Coracoid Process Fracture with Acromioclavicular Joint
Total Page：16
File Type：pdf, Size：1020Kb
(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 coracoidthe 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.