Houston Methodist. Leading Medicine

Shoulder FAQ

Question:

My daughter was involved in a terrible horseback riding accident where the horse reared up and then fell backwards with her pinned underneath. She survived and made it through all kinds of surgeries and rehab. Now it's several months later and they've discovered her shoulder blade was fractured, too. The surgeon is proposing a treatment she calls "benign neglect" -- let it heal on its own. Is this wise? Do you think we should insist on surgery? We're not too gung-ho on that plan but will face it if we must.

Answer:

Scapular fractures (the shoulder blade) are rare but can be life-threatening. That's because a traumatic force strong enough to break the scapula usually also causes other serious injuries. There can be head, neck, arm, chest, rib and even pelvic injuries along with the scapular fracture. These other injuries are serious enough to threaten life and can prove fatal. For example, a broken rib can puncture the lung, a chest wound can lead to pneumonia, and head, neck, and spinal cord injuries can be very disabling. Many times the scapular fractures are missed because the bone is well-covered by surrounding soft-tissues. It isn't until the patient is out of the intensive care unit (ICU) that symptoms of neck, back or arm pain, along with numbness and tingling in the arm alert the physician to yet another problem. X-rays and three-dimensional CT (3D-CT) scans are needed to make a clear and accurate diagnosis. The next dilemma is to decide the best treatment approach. Research-based evidence is not available so expert opinion is the next best thing for making treatment decisions. And experts in different parts of the world have not always agreed. In the United States, until recently, the approach has been nonsurgical sometimes referred to as "benign neglect" -- letting it heal on its own as your surgeon has suggested. But in other areas of the world like France, surgeons have used a more aggressive surgical approach. Several French studies have reported on the successful results using internal fixation (metal plates, screws, pins) to realign the misaligned pieces of the scapula and hold them together until healing takes place. This approach is gaining recognition based on a more complete understanding of these kinds of fractures and improved surgical techniques. The challenge now is to identify which patients require surgery and which ones can still be successfully treated conservatively. That's where you are with your daughter. There's no magic formula or one-size-fits-all treatment plan for these patients. Management is individually determined. Surgery is going to be more likely needed when there is excessive bony displacement or deformity, joint damage, and/or both. Scapular fractures in the presence of rib or chest injury are more likely to need surgery. Without sure proof that surgery will benefit the patient, surgeons must make these decisions based on their expertise and evaluation of the case. For those patients who may be able to successfully heal and rehab without surgery, a shoulder sling is worn for several weeks. Physical therapy begins approximately one month after injury. The therapist progresses the patient gradually through a full range of rehabilitation activities. Therapy begins with passive motion and eventually includes strengthening and endurance training. The patient can expect to be in therapy for three to six months. Peter A. Cole, MD, et al. Management of Scapular Fractures. In Journal of the American Academy of Orthopaedic Surgeons. March 2012. Vol. 20. No. 3. Pp. 130-141.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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