Working Diagnosis:
Nondisplaced fracture of the scapular spine

Treatment:
Treatment was initiated by placing him in a sling for comfort and starting light range of movement exercises. He returned to the clinic in 4 weeks, with significant improvements in pain and range of motion.

Outcome:
At his four-week follow-up, his repeat imaging still revealed the fracture with minimal healing or change in the interval Case Photo #8 However, with his significant improvement clinically, he began a stepwise, non-contact, return to sport for four more weeks. At eight weeks post-injury, he was able to return to sport. A dual X-ray absorptiometry scan was ordered and recommended to evaluate the patient’s bone mineral density, although this was not completed.

Author's Comments:
Scapular body fractures are relatively uncommon fractures; notably less common in isolation, as the mechanism is typically from a high-energy trauma. However, there are several case reports on fatigue/stress fractures of the scapula in young athletes (1,2). These injuries are typically treated nonoperatively, with significant clinical improvements shown in 4 weeks and full return to sport usually between 2-3 months (1). Due to this patient’s intermittent, chronic corticosteroid use, there was concern regarding his bone mineral density and possibly relation to this injury. Chronic corticosteroid use is widely known to cause osteoporosis and increased risk of fractures (3). However, there is only minimal evidence that chronic, intermittent oral corticosteroid use in younger populations, specifically young males, increases risk of limb fractures and without evidence of osteoporosis (4,5). With the relevance of chronic, intermittent corticosteroids in many young athletes for conditions such as asthma, or other autoimmune and rheumatologic conditions, additional studies are needed to properly evaluate the effects of corticosteroids on bone health and development during the peripubertal period.

Editor's Comments:
This case highlights the rare nature of scapular body fractures. Acute trauma is the primary mechanism for such fracture, which usually occurs from muscle contraction against a resisted force (1). These fractures respond well to conservative treatment with favorable outcomes and return to sport of approximately 2.5 months. The authors address the limited evidence for how comorbid conditions and their treatment regimens may affect our young athletic population.

References:
1. Neral M, Knapik DM, Wetzel RJ, Salata MJ, Voos JE. Scapular Body Fracture in the Athlete: A Systematic Review. HSS Journal. 2018;14(3):328-332.
2. Herickhoff PK, Keyurapan E, Fayad LM, Silberstein CE, McFarland EG. Scapular Stress Fracture in a Professional Baseball Player: A Case Report and Review of the Literature. The American Journal of Sports Medicine. 2007;35(7):1193-1196.
3. Kobza AO, Herman D, Papaioannou A, Lau AN, Adachi JD. Understanding and Managing Corticosteroid-Induced Osteoporosis. Open Access Rheumatology. 2021;13:177-190.
4. Melton LJ, Patel A, Achenbach SJ, Oberg AL, Yunginger JW. Long‐Term Fracture Risk Among Children With Asthma: A Population‐Based Study. Journal of Bone and Mineral Research. 2005;20(4):564–570.
5. Chalitsios CV, McKeever TM, Shaw DE. Incidence of osteoporosis and fragility fractures in asthma: a UK population-based matched cohort study. European Journal of Respiratory Medicine. 2021;57(1):2001251

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