So what exactly holds your shoulder on?

So while evading a piece of runaway machinery, this gent fell over a wall and landed heavily on his left shoulder.  Shoulder and scapula views were ordered.  What's he done?  Just as importantly, when does this need more than than just time in a sling and physio....?

There's a fracture through the glenoid neck.  So, a brief revioe wof the management of scapula fractures from our very own Mark Brinsden:

1.  Extra-articular (glenoid) scapular fractures:  Is the glenohumeral joint connected to the axial skeleton?  The answer lies in the integrity of the Superior Suspensory Complex (SSC):

If the circle is intact (and the clavicle is not fractured) the GHJ is still connected to the axial skeleton via the coracoid - CC ligaments - Clavicle - Sternum - Ribs - Spine.  If there is a fracture between the glenoid (neck) and the coracoid (v. rare) we would have to plate the glenoid back onto the scapular body to restore the integrity of the SSC.

2.  Intra-articular scapular fractures (glenoid).  Traditionally, any displaced (>2mm) intra-articular fracture would undergo ORIF.  There is increasing evidence that this is not required.  The modern-thinking is that even displaced intra-articular fractures maybe managed non-operatively as long as there is no subluxation of the humeral head anteriorly or posteriorly i.e. the displaced fragment is not behaving like a large bony Bankart lesion.

Finally, in the absence of a surgical indication the mainstay of management is analgesia and PHYSIO +++.  A scapular fracture is a massive trauma to the shoulder girdle and the soft tissue stiffness that can occur "downstream" is immense, so move please ++++++++!