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Injury Extra (2008) 39, 130—133

available at www.sciencedirect.com

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CASE REPORTS Greenstick fracture of the scapular blade; an unusual case of winging of the scapula

M. Tryfonidis a,*, J. Reynolds b, S. Ostlere c, S. Matthews d

a Buckinghamshire Hospitals NHS Trust, Stoke Mandeville Hospital, Aylesbury, United Kingdom b Trauma & Orthopaedics, John Radcliffe Hospital, Oxford, United Kingdom c Musculoskeletal Radiology, John Radcliffe Hospital and Nuffield Orthopaedic Centre, Oxford, United Kingdom d Trauma Surgeon, John Radcliffe Hospital, Oxford, United Kingdom

Accepted 3 October 2007

Case report obtained which demonstrated a greenstick fracture of the left scapular blade consisting of an incomplete transverse A 14-year-old boy presented with an isolated injury to his fracture with intact posterolateral cortex (Fig. 3). There was left shoulder following a direct impact onto the posterior neither intrathoracic injury nor rib fractures. After obtaining aspect of his shoulder after falling off his skateboard. He parental consent and patient agreement an operative course complained of pain localised to the injury site. He was of treatment was planned to correct the cosmetic deformity. awareofanapparentscapulardeformity.Therewereno The patient had manipulation of the left scapula under symptoms suggestive of either neurological or cardio- general anaesthetic guided by image intensifier. This resulted respiratory involvement. in a satisfactory reduction of the fracture (Fig. 4). There was On inspection the left shoulder was held lower than the no neurovascular deficit postoperatively. right and there was winging of the left scapula (Fig. 1), which Postoperatively the patient’s left arm was placed in a sling was very tender to palpation. There was marked limitation of and allowed to mobilise as tolerated after 2 weeks. On left shoulder movements due to pain. Adequate testing of follow-up assessment 4 weeks postmanipulation there was rotator cuff integrity as well as serratus anterior and deltoid no reappearance of clinical deformity, no neurovascular function was not possible due pain inhibition. Neurovascular deficit, he was pain-free and repeat X-rays confirmed a stable examination was unremarkable. fracture position with evidence of healing (Fig. 5). Subsequent examination prior to intervention demon- strated intact rotator cuff power, normal deltoid power as Discussion well as decreased scapular prominence on active shoulder forward flexion indicating active serratus anterior function. By far the commonest cause of scapular winging is paralysis of There was active forward flexion of 1808, abduction of 1808 serratus anterior due to long thoracic nerve palsy,3,9 but but internal and external rotation was limited to 708 due to other causes have been described including spinal accessory discomfort. nerve palsy, dorsal scapular nerve palsy, as well as scapular or AP and lateral radiographs of the left the shoulder (Fig. 2) thoracic neoplasms.6,7 This is only the second reported case revealed a fractured left scapular blade with apex ventral in the world literature of a greenstick fracture of the scapula angulation but no displacement (AO/OTA 09-A). A CTscan was causing a deformity resembling scapular winging. In common with the previously reported case,2 our patient’s fracture was * Corresponding author. Tel.: +44 07931793936. caused by a low energy injury resulting in an obvious defor- E-mail address: [email protected] (M. Tryfonidis). mity with no significant restriction of the shoulder girdle

1572-3461 # 2007 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2007.10.008 Greenstick fracture of the scapular blade 131

Figure 1 Posterior and lateral views of the patient showing winging of the left scapula. movements. We used CT scan to obtain a more accurate X-rays alone, and may have manifested intra-operatively assessment of the anatomical location, type and extend of with potentially life-threatening complications. the fracture as well as exclude intrathoracic injuries. This As there are no available data describing the remodelling was an important part of our patient assessment as significant potential of the scapula the main concern was a potentially intrathoracic or rib injuries may have been missed with plain residual unsightly deformity. Due to the risks of open reduc-

Figure 2 Plain radiographs of the left shoulder showing an angulated fracture of the left scapular blade.

Figure 3 (A) CTscan (2-D reformat) demonstrating the greenstick fracture of the left scapula. The transverse fracture (small arrow) is incomplete as the posterolateral cortex (large arrow) is bent but intact. (B) CT scan (3-D reformat) demonstrating the actual anatomical location of the fracture as well as the resulting deformity. 132 M. Tryfonidis et al.

Figure 4 Intraoperative radiography with image intensifier before (left) and after manipulation (right).

Figure 5 Plain scapula radiographs 4 weeks post-reduction demonstrating satisfactory and stable fracture position.

tion and internal fixation1 we elected to treat this injury stick fracture of the scapula closed reduction should be closed. In the event of loss of reduction as a result of considered as a first line management. We also believe that persistent deforming forces (a recognised phenomenon with when treating this type of fracture with closed reduction one greenstick fractures4,5,8) we planned to use a percutaneous should be prepared to use a minimally invasive fixation screw. This situation though never occurred as the reduced technique if there is evidence of elastic recoil of the fracture fracture remained in a satisfactory position throughout the towards its original position. course of treatment. References Conclusion 1. Bauer G, Fleischmann W, Dussler E. Displaced scapular fractures: We present a case of an angulated greenstick fracture of the indication and long term results of open reduction and internal scapula causing a deformity resembling scapular winging. It fixation. Arch Orthop Trauma Surg 1995;114:215—9. 2. Bowen TR, Miller F. Greenstick fracture of the scapula: a cause of resulted from a low energy injury and had no other associated scapular winging. J Orthop Trauma 2006;20:147—9. injuries. This was successfully treated with closed reduction 3. Connor PM, Yamaguchi K, Manifold SG. Split pectoralis major resolving the unsightly deformity. transfer for serratus anterior palsy. Clin Orthop 1997;341: Based on this case we are in agreement with the recom- 134—42. mendations of the authors of the single previously reported 4. Evans EM. Rotational deformity in the treatment of fractures of similar case2 that in treating a significantly angulated green- both bones of the forearm. J Bone Joint Surg 1945;27:373—9. Greenstick fracture of the scapular blade 133

5. Fuller DJ, McCullough CJ. Malunited fractures of the forearm in 8. Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm children. J Bone Joint Surg 1982;64B:364—7. fractures in children. J Paediatr Orthop 1990;10:705—12. 6. Kuhn JE, Plancher KD, Hawkins RJ. Scapular winging. J Am Acad 9. Velpeau AM. Luxations de l’ epaule. Arch Gen Med 1837;14(Suppl. Orthop Surg 1995;3:319—25. 2):269—305. As reported in: Connor PM, Yamaguchi K, Manifold 7. Pilling L, Steinert V, Hormann D. Fractures of the scapula in SG. Split pectoralis major transfer for serratus anterior palsy. Clin childhood. Zentralbl Chir 1980;105:1302—4. Orthop 1997;341:134—142..