Working Diagnosis:
Nondisplaced fracture through the anterosuperior to posterosuperior glenoid extending into the base of the coracoid, that also extends into the body of the scapula.

Treatment:
The patient was strictly limited to non-weight bearing activity and rest for 8-weeks following his injury to allow for proper fracture healing. After this initial period he participated in physical therapy and was able to progress to full activity.

Outcome:
The patient returned to full play as the fall season began, approximately 4 months after the initial injury occurred.

Author's Comments:
This patient presented with symptoms and exam findings classic for an AC joint sprain with an acute stress response. His increased pain and limited range of motion after the injury were suspicious, as improvement was expected with rest, ice, and anti-inflammatory medications. Imaging of the patient revealed extensive fracture and damage to the scapula and glenoid. These findings demonstrate that while an injury like this may present as a more benign condition, it is important to consider more damaging problems within the differential and evaluation of the athlete so more serious injuries, such as fractures which may require longer healing times, are not overlooked. While AC joint sprains are common in athletes, scapular fractures make up only 5% of shoulder fracture and are important to consider to prevent delayed diagnosis that may result in prolonged damaged, poor fracture healing, and chronic pain.

Editor's Comments:
This case illustrates the importance of following up with the patient during the course of sideline coverage. Many times, the football sideline is a busy place and it is important for young sports medicine physicians to check-in with the injured student athletes during and sometime after the event. The main concern for this case is obtaining a broad differential diagnosis of shoulder, so that the final diagnosis of a scapula fracture was not missed. If a low grade AC sprain was the final diagnosis, imaging and further work up may have not been done, and perhaps worsening the outcome for the patient. Another diagnosis that cannot be missed is the "floating shoulder" which is an unstable displaced fracture of the surgical or anatomical neck of the scapula. This injury is rare and typically occurs with higher impact injuries (MVA or motorcycle). Floating shoulder injuries are often overlooked and can involve associated injury to nearby structures, i.e. brachial plexus, clavicle fracture, and subclavian artery injury. Luckily, this patient did not have a floating shoulder.

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