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Multiple Trauma and Scapula Fractures: So What?Veysi T. Veysi, FRCS, Rajnish Mittal, FRCS, Sanjeev Agarwal, FRCS, Anis Dosani, FRCS, and

Peter V. Giannoudis, MD, EEC(Orth)

Background: Scapula fractures arerare and are presumed to indicate severe

underlying trauma. We studied injury pat-

terns and overall outcome in patients with

multiple injuries with scapula fractures.

Methods: We carried out a retro-spective review of patients with multiple

injuries (Injury Severity Score [ISS]> 16)

with chest and musculoskeletal injuries

admitted to our institution between 1993

and 1999 to investigate whether the pres-

ence of a scapula fracture is a marker of

increased morbidity and mortality.Results: There were 1,164 patients

admitted with multiple trauma. Seventy-

nine (6.8%) of the 1,164 sustained a scap-

ula fracture, forming the study group. The

remainder of the patients (n 1,085)

formed the control group of the study.

Both groups of patients were similar with

regard to age and Glasgow Coma Scale

score (age, 42 17.8 [ SD] vs. 40 22;

GCS score, 11.2 5.1 vs. 11 5 in the

study and control groups, respectively).

The overall ISS was significantly higher in

those with scapula fractures (27.12

15.13 vs. 22.8 14.4, p 0.01). Patients

with scapula fractures also had more se-

vere chest injuries (Abbreviated Injury

Scale score of 3.46 1.1 vs. 3.1 1.0,

respectively), but not significantly so.However, the incidence of rib fractures

was significantly higher in the patients

with scapula fractures (p < 0.05). The in-

cidence and severity of head and abdom-

inal injuries were similar in the two

groups. The severity of extremity injuries

in patients with scapula fractures was sig-

nificantly lower (2.4 0.6 vs. 2.7 0.7, p

0.001). The rate of admission, the length

of intensive care unit stay, and the overall

length of hospital stay were similar in the

two groups. The overall mortality rate

was 11.4% in patients with scapula frac-

tures and 20% in those without scapula

fractures (p 0.1).

Conclusion: Patients with scapulafractures have more severe underlying

chest injuries and overall ISS. However,this did not correlate with a higher rate of

intensive therapy unit admission, length of

hospital stay, or mortality.

Key Words: Scapula, Fracture, Mul-tiple injuries, Chest injuries.

J Trauma. 2003;55:11451147.

The scapula is surrounded by a thick envelope of muscles

that protect it during an impact. The anatomic position of

the scapula on the posterolateral corner of the upper

body is also thought to be a protective feature. These two

factors combine to make fractures of the scapula rare and torequire high-energy trauma for injury. The presence of a

scapula fracture therefore is believed to indicate severe un-

derlying injuries.1,2 Not surprisingly, chest trauma is the most

common associated injury with scapula fractures and may

contribute to a worse outcome in these patients.3

The purpose of this study was to investigate the inci-

dence and clinical features of scapula fractures in patients

with multiple injuries with chest injuries. Furthermore, the

impact of its presence on mortality and overall outcome was

assessed.

PATIENTS AND METHODSA review of prospectively collected data in our trauma

unit for the years 1993 through 1999 was undertaken. This

collection of data forms part of the Trauma Audit and Re-

search Networks ongoing study into the epidemiology of

trauma in the United Kingdom. Data collected include demo-

graphic details, prehospital care, trauma history, admission

vital signs, fluid and blood product resuscitation require-ments, details of injuries and their severity scores (Abbrevi-

ated Injury Scale [AIS] score), operations, length of intensive

care unit and hospital stay, the overall Injury Severity Score

(ISS), complications, and mortality. In addition, review of the

hospital records and radiographs of the patients included in

the study was carried out. The scapula fractures were classi-

fied according to the classification of Thompson et al.1 After

hospital discharge, patients were followed up in the outpa-

tient trauma clinics. The mean time to follow-up was 1 year

3 months (range, 3 months7 years).

Inclusion criteria included adult patients who suffered mul-

tiple trauma with an ISS 16 admitted to the hospital for more

than 72 hours. Patients with burns or inhalation injuries and

patients transferred to other units within 48 hours of admission

were excluded from the study. Patients identified with scapula

fractures formed the study group (group 1) and those without a

fractured scapula made up the control group (group 2).

Statistical analysis was carried out using SPSS version

9.0 for Windows. The independent samples ttest was used to

analyze parametric data and the Mann-Whitney U test was

used for nonparametric data. Mortality figures were analyzed

using the 2 test. The null hypothesis was rejected where

p 0.05.

Submitted for publication May 10, 2002.

Accepted for publication October 16, 2002.

Copyright 2003 by Lippincott Williams & Wilkins, Inc.

From the Department of Trauma and Orthopaedics, St Jamess Uni-

versity Hospital, Leeds, United Kingdom.

Address for reprints: Peter V. Giannoudis, MD, Department of Trauma

and Orthopaedics, St Jamess University Hospital, Beckett Street, Leeds LS9

7TF, United Kingdom; email: pgiannoudi@aol.com.

DOI: 10.1097/01.TA.0000044499.76736.9D

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RESULTSOne thousand one hundred sixty-four patients were admit-

ted to our institution and met the inclusion criteria. Of the 1,164,

79 (6.8%) sustained a scapula fracture (group 1) and the remain-

der (93.2%) formed the control group of the study (group 2).

There was no difference between the two groups in terms of age,

sex distribution, or admission Glasgow Coma Scale score (Table

1). The patients in group 1 had a significantly higher overall ISS

compared with those in group 2 (27.12 15.1 [ SD] vs. 22.8

14.4, respectively; p 0.01).

Motor vehicle collision was the overwhelming cause of

injury in both sets of patients, accounting for 66% of the

patients in group 1 and 56% in group 2. Fall was the next

most common cause (23% in group 1 vs. 22.9% in group 2).

Other causes included assaults and sports injuries. There was

no statistical difference between the two groups in terms of

the mechanism of injury (p 0.05).

Of the 79 patients with scapula fractures, 56% (44 pa-

tients) sustained type III fractures (major fractures of thebody), 42% (33 patients) sustained type II (fractures of the

glenoid and neck of scapula), and 2% (2 patients) had type I

(coracoid, acromion, and small fractures of the body) frac-

tures of the scapula. Of the 79 patients, 2 required excision of

calcified deposits from the rotator cuff in the long term. The

four patients with brachial plexus injuries went on to have

problems with upper limb function. Although the purpose of

this study was not to assess the functional outcome, the

remainder of the 75 patients at discharge achieved good

functional recovery in the upper limb, as they were all inde-

pendently carrying out all their activities of daily living.

The mean number of chest injuries was 1.94 in group 1and 1.6 in group 2 (p 0.05), and the mean AIS score for the

chest region was 3.46 1.1 and 3.1 1.06 for groups 1 and

2, respectively (p 0.437). The various chest injuries sus-

tained by the two groups of patients are listed in Table 2.

Although in group 1 all of the patients sustained musculo-

skeletal injuries, their incidence in group 2 was only 50% (p

0.01). However, AIS scores for musculoskeletal injuries were

significantly lower in group 1 compared with group 2 (2.4 0.6

vs. 2.7 0.7, p 0.001). Although fractures of the clavicle

were the most common upper limb injury in the two groups, the

incidence was significantly higher in group 1 (39% vs. 12%,p

0.05). There was no statistical difference in the incidence of

humerus fractures (15% vs. 8.5%). Four patients in group 1 and

none in group 2 had brachial plexus injuries (p 0.05). The

incidence of femur fractures between group 1 and group 2 (7%

vs. 11.5%) and the incidence of pelvic fractures (33% vs. 24.5%)

were not significantly different.

The incidence of head injuries in the two groups was notsignificantly different (33% in group 1 vs. 34% in group 2, p

0.347). The severity of the head injuries was an AIS score of 3.4

1.0 in group 1 versus an AIS score of 3.75 1.05 in group

2. This difference failed to reach significance (p 0.06).

The incidence (33% in group 1 vs. 27% in group 2, p

0.1) and severity (AIS score of 3.1 1.4 in group 1 vs. 2.8

1.05 in group 2, p 0.2) of abdominal injuries were

similar in the two groups. Forty-three percent of the patients

with scapula fractures and 37% of those without scapula

fractures required admission to the intensive care unit (p

0.034). There was no difference in the length of stay in the

intensive care unit between the two groups (5.4 days vs. 5.9days, p 0.4). The overall length of hospital stay was also

similar, 20.8 days versus 17.4 days in groups 1 and 2, re-

spectively (p 0.69).

The incidence of pulmonary complications including

pneumonia, adult respiratory distress syndrome, multiple sys-

tem organ failure, and pulmonary embolism was not signif-

icantly different among the two groups (1.2% vs. 4.6%, p

not significant). One patient in group 1 was diagnosed with

pneumonia. The distribution of complications in group 2 is

listed in Table 3.

The mortality rate in group 1 was 11.4% (n 9) com-

pared with 20% (n 217) in group 2 (p 0.1). The meanISS of the nonsurvivors in group 1 was 40.3 12.6 versus 44

15.4 in group 2 (p 0.15). Six (66.7%) of the deaths

occurred in the first 24 hours in group 1 versus 126 (58%) in

group 2. There was no statistical difference in the overall

Table 1 Demographics

Group 1(Scapula Fracture)

Group 2(No Scapula Fracture)

p Value

Age (yr)

Mean 42 41 N/S

Range 1680 1788

Sex

(male to female

ratio)

62:17 775:310 N/S

GCS score

Mean 11.2 11 N/S

Range 315 315

N/S, not significant.

Table 2 Incidence of Chest Injuries

Group 1(%)

Group 2(%)

p Value

Rib fracture 48.1* 39.07* 0.05

Pneumothorax 28 23 N/S

Pulmonary contusion 15.2 25 N/S

Flail segment 10.1 7 N/S

Vertebral fracture 3.8 7 N/S

Major vessel/heart injury 2.6 7 N/S

* Significant difference.

Table 3 Incidence of Systemic Complications in Group 2

Complication No (%)

Pneumonia 20 (1.8)

Adult respiratory distress syndrome 23 (2.1)

Pulmonary embolus 3 (0.3)

Multiple organ failure 4 (0.4)

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timing of death between the two groups (mean, 3.9 vs. 6.4

days; p 0.68). Analysis of the injuries and the severity

scores between the mortality groups revealed that a higher

number of patients had sustained head injuries in group 2

compared with group 1 (56% vs. 61%), but this difference did

not reach significance (p 0.05).

DISCUSSIONIsolated fractures of the scapula are uncommon injuries.

Our incidence of 6.8% is similar to the previously reported

rates of 8% to 19%.46 In common with previously published

studies, we found high-energy trauma to be the leading cause

of fractured scapulae.7,8 The 3.5:1 male-to-female ratio seen

in this study parallels other published data and reflects the

male predominance in trauma.9

The higher ISS in group 1 reflects the higher incidence of

chest and musculoskeletal injures. However, we are aware of

the limitations of the ISS and the AIS scale as grading

systems for patients with multiple injuries. By taking intoconsideration the most severe injuries in each body region

only, the consequence of the cumulative effects of other

injuries are underestimated.

Rib fractures were the most common chest injury associated

with scapula fractures (48.1%) and, in agreement with other

studies, this was significantly higher than in group 2.1,4 The

occurrence of pneumothorax in group 1 (28%) was higher than

in group 2 (22.85%) but not significantly so. The rates were

similar to those reported in other studies.4,7 The occurrence of

pulmonary contusion was also similar between the two groups

(15.2% in group 1 vs. 21% in group 2) but significantly lower

than the 52.3% incidence reported by Thompson et al.1

Theincidence of thoracic vertebral fractures in the study group was

3.8% and, although lower than the control group, this difference

was not significant. McGinnis and Denton found figures similar

to ours.4 Overall, the severity of chest injury was higher in group

1, and this reflects the greater force applied at the time of the

impact leading to the scapula fracture.

As with previous reports, we found that a higher number

of patients sustained clavicle fractures in group 1 compared

with group 2. This finding is not unexpected, as a more

central force application is required to produce a scapula

fracture. However, there was no difference in the incidence of

humerus fractures. The need for vigilance for neurovascularproblems is emphasized by the finding that all patients with

brachial plexus injuries were in the study group.

The overall AIS score for the musculoskeletal system

was significantly higher in group 2. This can be explained by

the higher incidence of lower limb injuries in group 2. It

further suggests that the presence of a scapula fracture indi-

cates trauma to the central and upper parts of the body,

sparing the lower regions.

The two groups were similar in the incidence and severity

of associated head and abdominal injuries, as reflected by the

similar AIS scores. The higher AIS scores for chest injuries in

the study group is offset by the higher AIS scores for musculo-

skeletal injuries in the control group. These factors are reflected

in the similar intensive care unit admission rates and length of

hospital stay figures between the two groups.

The cause of posttraumatic pulmonary complications re-

lies not only on injuries to the chest but also on factors that

compound these, such as fat emboli and immobilization. The

significance of more severe musculoskeletal injuries in thecontrol group is reflected in the incidence of pulmonary

complications. Among the patients with scapula fractures,

only one patient had a pulmonary complication (1.2%). Pa-

tients in group 2 had a higher incidence (4.6%) of pulmonary

complications such as adult respiratory distress syndrome,

pneumonia, pulmonary emboli, and multiple organ failure,

but this difference did not reach significance. The higher rate

of pulmonary complications in group 2 can be further ex-

plained by the higher incidence of pulmonary contusion. We

speculate that the direction of force required to produce a

scapula fracture (lateral or posterolateral) may confer a pro-

tective influence on the underlying lung parenchyma.The mortality rate of 11.4% in group 1 is similar to the

14.3% reported by Thompson et al.1 and 9.7% reported by

Armstrong and Van der Spuy.6 However, the higher mortality

rate (20%) noted in group 2 may be related to the finding that

a higher number of patients in group 2 sustained head inju-

ries. The higher mortality noted in group 2 could also be

related to the more severe extremity injuries seen in this

group. Although the patients in group 2 had less severe chest

injuries, the compounding effects of the musculoskeletal in-

juries worsen the prognosis in this group of patients. The

similarity in the timing of death in the groups suggests that

the cause of death in the two groups is likely to be similar. Insummary, we found that patients with scapula fractures had

more severe chest injuries and overall ISS, but this was not

reflected by the intensive therapy unit stay, the length of

hospital stay, or the mortality rates.

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2. McGahan JP, Rab GT, Dublin A. Fractures of the scapula.

J Trauma. 1980;20;880 883.

3. Stepens NG, Morgan AS, Corvo P, Bernstein BA. Significance of

scapular fracture in the blunt-trauma patient.Ann Emerg Med. 1995;

26:439 442.4. McGinnis M, Denton JR. Fractures of the scapula: a retrospective

study of 40 fractured scapulae. J Trauma. 1989;29:1488 1493.

5. Imatani RJ. Fractures of the scapula: a review of 53 fractures.

J Trauma. 1975;15:473 478.

6. Armstrong CP, Van der Spuy J. The fractured scapula: importance

and management based on a series of 62 patients. Injury. 1984;

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7. McLennan JG, Ungersma J. Pneumothorax complicating fracture of

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9. Scavenius M, Sloth C. Fractures of the scapula.Acta Orthop Belg.

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