Scapular fractures are rare, typically resulting from high-impact trauma like car accidents or falls, and represent 3–5% of shoulder girdle fractures. They most commonly affect the body (45%), glenoid process (35%), acromion (8%), and coracoid process (7%). These injuries often coincide with rib, humerus, skull fractures, CNS deficits, and major vascular injuries. Pain management plays an important role in cases involving rib fractures, as insufficient analgesia can contribute to respiratory issues. Scapular fractures can affect shoulder girdle function and may result in chronic pain from impingement or malunion. Most such injuries are managed conservatively, though pain control is complicated by complex innervation. Brachial plexus injuries occur in 5–13% of scapular fracture cases and can influence recovery.
Rib fractures often caused by blunt chest trauma are present in up to 12% of trauma cases and are associated with increased morbidity, disability, and mortality. Pulmonary complications can develop due to impaired gas exchange resulting from the injury and suboptimal pain control, which affects breathing mechanics. Outcomes are influenced by factors such as number of ribs fractured, comorbidities, age, and pain levels. Improving analgesia can help enhance pulmonary hygiene and decrease the risk of atelectasis or pneumonia.
Systemic analgesics and opioids are commonly administered but may have significant side effects, especially in older adults. Regional nerve and fascial plane blocks can provide effective pain relief as part of a multimodal approach. Identifying the sources of pain in scapular and rib injuries enables more targeted nerve block interventions.
Dermatomes:
Myotomes:
Osteotomes:
A 30-year-old man with no prior medical conditions arrived at the Emergency Department following a high-velocity motorcycle collision with a truck. He complained of right shoulder and anterior chest wall pain. Vital signs were stable, except for tachypnea attributed to pain during inspiration.On examination, the right shoulder demonstrated bruising, abrasions, and generalized swelling across the shoulder and anterior chest. Both passive and active ranges of motion were limited due to pain. Sensory examination was unremarkable, with no evidence of proximal or distal neurological deficits. No nerve injury was identified, and review of other systems was within normal limits.A scapular view X-ray of the right shoulder revealed fractures of the body and acromion of the scapula. Chest X-ray (AP view) identified anterolateral fractures of ribs 2 to 4 and a distal right clavicular fracture.
The patient was started on a multimodal analgesic regimen, including paracetamol 650 mg every 8 hours, gabapentin 300 mg every 8 hours, and intravenous fentanyl infusion at 50 micrograms per hour. Despite these medications, he continued to experience severe pain, reporting a Numerical Rating Scale (NRS) score of 7 out of 10.
Dermatomal, osteotomal, and myotomal mapping was performed, and the decision was made to proceed with a Selective Supraclavicular Nerve Block combined with Upper Trunk Block (SCUT), as well as a Superficial Serratus Plane Block. Following a thorough pre-anaesthetic assessment, written informed consent was obtained from the patient for the analgesic procedures. He was positioned in an upright sitting posture, and American Society of Anesthesiologists (ASA) standard monitoring was applied. Procedural sedation was provided using intravenous midazolam 1 mg for anxiolysis.
Selective Supraclavicular and Upper Trunk Blocks (SCUT)
The patient was positioned with back support and a thin pillow to maintain neck extension. Using sterile technique, an ultrasound-guided block was performed with a high-frequency linear transducer (15–6 MHz, ESAOTE system). The operator sat on the injury side, with the machine opposite. A 22G Quincke spinal needle delivered a mix of 2% lignocaine with adrenaline (1:200000) and 0.2% ropivacaine. For the supraclavicular nerve, identified as a hypoechoic cluster near the sternocleidomastoid and scalene muscles, 5 ml of local anaesthetic was injected in 0.5 ml aliquots at 3 and 9 o’clock positions following negative aspiration. For the upper trunk block, C5 and C6 ventral rami were traced to the upper trunk, followed by 5 ml LA administered in aliquots after negative aspiration.
SUPERFICIAL SERRATUS PLANE BLOCK:
The patient was positioned supine with the arm abducted. Using ultrasound equipment, the probe was placed sagittally to identify the 5th rib in the mid-axillary line, along with the latissimus dorsi and serratus anterior muscles. The thoracodorsal artery was confirmed by color Doppler, ensuring correct plane identification. A mixture of 0.2% ropivacaine and 1:200000 lignocaine with adrenaline (up to 0.5ml/kg, max 40 mL) was used. After local anesthetic infiltration, a 22G quincke’s needle was advanced in-plane from superior-anterior to posterior-inferior. Aspiration excluded vascular puncture; 2–3 ml of LA was injected for hydrodissection, followed by the remaining solution in the same plane under ultrasound guidance.
After block performance, patient reported NRS pain score of 3/10, slight increase in mobility of shoulder and reduction in tachypnea.
ALTERNATIVE ANALGESIC/ANAESTHETIC BLOCK OPTIONS:
A combination of ISB and T7–T8 TPVB with catheter placement can provide effective anesthesia and prolonged analgesia for scapular and rib fractures.
Superior Trunk Block (STB) plus TPVB:
STB is recommended over ISB due to a lower risk of hemi-diaphragmatic palsy, particularly in patients with thoracic injuries.
Described by Galluccio et al., this technique, combined with an Supraspinatus nerve block, involves two injections interfacial plane between deltoid and subscapularis and another in the pericapsular space deep to subscapularis before the hyaline cartilage of the shoulder joint to anesthetize articular branches of axillary, lateral pectoral and musculocutaneous nerves.
A novel approach for combined supraspinatus and axillary nerve block with a single injection in the infraspinatus-teres minor interfascial plane described by Kim et al.
While scapula fractures may be infrequent, they unleash significant pain and present unique challenges particularly if associated with shoulder and rib fractures. Harnessing advanced regional anesthesia techniques not only greatly improves patient comfort and mobility but also accelerates recovery. In this case, Selective supraclavicular nerve block and Upper Trunk block combined with Superficial Serratus Plane block provided analgesia for combined scapula and rib fractures. There was sufficient improvement in pain scores, mobility and improvement in overall clinical status. Careful identification and mapping of dermatomes, myotomes, and osteotomes are critical steps in the planning process upon patient arrival. By employing site-specific regional anaesthesia techniques for on-arrival blocks, clinicians can tailor interventions to the individual anatomy and injury pattern, optimizing both anaesthesia and analgesia. Targeted block strategies not only enhance the efficacy of pain control but also influences patient outcomes in the Emergency Department.
Dr Gowtham Kumar B Registrar Department of Anaesthesiology and Critical Care, Kauvery Hospital, Alwarpet, Chennai.
Dr Velmurugan Deisingh Senior Consultant, Head of Dept Department of Anaesthesiology and Critical Care, Kauvery Hospital, Alwarpet, Chennai.
