 3. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 7505. Annotations by author

 

3. Scapular Y view (Image 4)

Image 4. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 48080. Annotations by author

 

• PEARL: CT can be used to further characterize the fracture if there is concern for intra-articular extension, significant displacement, or high suspicion for concurrent injuries

Image 5. Case courtesy of Dr David Cuete, Radiopaedia.org, rID: 28072

 

4. What is your management and disposition from the ED?

This patient can be placed in a sling and follow up with orthopedics and/or sports medicine in 1-2 weeks. Most isolated scapular fractures are minimally displaced and require a sling for 2 weeks, followed by early shoulder mobility.

• PEARL: Indications for operative management include the following [2]

• Open fractures or neurovascular compromise

• Glenoid: displaced intra-articular fracture

• Scapular neck: fracture with significant angulation

• Scapular spine: comminuted fracture

• Acromion: fracture with subacromial space impingement

• Coracoid process: fracture with > 1cm displacement or third-degree acromioclavicular separation

 

Reference

1. Cole, Peter A et al. "Scapula fractures" Current reviews in musculoskeletal medicine vol. 6,1 (2013): 79-87. Doi:10.1007/s121178-012-91515-x

2. Egol K, Koval, KJ, Zuckerman JD. Handbook of Fractures. Lippincott Williams & Wilkins. 2010 ISBN: 160547760

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