Department of Emergency Medicine, The University of California San Francisco, San Francisco, CA.
The University of California San Francisco, San Francisco, CA.
Acad Emerg Med. 2018 Jul;25(7):738-743. doi: 10.1111/acem.13377. Epub 2018 May 25.
Scapular fractures have been traditionally taught to be associated with significant injuries and major morbidity. As we demonstrated with sternal fracture, pulmonary contusion, and rib fracture, increased chest computed tomography (CT) utilization and head-to-pelvis CT (pan-scan) protocols in blunt trauma evaluation, however, may diagnose minor, clinically irrelevant scapular fractures, possibly rendering previous teachings obsolete.
The objectives were to determine the 1) percentages of scapular fractures seen on chest CT only (SOCTO) versus seen on both chest x-ray (CXR) and CT and of isolated scapular fracture (scapular fracture without other thoracic injuries); 2) frequencies of associated thoracic injury with scapular fracture; and 3) proportion of patients admitted, mortality, hospital length of stay, and injury severity scores (ISS), comparing four patient groups: scapular fracture, nonscapular fracture, scapular fracture SOCTO, and isolated scapular fracture.
We conducted a preplanned analysis of patients prospectively enrolled in the NEXUS Chest CT study at nine Level I trauma centers with the following inclusion criteria: age > 14 years, blunt trauma within 6 hours of ED presentation, and receiving chest imaging during ED trauma evaluation.
Of 11,477 subjects, 4,501 (39.2%) patients who had both CXR and chest CT and 2.7% of these had scapular fractures; 60.3% of these were SOCTO and 23 (19.0%) were isolated scapular fracture. The most commonly associated thoracic injuries were rib fracture, pulmonary contusion, pneumothorax, and thoracic spine fracture and all injuries were more common in scapular fracture patients than nonscapular fracture patients. Although scapular fracture patients had higher admission rates (86.8% vs. 47.4%; difference in proportions = 39.4% [95% confidence interval {CI} = 32.8% to 44.1%]), ISS (21 vs. 5), and length of stay (9.2 days vs. 5.6 days; mean difference = 3.4 days [95% CI = 2.1 to 4.7 days]) than patients without scapular fracture, their hospital mortality was not significantly different (5.6% vs. 3.0%; difference in proportions = 2.6% [95% CI = -8.2% to 0.3%]; unadjusted odds ratio = 1.9 [95% CI = 0.9 to 4.2]). Patients with scapular fracture SOCTO and isolated scapular fracture had higher admission rates and median ISS than nonscapular fracture patients, but their mortality was similar.
Under current blunt trauma imaging protocols that commonly include chest CT, most scapular fractures are SOCTO and most are associated with other thoracic injuries. Although patients with scapular fracture SOCTO and isolated scapular fracture have higher admission rates and ISS than nonscapular fracture patients, their hospital mortality is similar.
肩胛骨骨折传统上被认为与严重损伤和高发病率有关。然而，正如我们胸骨骨折、肺挫伤和肋骨骨折所证明的那样，在钝性创伤评估中增加胸部计算机断层扫描（CT）的使用和头到骨盆 CT（全景扫描）方案可能会诊断出轻微的、临床无关的肩胛骨骨折，这可能使以前的教学过时。
目的是确定 1）在仅进行胸部 CT 检查（SOCTO）时看到的肩胛骨骨折百分比与在胸部 X 射线（CXR）和 CT 上均看到的肩胛骨骨折百分比，以及孤立性肩胛骨骨折（无其他胸部损伤的肩胛骨骨折）的百分比；2）肩胛骨骨折的相关胸部损伤频率；3）与四个患者组（肩胛骨骨折、非肩胛骨骨折、SOCTO 肩胛骨骨折和孤立性肩胛骨骨折）相比，住院、死亡率、住院时间和损伤严重程度评分（ISS）的比例。
我们对在九个一级创伤中心前瞻性纳入 NEXUS 胸部 CT 研究的患者进行了一项预先计划的分析，纳入标准为：年龄>14 岁，在急诊科就诊后 6 小时内发生钝性创伤，以及在急诊科创伤评估期间接受胸部影像学检查。
在 11477 名受试者中，4501 名（39.2%）同时进行 CXR 和胸部 CT 检查，其中 2.7%的患者有肩胛骨骨折；其中 60.3%为 SOCTO，23 例（19.0%）为孤立性肩胛骨骨折。最常见的相关胸部损伤是肋骨骨折、肺挫伤、气胸和胸椎骨折，所有这些损伤在肩胛骨骨折患者中比非肩胛骨骨折患者更常见。尽管肩胛骨骨折患者的住院率（86.8%比 47.4%；比例差异=39.4%[95%置信区间（CI）=32.8%至 44.1%]）、ISS（21 比 5）和住院时间（9.2 天比 5.6 天；平均差异=3.4 天[95%CI=2.1 至 4.7 天]）高于无肩胛骨骨折患者，但他们的住院死亡率没有显著差异（5.6%比 3.0%；比例差异=2.6%[95%CI=-8.2%至 0.3%]；未调整的优势比=1.9[95%CI=0.9 至 4.2]）。SOCTO 肩胛骨骨折和孤立性肩胛骨骨折患者的住院率和中位 ISS 均高于非肩胛骨骨折患者，但死亡率相似。
在当前包括胸部 CT 在内的常见钝性创伤成像方案下，大多数肩胛骨骨折为 SOCTO，大多数与其他胸部损伤有关。尽管 SOCTO 肩胛骨骨折和孤立性肩胛骨骨折患者的住院率和 ISS 高于非肩胛骨骨折患者，但他们的住院死亡率相似。
