Scapular fracture and risk of great vessel injury in geriatric blunt trauma: A TQIP analysis.

INTRODUCTION: Scapular fractures are markers of high-energy blunt thoracic trauma and may indicate severe intrathoracic injury. Despite the substantial mortality linked with great vessel injuries (GVI), data specifically examining scapular fracture and GVI in the geriatric population remain limited. We hypothesized that scapular fracture, particularly when accompanied by concomitant thoracic fractures, is independently associated with GVI in geriatrics with blunt trauma.

METHODS: We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database (2017-2023). Patients aged ≥ 65 years with a blunt mechanism of injury and AIS severity 2-5 in the neck, thorax, or upper extremity were included. GVI was defined using specific AIS codes for major thoracic and cervical vessels. Multivariable logistic regression evaluated association between scapular fracture patterns and GVI, including isolated scapular fractures, those with concomitant sternal, rib or flail chest fractures. Models adjusted for age, sex, race, mechanism, ISS, shock index, and modified frailty index. Vessel-specific analyses were also performed. Primary outcome was GVI. Secondary outcomes were mortality and LOS.

RESULTS: A total of 677,134 patients were included. Median age was 76 [70-82] years; 54.1% were female. Scapular fractures were identified in 5.0% of patients and GVI in 0.7%. In multivariable regression, isolated scapular fracture was associated with lower odds of GVI (aOR 0.783, 95% CI 0.704-0.871, p < 0.001), while scapular fracture with sternal fracture was associated with significantly higher odds (aOR 1.423, 95% CI 1.122-1.806, p = 0.004). Among vessel-specific analyses, subclavian artery injury demonstrated the highest association with scapular fracture (aOR 1.527, 95% CI 1.113-2.094, p = 0.009). GVI was associated with markedly higher in-hospital mortality (25.1% vs. 4.2%; OR 7.726, 95% CI 7.234-8.251, p < 0.001).

CONCLUSION: In geriatric blunt trauma, isolated scapular fracture is not an independent predictor of GVI. After a fall, a scapular fracture without a sternal fracture does not by itself suggest a missed vascular injury. In contrast, combined scapular and sternal fractures represent a high-risk pattern that warrants a heightened index of suspicion and a low threshold for CT angiography, with particular attention to the subclavian vessels.

LEVEL OF EVIDENCE: Prognostic/Epidemiologic; Level III.