(aspects of sports medicine)

Coracoid Process Fracture With Acromioclavicular Joint Separation in an American Football Player: A Case Report and Literature Review Matthew DiPaola, MD, and Paul Marchetto, MD

Abstract 336 collegiate American football to palpation over the AC joint and Coracoid process fractures are rare players had a history of shoulder coracoid process. In addition, he had and few cases have been report- injury, 41% of which were acromio- pain with cross-body adduction of the ed in the orthopedic literature. In clavicular (AC) joint injuries. None symptomatic arm. Anteroposterior this article, we report the case of of these football players had a his- (AP), lateral, and axillary radiographs an American football player with tory of coracoid fracture. of both shoulders were obtained. The a coracoid process fracture in the setting of acromioclavicular sep- Coracoid fractures and ipsilateral AP radiograph showed a nondis- aration and describe incidence, shoulder injuries often occur concur- placed fracture of the coracoid and mechanism of injury, and treatment. rently. Ogawa and colleagues1 found a grade II AC separation (Figures 1, Although rare, coracoid process that 37 of 67 coracoid fractures were 2). Radiographic examination of the fracture should be considered in the associated with ipsilateral AC dis- asymptomatic shoulder confirmed differential diagnosis for shoulder locations. With the incidence of AC that the growth plates in this region pain. Treatment varies according to fracture type. Based on our lit- erature review, we recommend that clinicians initially treat nondisplaced “There is evidence that, of the athletes coracoid fractures nonoperatively. who sustain this injury, football players oracoid process fractures perhaps are at highest risk.” are relatively rare and have been estimated to account for 3% to 13% injury as high as it is in the football were closed. The patient was treated Cof all scapular fractures, with scapu- population, it is incumbent upon the conservatively, with a sling, and he lar fractures in turn accounting for sports medicine physician and gener- was advised not to participate in only 1% of all fractures.1 Kaplan al orthopedist to remain cognizant of sports until fracture healing was con- and colleagues2 found that 50% of the potential for concurrent coracoid firmed on follow-up. fracture and shoulder injury. There The patient returned at 8 weeks Dr. DiPaola is currently Shoulder and is evidence that, of the athletes who for follow-up. On examination, both Elbow Fellow at the NYU Hospital for Joint sustain this injury, football players shoulders had full active and pas- Diseases, New York, New York. He was a perhaps are at highest risk.3-5 sive range of motion, and the patient resident at Thomas Jefferson University at the time the article was written. was nontender to palpation. Follow- Dr. Marchetto is Associate Professor, Case Report up radiographs in 3 planes showed Department of Orthopedic Surgery, A 15-year-old boy injured his right a fully healed coracoid (Figures 3, Thomas Jefferson University Hospital, shoulder while playing in a high 4). The patient was cleared for full Rothman Institute, Philadelphia, school football game. At time of athletic participation in contact and Pennsylvania. presentation, he reported that he had collision sports. Address correspondence to: Matthew been carrying the ball and was tack- We have obtained the patient’s DiPaola, MD, Hospital for Joint Diseases, led from the front and side while he guardian’s informed, written consent 301 E. 17th St, New York, NY 10003 (e- was lowering his shoulder. He com- to publish the case report. mail, [email protected]). plained of pain over the AC joint and Am J Orthop. 2009;38(1):37-40. Copyright, vague pain over the anterior deltoid. Discussion Quadrant Healthcom Inc. 2009. All rights On examination, forward flexion was Paramount to diagnosing coracoid reserved. restricted to 150º, and he was tender fracture are taking a thorough history,

January 2009 37 Coracoid Process Fracture With Acromioclavicular Joint Separation

Figure 1. Initial-presentation axillary radiograph shows coracoid process fracture. Figure 2. Initial-presentation scapu- lar Y radiograph shows coracoid performing a physical examination was found unexpectedly at surgery in process fracture. with a focus on mechanism of injury, a patient with negative radiographs.12 and maintaining a high index of sus- Another was found in an unusual from its base. (3) The last is when a picion. Standard plain radiography, case in which there was a full tear resisted flexion of the arm and elbow consisting of 3 shoulder views, may of the coracoclavicular (CC) liga- leads to a forceful pull of the muscles not be revealing, and further studies, ment.11 Five patients (2 treated surgi- that insert into the coracoidthe such as radiograph at 45˚ to 60˚ ceph- cally, 3 treated conservatively) had pectoralis minor and the coracobra- alad tilt, computed tomography, and minimal cosmetic deformity with full chialis.11,14 As with the second mech- magnetic resonance imaging, may be painless range of motion at a mini- anism, there is an avulsing force, but necessary. The literature offers some mum 6-week follow-up.8,10-12 One through different structures. Asbury

“[For] diagnosing coracoid fracture....further studies, such as radiograph at 45˚to 60˚cephalad tilt, computed tomography, and magnetic resonance imaging, may be necessary.” guidance with respect to treatment patient (treated conservatively) had and Tennent5 reported on the unusual and classification of this injury. an unknown posttreatment course.9 case of a cricket player who sustained The largest series of coracoid Mechanism of Injury. At least an avulsion fracture of the coracoid fractures, which originated outside 3 mechanisms of injury have been through throwing (no direct trauma). the United States, consisted of 67 proposed for coracoid fractures. (1) It is unknown which of these mecha- cases1 and 12 cases.6 Most common- The first is direct trauma to the ante- nisms is more critical in the devel- ly, these injuries occur by means of rior lateral chest, such as occurred opment of the injury. Some studies direct trauma, motor vehicle acci- in a trapshooter.13 (2) The second have implicated a combination of dents, or falls.1,6,7 is thought to be from a continuum mechanisms to explain a particular According to our literature search, of similar forces which generates injury pattern.11 the largest US series consisted of only the AC dislocation.11 Typically, this Classification by Radiographic 4 cases, 2 involving football players.8 dislocation occurs with a direct blow Appearance. Other authors have Only 6 cases of coracoid fractures to or fall on the AC joint. The direct attempted to classify coracoid frac- have been reported in American foot- force displaces the acromion caudad tures according to their radiograph- ball players.8-12 Mechanism of injury while the coracoid is pulled with the ic appearance. After retrospectively was either direct trauma to the shoul- clavicle by the CC ligament cepha- analyzing 12 cases, Eyres and col- der or a fall. Two patients were treat- lad. If the force is sufficient, the leagues6 proposed a 5-grade sys- ed surgically. One coracoid fracture coracoid may be avulsed or fractured tem: (I) avulsion of the tip of the

38 The American Journal of Orthopedics® M. DiPaola and P. Marchetto

Figure 3. Follow-up axillary radiograph shows healed coracoid process fracture. Figure 4. Follow-up scapular Y radiograph shows healed coracoid coracoid; (II, III) fracture of the were most often associated with process fracture. body of the coracoid; (IV) fracture other, concurrent shoulder injuries. at the base of the coracoid; and (V) In light of new evidence regarding centage of these injuries occur in fracture at the base with glenoid successful conservative treatment the nontrauma population—in ath- involvement. Another notation was for “floating shoulder” injuries, it is letes, football players in particular. made for clavicular involvement. unclear whether the same operative Coracoid fracture should be part of After analyzing 67 cases, Ogawa course would now be recommend- the differential diagnosis for football and colleagues1 created a simpler ed for these patients.15 More study players being evaluated for shoulder system based on the position of the is needed. pain. Mechanism of injury should fracture relative to the CC ligament: Our literature review indicates be elicited from these patients dur- posterior (I) and anterior (II) to the that surgeons have taken multiple ing history taking and the physical attachment of the CC ligament. approaches in the surgical treatment examination. Treatment should be These authors have used these of coracoid fractures. For fractures dictated by presence of concurrent systems to roughly guide therapy, with associated AC pathology, some injury, fracture location, and degree though associated injuries have his- have opted to address only the AC of displacement. torically played a significant role in joint,8,9,16,17 and others have found determining treatment plans. that surgical reduction of the cor- Authors’ Disclosure Treatment. No randomized con- acoid reduced the AC indirectly.12 Statement trolled trials have evaluated treat- Ogawa and colleagues1 favored a The authors report no actual or poten- ments of coracoid fractures. Eyres single malleolar screw for fixation of tial conflict of interest in relation to and colleagues6 recommended con- the coracoid with concurrent wiring this article. servative treatment for all nondis- of a fractured clavicle or AC dislo- placed fractures and for displaced cation. They recommended treating References grade I–III fractures and recom- concurrent AC dislocation and stable 1. Ogawa K, Yoshida A, Takahashi M, Ui M. Fractures of the coracoid process. J Bone mended surgical stabilization for coracoid fracture as one treats simple Joint Surg Br. 1997;79(1):17-19. grade IV–V fractures and for frac- AC dislocations. 2. Kaplan LD, Flanigan DC, Norwig J, Jost P, Bradley J. Prevalence and variance of shoul- tures combined with dissociation Conservative therapies have his- der injuries in elite collegiate football players. of the clavicle and scapula. Ogawa torically involved applying an AC Am J Sports Med. 2005;33(8):1142-1146. 1 3. Combalía A, Arandes JM, Alemany X, Ramón and colleagues reported treating immobilizer, a sling, or a Velpeau R. Acromioclavicular dislocation with epiphy- “relatively stable” type II fractures bandage.8,10 seal separation of the coracoid process: report of a case and review of the literature. nonoperatively, except those associ- J Trauma. 1995;38(5):812-815. ated with other shoulder injuries. Conclusions 4. Mariani PP. Isolated fracture of the coracoid process in an athlete. Am J Sports Med. However, Ogawa and colleagues Coracoid fractures are uncom- 1980;8(2):129-130. operated on a majority of type I frac- mon. They occur in the context of 5. Asbury S, Tennent TD. Avulsion fracture of tures (31/53) with mostly excellent trauma, as in motor vehicle acci- the coracoid process: a case report. Injury. 2005;36(4):567-568. results. Incidentally, these fractures dents. However, a significant per- 6. Eyres KS, Brooks A, Stanley D. Fractures of

January 2009 39 Coracoid Process Fracture With Acromioclavicular Joint Separation

the coracoid process. J Bone Joint Surg Br. Commentary ligament disruption alone. The sever- 1995;77(3):425-428. 7. Wilber MC, Evans EB. Fractures of the Acromioclavicular (AC) joint separa- ity of trauma should be taken into scapula. An analysis of forty cases and a tion is a common injury that most typ- account. If radiographic evaluation review of the literature. J Bone Joint Surg Am. 1977;59(3):358-362. ically occurs because of disruption raises suspicion but is nondiagnostic, 8. Bernard TN Jr, Brunet ME, Haddad RJ Jr. of the suspensory ligaments between the surgeon should consider a Velpeau Fractured coracoid process in acromioclavicu- lar dislocations. Report of four cases and review the coracoid and clavicle as well as axillary view or computed tomogra- of the literature. Clin Orthop. 1983;(175):227- disruption of the acromioclavicular phy (CT) scan for better delineation of 232. 9. Protass JJ, Stampfli FV, Osmer JC. Coracoid joint capsule. Articles such as this the coracoid. CT scan will also help process fracture diagnosis in acromioclavicular one by DiPaola and colleagues help guide treatment and should clearly separation. Radiology. 1975;116(1):61-64. 10. Montgomery S, Lloyd RD. Avulsion fracture of remind the practicing orthopedic sur- differentiate displaced from nondis- the coracoid epiphysis with acromioclavicular geon that every injury is unique and placed injuries. separation: report of two cases in adolescents that even straightforward-appearing This case presentation by DiPaola and review of the literature. J Bone Joint Surg Am. 1977;59(7):963-965. injuries can hide significant pathol- and colleagues reinforces the fact 11. Wilson KM, Colwill JC. Combined acromiocla- ogy. Thorough evaluation of every that nonoperative management can vicular dislocation with coracoclavicular liga- ment disruption and coracoid process fracture. patient, especially in the trauma set- be successful in the treatment of this Am J Sports Med. 1989;17(5):697-698. ting, is necessary to avoid the pitfall injury. The surgeon should have a 12. Zettas JP, Muchnic PD. Fractures of the cora- coid process base in acute acromioclavicular of missing injuries such as this. clear understanding of the coracoid separation. Orthop Rev. 1976;5(11):77-79. The authors use a fairly straight- anatomy, especially the close rela- 13. Boyer DW Jr. Trapshooter’s shoulder: stress fracture of the coracoid process. Case report. forward case with successful outcome tionship of the suprascapular nerve, J Bone Joint Surg Am. 1975;57(6):862. by closed management to highlight if open reduction and internal fixa- 14. Hak DJ, Johnson EE. Avulsion fracture of the coracoid associated with acromioclavicular the importance of heightened clinical tion is planned. Reports such as this dislocation. J Orthop Trauma. 1993;7(4):381- suspicion and thorough evaluation. reinforce the adage that there may be 383. Their clear review of the literature and a snake under every rock, and it is 15. van Noort A, te Slaa RL, Mart RK, van der Werken C. The floating shoulder. A multicentre recommendations regarding the eval- helpful for surgeons to keep in mind study. J Bone Joint Surg Br. 2001;83(6):795- uation and treatment of these patients these rare presentations of somewhat 798. 16. Smith D. Coracoid fracture associated with are helpful, allowing the orthopedic common injuries so that a more thor- acromioclavicular dislocation. Clin Orthop. surgeon to deal with this problem ough evaluation is undertaken with 1975;(108):165-167. 17. Ishizuki M, Yamaura I, Isobe Y, Furuya K, appropriately. Clinical presentation each and every patient. Tanabe K, Nagatsuka Y. Avulsion fractures of in AC joint separations associated the superior border of the scapula: report of five Xavier A. Duralde, MD cases. J Bone Joint Surg Am. 1981;63(5):820- with coracoid fractures may be very 822. similar to those occurring because of Atlanta, GA

This paper will be judged for the Resident Writer’s Award.

40 The American Journal of Orthopedics®