The prevalence and significance of missed scapular fractures in blunt chest trauma

Department of Radiology, Dartmouth-Hitchcock Medical Center, Hanover, NH 03756.

Recent concepts regarding surgical management of fractures of the glenoid and scapular neck provide a new imperative to their early recognition. The initial routine supine chest radiograph obtained in patients with major blunt chest trauma provides the earliest opportunity to identify scapular fractures. A retrospective analysis of 100 patients with major blunt chest trauma who were discharged with the diagnosis of scapular fracture was performed to determine (1) the frequency with which the diagnosis of scapular fracture was made on the initial chest radiograph and (2) the prevalence and type of regional injuries that could serve to identify which of these patients are most likely to have sustained scapular fracture(s). The scapular fracture was diagnosed on the initial chest radiograph in only 57 (57%) of 100 patients and, although present, was not recognized in 43 (43%) of 100. In the group in which the fractures were not recognized, the fracture was visible and frankly overlooked in 31 (72%) of 43. The fracture was not included on the examination in eight (19%) of 43; and it was obscured by superimposed structures or artifacts in four (9%) of 43. Ipsilateral regional injuries were present in 88 (88%) of 100. These included multiple upper rib fractures in 40 (40%), clavicular fractures in 17 (17%), acromioclavicular separation in six (6%), and "other" in 26 (26%). "Other" included subcutaneous emphysema, pneumothorax, pleural effusion, and pulmonary contusion. The presence of ipsilateral regional skeletal injuries and soft-tissue injuries after major blunt chest trauma should prompt a diligent search for concomitant scapular fractures.
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