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1 nstrumentation or 1 cm), have progressed . vant anatomy, andof mechanism injuryfractures, related to diagnosis ofwith coracoid a focus fractures on injurytion classifica- and the typesinjuries of associated foundwith coracoid in fractures, conjunction dications for coracoidincluding fractures a succinct review of the outcomes after surgical manage- ment, and work for coracoid fractures. The purpose of this study(1) is to review the incidence, rele- (2) describe relevant workup for (3) discuss relative surgical in- (4) discuss the areas of future primarily based on level IVdence. and V evi- Thecoracoid surgical fractures indications arebetter for evolving understanding of as associated a juries in- and surgical i techniques improve. ies, the literature oracoid fractures arerare relatively injuries that typically occur Abstract Fractures of the coracoid are relativelymanagement rare, guidelines remain and unclear. Most current coracoid fractures occur in conjunction with other injuries, including dislocationsfractures. and Identifying coracoid fractures can be difficult becausefractures most are nondisplaced and can be missedbe on masked radiographs by or other may injuries. Management is largelylocation guided and by displacement. fracture Conservative treatment is preferred for fractures that are minimally displaced, whereas indications forfixation surgical include fractures that are displaced ( to a painful nonunion, orsuperior are shoulder associated with suspensory the complex. disruptiontreatment of has Although the been conservative historically favored,been satisfactory outcomes reported have for both surgicalprovide and a nonsurgical treatment. comprehensive We reviewstrategies for of coracoid diagnosis fractures. and management Review Article surrounding the management of cora- coid fractures is limited. Theevidence available to guide treatment decisions is because of high-energyas trauma, a such motor vehicle accident.blunt However, traumaactivities have also related been described asmechanism to a of sporting repetitive stress-related injury injuries. Most coracoid along fractures do not occur with inlation iso- becausemechanism of of injury the andassociated is with high-energy additional typically injuriesthe to affected shoulder,the particularly to other structuresshoulder suspensory of complex the (SSSC). Careful superior clinical evaluationimaging including of theessential because affected the presence shouldercomitant of injuries is con- may affect treatment decision-making. Owing to the relative rarity of these injur C Fractures of the : Evaluation, Management, and Outcomes 2020;00:1-10 Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. DOI: 10.5435/JAAOS-D-19-00148 Copyright 2020 by the American Academy of Orthopaedic Surgeons. From the Department ofSurgery, Orthopaedic Madigan Army Medical Center (Dr. Galvin), Tacoma, WA,Department the of Orthopaedic Surgery, Boston University School of Medicine (Dr. Kang and Dr. Li), Boston, MA,the and Department of Orthopaedic Surgery, University of Missouri School of Medicine (Dr. Ma), Columbia, MO. Dr. Li or an immediateholds family equity member in JoMI.following None authors of or the anyfamily immediate member has received anything of value from oroptions has held stock in a or commercial company stock or institution related directlyindirectly or to the subjectDr. of Galvin, this Dr. article: Kang, and Dr. Ma. J Am Acad Orthop Surg Month 2020, Vol 00, No 00 Jeansol Kang, MD Richard Ma, MD Xinning Li, MD Joseph W. Galvin, DO

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the attachment of the conjoint tendon joint injuries should more commonly Regional Anatomy of the at the coracoid process, resulting in involve a tear of the CC ligaments Coracoid avulsion of the coracoid tip.5-10 Fatigue rather than a coracoid fracture.23 To fractures of the coracoid process have explain the combined coracoid frac- Most coracoid fractures are associated also been described in trap shoot- ture and AC separation in adults, Li with additional injuries to the affected ers,11,12 cricket players,6,13,14 and ten- et al24 proposed a two-step mech- shoulder, particularly to the SSSC. nis players,7 where it is likely that anism in which the sudden contrac- Therefore, surgeons should understand repetitive direct microtrauma ulti- tion of the conjoint tendon and the complex anatomy of the coracoid mately leads to bony failure of the muscle produces a process and have knowledge of the coracoid. In addition, isolated frac- fracture of the coracoid and the com- attachment sites of the conjoint tendon, tures can occur secondary to iatrogenic ponent residual force along the CC coracoclavicular (CC) (trapezoid and surgical etiologies such as trans- ligaments determines whether the CC conoid) ligaments, coracoacromial coracoid drilling for suture button ligament is disrupted. (anterior and posterior bundles) liga- fixation of unstable acromioclavicular ment (CAL), , (AC) joint separations and after and pectoralis minor. The minimum reverse shoulder arthroplasty.15-17 Physical Examination distance between the tip of the coracoid Most coracoid fractures occur in Findings and the most anterior CC ligament conjunction with other ipsilateral (trapezoid) is 25.1 mm, and sex differ- Identifying coracoid fractures via shoulder injuries. This pattern is typi- ences are present with a mean of physical presentation can be difficult as cally because of high-energy trauma, 28.1 mm and 22.0 mm in men and physical examination findings may be most often a direct blow from a motor women, respectively.1 nonspecific and are often masked by vehicle accident or fall.18-21 Associated other concomitant shoulder injuries. injuries include glenohumeral joint Isolated fractures typically present Epidemiology and injuries, AC joint injuries, with pain and tenderness to palpation tears, and fractures of the acro- Mechanism of Coracoid over the coracoid. Patients may also mion, , distal , and Fractures exhibit limited, painful active shoulder .18,19 The most common abduction, flexion, and/or external McGinnis and Denton2 described the associated injury is AC joint separa- rotation, but the neurovascular exam- prevalence of coracoid fractures tion.9,18-20 In the largest series of ination is usually normal.6,13,25 between3%to13%ofallscapula coracoid fractures involving nonsport- Examination findings in nonisolated fractures after a review of the litera- related trauma, Ogawa et al18 found cases vary depending on the associated ture in 1989. More recent data from that 58% (39/67) of patients with injuries. The most common combi- two systematic reviews of scapula coracoid fractures had associated AC nation of coracoid fracture with AC fractures in 2006 and 2008 reported joint injuries. Similarly, in a review of joint injury may present with addi- the prevalence of apophyseal (acro- sport-related coracoid fractures, Kna- tional findings of pain and tenderness mion, coracoid, and scapular spine) pik et al20 reported concurrent AC joint to palpation over the AC joint, visible fractures at 6% and 8.2%, respec- injury in 60% of patients. deformity, and painful cross-body tively.3,4 Isolated coracoid fractures The mechanism resulting in this adduction.21,24,26-28 Owing to the are rare, with 43 case reports in the combination of injury proposed by presence and severity of associated English literature and few retrospec- Wilson et al involves a direct force to injuries, coracoid fractures may be tive case series. the AC joint, causing caudad dis- overlooked—therefore, the physical Coracoid fractures are generally placement of the and scap- examination should be performed due to high-energy direct impact ula, whereas the CC ligaments pull the with a focus on the reported mech- injuries or eccentric pull through soft- coracoid cephalad.10 This may result anism of injury. tissue attachments (ie, conjoint ten- in a coracoid fracture in skeletally don or CC ligaments) resulting in immature patients in whom the CC failure of the . Isolated fractures, ligaments are relatively stronger than Imaging as described in case reports, are often the unfused epiphyseal plate of the because of acute trauma, wherein a coracoid.9,22 However, this may not True anterior-posterior, scapular-Y, sudden and violent contraction of the explain all coracoid fractures in and axillary lateral views will help coracobrachialis and the short head adults, where the relative strength of visualize the fracture. An MRI or CT of the brachii muscles during the coracoid and clavicle in relation to scan with three-dimensional recon- resisted flexion places stress at the CC ligaments suggest that AC struction assists in understanding the

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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Joseph W. Galvin, DO, et al

Figure 1

Photographs showing relevant anatomy for classification of coracoid fractures and the Ogawa coracoid fracture classification. In type I fractures (green), the fracture line is proximal or behind the CC ligaments. In type 2 fractures (yellow), the fracture is distal or in front of the CC ligament. AC = acromioclavicular, CA = coracoacromial, CC = coracoclavicular. (Adapted with permission from Simovitch R, Sanders B, Ozbaydar M, Lavery K, Warner JJ. Acromioclavicular joint injuries: diagnosis and management. J Am Acad Orthop Surg. 2009;17(4):207-219 [Figure 1 from manuscript]. Frank RM, Cotter EJ, Leroux TS, Romeo AA. Acromioclavicular Joint Injuries: Evidence-based Treatment. J Am Acad Orthop Surg 2019. doi: 10.5435/JAAOS-D-17-00105 [Figure 2A from manuscript].) Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. fracture morphology and displace- more detailed classification system fracture displacement, and the pres- ment. In addition, it should be noted based on a review of 12 coracoid ence of associated injuries to other that the coracoid has two secondary fractures. In the classification by Eyres structures of the SSSC.18,19 Isolated ossifications centers, one over the (Figure 2), coracoid fractures are coracoid fractures that are either angle of the coracoid and another at divided into five types and sub- nondisplaced or minimally displaced the tip, and these can close as late as grouped into A or B according to the can be treated successfully with non- 29 25 years of age. This is important presence or absence of associated in- surgical management.20,26,30-32 Even in the setting of trauma in the pedi- juries to the clavicle or its ligamentous with displacement, isolated coracoid atric and young adult patient when connection that affects scapula sta- tip fractures (ie, Eyres type 1/Ogawa attempting to distinguish a cora- bility. Type I coracoid fracture in- type II injuries) and fracture between coid fracture from normal unfused volves the tip or epiphyseal area, type the CC and coracoacromial (CA) lig- apophysis. II is midprocess, type III is a basal aments (Eyres type 2 to 3) can be fracture, type IV is with the superior successfully treated with nonsurgi- body of the scapula involved, and cal management.18,19 Improved sur- Classification type V is extension into the glenoid gical instrumentation, including the fossa. Both Ogawa et al and Eyres et al18,19 expanded use of suture anchors, has have proposed a classification system resulted in some authors advocating for coracoid fractures based on the Management for fixation of displaced coracoid tip 33 anatomic location of the fracture line. fractures. Conservative treatment of Ogawa et al18 divided the fracture Conservative Management coracoid fractures typically originates into two types based on the anatomic Definitive treatment guidelines for with sling immobilization to decrease location of the fracture in relation to coracoid fractures are lacking and pain and minimize further displace- the attachment of the CC ligaments typically rely on recommendations ment of the coracoid fracture.30-32 (Figure 1). Type I fractures are located based on level IV and V evidence. Passive motion and active assisted behind the attachment, whereas type Coracoid fracture treatment is typi- range of motion with physiother- II fractures are in front of the CC cally described based on the location of apy are initiated 6 weeks after the ligaments. Eyres et al19 proposed a fracture plane relative to the coracoid, injury.31,32 A recent systematic review

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Figure 2 toward the tip of the coracoid may be more related to a traction mechanism of injury to the coracoid through the attached ligaments and tendons, proximal coracoid fractures that extend into the scapular body and glenoid often represent a more unstable and severe shear-type mech- anisms because of impaction from the humeral head or clavicle. Eyres et al19,37 have therefore advocated for coracoid stabilization in the latter scenario. Although using a different classification system, Ogawa et al18,38 similarly raised the concern that cor- acoid fractures which occur at the Illustration showing the Eyres coracoid fracture classification: type I, tip or base and posterior to the CC liga- epiphyseal fractures (yellow); type 2, midprocess (red); type 3, basal (green); type ments (Ogawa type I injuries) often 4, superior body of the scapula (orange); AND type 5 (blue), extension into the represent a notable disruption of the . The suffix A or B can be used to denote the presence or absence of scapuloclavicular connection and damage to the clavicle or its ligamentous connection to the scapula. (Adapted with permission from Simovitch R, Sanders B, Ozbaydar M, Lavery K, Warner JJ. therefore should be stabilized; how- Acromioclavicular joint injuries: diagnosis and management. JAmAcadOrthop ever, this is a relative surgical indica- Surg 2009;17(4):207-219 [Figure 1 from manuscript].) Adaptations are themselves tion. In addition to fracture patterns works protected by copyright. So in order to publish this adaptation, authorization and associated injuries, some authors must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. have advocated for the consideration of surgical intervention for displaced coracoid fractures in individuals who of sport-related coracoid fractures shoulder function.34-36 Although the may engage in heavy overhead work identified return to sporting activities, combination of coracoid and AC joint (ie, manual laborers) to minimize typically occurring 2 to 3 months after injuries have been treated non- morbidity risk related to fracture the initial coracoid injury with docu- surgically with success,20,31,32 some nonunion.27,37 mentation of fracture stability.20,32 authors advocate for surgical treat- ment of coracoid fractures associated with AC joint injuries.19,37,38 One Ogawa Type 1—Surgical Surgical Management treatment strategy to address double- Techniques Surgical management of coracoid disruption SSSC injuries that include fractures are typically reserved for both AC and coracoid injuries is to Our preferred surgical technique for unstable, displaced coracoid fractures first stabilize the AC joint pathology surgical fixation of Ogawa type 1 or coracoid fractures that are associ- and then reassess the position of the (proximal to the CC ligaments) dis- ated with other SSSC injuries. Gener- coracoid fracture. If the coracoid placed coracoid fractures involves ally accepted surgical indications for fracture is relatively reduced and well- fixation with a cortical screw and coracoid fractures are listed in Table 1. positioned after surgical stabilization washer perpendicular to the fracture As described previously, the most of the AC joint, then the coracoid can line. Preoperative 3D CT scan is common concomitant injury to the be treated nonsurgically.38 paramount to assist in defining the SSSC with coracoid fractures are AC In addition to scenarios where the fracture plane orientation and plan- joint injuries.18,20 The combination coracoid fracture occurs in conjunc- ning the trajectory of screw fixation of a coracoid injury in addition to tion with additional injuries to the (Figure 3, A). The patient is posi- another injury to the SSSC is impor- SSSC, isolated displaced coracoid tioned supine on a radiolucent table. tant to recognize because it represents fractures that extend into the scapula The table is inclined approximately two disruptions (double disruption) of or glenoid with displacement (.1cm) 15° to allow improved visualization the SSSC complex, which creates an (Eyres type IV and V injuries, during exposure. A small bump is unstable anatomic situation that may respectively) warrant surgical consid- placed under the ipsilateral scapula result in persistent disability and poor eration. Although fractures that occur to make the scapula and coracoid

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Table 1 Indications for Surgical Management of Coracoid Fractures 1. Coracoid fractures complicated by other injuries to the superior shoulder suspensory complex (ie, acromioclavicular joint dislocation) or a double disruption scenario. 2. Displaced Eyres type IV and V fractures. 3. Ogawa type I fractures with scapuloclavicular dissociation. 4. Symptomatic coracoid fracture nonunion (pain and tenderness over coracoid with no radiographic signs of healing after 6 mo of conservative management).

Figure 3

A, Photograph showing preoperative 3D CT scan demonstrating the displacement and rotation of a coracoid base fracture (arrow). B, Photograph showing large C- fluoroscopy is brought in to the operating room from the opposite side of the table to obtain orthogonal imaging for fracture reduction and fixation. more prominent. The entire chest, coracoid with care taken not to place and CA ligament insertion to visu- shoulder, and ipsilateral extremity it into the fracture site, and a blunt alize the orientation of the fractured are prepped and draped in a sterile retractor is placed under the deltoid coracoid process for provisional pin fashion. A padded mayo stand is around the humerus with care taken fixation (Figure 4, B). The Lahey helpful for supporting the surgical to protect the axillary nerve. A Lahey clamp is then used to manipulate arm. Large C-arm fluoroscopy is (triple prong) clamp is used to grasp the coracoid fracture, which involves brought in from the opposite side of the coracoid for ease of manipula- extension of the fracture frag- the table to obtain orthogonal tion. With coracoid fractures poste- ment because of the deforming imaging (Figure 3, B). By positioning rior to the CC ligaments (Ogawa force of the conjoined tendon while the patient on a radiolucent table, it type 1 fractures), it is difficult evaluating the reduction on the allows the surgeon to obtain a good to visualize the fracture reduction anterior-posterior and scapular-Y quality scapular-Y fluoroscopic view directly because of the CA and cor- fluoroscopic view. Once reduced, which is key to obtaining an indirect acohumeral ligaments laterally, the the fracture is provisionally fixated fracture reduction (Figure 4, A). A intact pectoralis minor medially, and with 1 to 2 Kirschner wires. Defini- standard deltopectoral approach is the CC ligaments attached to the tive fixation is achieved with 1 to performed. A large spiked Hohmann fractured fragment. It is helpful to 2 bicortical solid screws with retractor is placed at the base of the release some of the pectoralis minor washers (Figure 5, A). Postoperative

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Figure 4 an effective technique. A standard deltopectoral approach is performed. Once the fracture site is exposed, a biocomposite suture anchor (6.5-mm) is placed in line with the intra- medullary canal of the coracoid. Next, the nonabsorbable sutures are passed through the fractured coracoid process and tied down to secure the fracture. The authors then describe placing two additional smaller (3.0- mm) biocomposite suture anchors. The limbs from these sutures are passed through the proximal conjoint tendon to augment the fixation.

Outcomes

Owing to the rarity of isolated cora- A, Photograph showing the scapular-Y fluoroscopic image obtained with the coid fractures, few large series exist, large C-arm. B, Displacement and rotation of the coracoid fracture fragment is documenting clinical outcomes after visualized (arrow). conservative and surgical treatment (Table 2). Ogawa et al18 retrospec- Figure 5 tively reviewed 67 patients with iso- lated coracoid fractures. Forty-five patients were available for a follow- up at a mean of 37 months (12 to 117 months). Type 1 fractures (31 patients), type 2 fractures (3 patients), and 1 patient of unknown classifica- tion were treated with a cortical screw and washer. Eight patients with type 2 fractures were treated conser- vatively with a sling. Overall, 87% of patients had a good outcome, with only 13% having a fair outcome. No notable difference was observed in the outcomes between patients with type1and2fracturesandbetween those undergoing conservative and surgical treatment. All type 2 frac- A, Photograph of the scapular-Y view obtained with C-arm intraoperatively after tures treated conservatively with a reduction and fixation shows anatomic reduction of the coracoid fracture with a sling had good outcomes. In a large screw and washer bicortical fixation. B, Postoperative anterior-posterior retrospective case series, Hill et al37 radiograph demonstrating anatomic fixation of the coracoid fracture. analyzed the outcomes of 22 patients with isolated coracoid process frac- radiograph shows anatomic reduction surgically. However, in the rare cases tures treated with surgical fixation of the coracoid fracture with screw that warrant surgical reduction and (20 type 1 fractures and 2 type 2 and washer fixation (Figure 5, B). fixation because of displacement and fractures). A total of 17 patients Typically, Ogawa type 2 (distal to potential subscapularis impingement, underwent open reduction and fixa- the CC ligaments) coracoid fractures the technique described by Kennedy tion with 1 to 3 lag screws, whereas 5 are successfully managed non- et al33 with suture anchor fixation is patients underwent surgical fixation

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Table 2 Outcomes of Coracoid Fracture Management Fracture Mean No. of Type (Ogawa Follow-up Study Patients Classification) Treatment Outcomes (mo)

Martin- 77—type 1 fractures Conservative: Very good result in 5 28 (12-60) Herrero (all fractures had 7 patients patients. Good result et al5 either ipsilateral (sling, 2-4 wk) in 2 patients. No patient AC joint separation reported clinical outcome or superior glenoid scores. fracture) Eyres 12 12—coracoid fractures Surgical treatment Conservative: 8 of 9 treated Unk et al19 (did not specify (1 large fragment conservatively regained according to the cancellous screw): full shoulder range of Ogawa classification) 2 patients motion. One patient had less than 90° shoulder elevation; Conservative Surgical treatment (sling): 10 patients (2 patients)—regained shoulder motion at 6 and 9 wk. Ogawa 67 53-type 1 fractures, Surgical treatment 45 patients available for 37 (12-117) et al18 11-Type 2 fractures, (screw & washer): follow-up. 87% excellent 31 type 1, 3 type 2 results, 13% fair results. fractures, 1 unk classification. 3—unknown Conservative No notable difference classification treatment (sling): between type 1 & 2 8 type 2 fractures fractures or between conservative and surgical management. 8 patients—type 2 fractures had excellent outcome with sling treatment. Ogawa 15 10—type 1 fractures Conservative: 4 type 1 In the subacute/chronic 23 (12-41) et al36 fractures (presenting type I fracture with , 5 wk from injury) persistent pain and 4 type 2 fractures functional impairment, surgical treatment of the coracoid fracture results in gratifying outcome (5 of 6 patients) 5—type 2 fractures Surgical treatment: 6 type 1 Type II coracoid fractures— fractures (presenting . 5 conservative treatment is wk from injury with painful indicated (4 of 5 good nonunion) outcomes). When presenting with chronic subcoracoid impingement, surgical treatment was effective in 1 case. 1 type 2 fracture (due to painful impingement, 44 wk post injury) (continued) AC = acromioclavicular, SSSC = superior shoulder suspensory complex, unk = unknown

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Table 2 (continued) Outcomes of Coracoid Fracture Management Fracture Mean No. of Type (Ogawa Follow-up Study Patients Classification) Treatment Outcomes (mo)

Ogawa 36 36—type 1 fractures Surgical treatment Surgical treatment—all 15 (12-36) et al38 (34 of 36 patients (4.5-mm AO malleolar cases achieved bony with double screw and washer): union. The Constant disruptions 36 patients score ratio to the intact of SSSC) side at the follow-up survey was 93% 6 7.4% (range, 75%-100%) on average, with the exception of one Patient presenting with partial paralysis of the brachial plexus as a sequela of the initial trauma. Hill et al37 22 20—type 1 fractures, Surgical treatment, The median DASH 23.5 (12-72) 2 type 2 fractures w/ l-3 lag score = 12.3 (range: concomitant anterior screws only: 0 -74; mean = 10.1); glenoid rim lesions. 17 patients 16 (84%) returned to previous work or employment; (All patients had Surgical treatment, No infections or ipsilateral SSSC 0-2 lag screws nonunions. 2 injury and/or 1 plate (1.5 or patients required additional fracture 2 mm recon, t-plate, hardware removal of the scapula) 1/4 tubular, 1/3 tubular): 5 patients

AC = acromioclavicular, SSSC = superior shoulder suspensory complex, unk = unknown with a combination of screws and a Ogawa type 1 coracoid fractures with a tive management in a sling. Ogawa smallplate.Atameanfollow-upof screw 6 washer or buttress plate gen- et al36 followed five patients with 23.5 months, the median Disabilities of erally results in good outcomes at the type 2 coracoid fractures for a mean the Arm, Shoulder and (DASH) short-term follow-up. In contrast to the follow-up 23 (12 to 41) months. score was 12.3 (range: 0 to 74; mean = case series by Ogawa et al and Hill et al Four of five patients had good out- 10.1) and 16 (84%) returned to pre- in which type 1 fractures were treated comes at the final follow-up despite vious work or employment. In addi- surgically with a screw and washer, developing a nonunion. One patient tion, there were no infections or Martin-Herrero et al5 reported on had painful subcoracoid impinge- nonunions; however, two patients seven type 1 fractures treated conser- ment because of the displaced cora- required implant removal. Further- vativelywithaslingfor2to4weeks.At coid tip and obtained symptom relief more, Ogawa et al38 analyzed the the mean follow-up of 28 months with surgical treatment. In addition, outcomes of 36 type 1 fractures treated (range 12 to 60 months), the authors in another case series by Ogawa with open reduction internal fixation reported “very good” results in five et al,18 eight patients with type 2 with a 4.5-mm malleolar screw and patients and “good” results in two fractures were treated conservatively washer. Thirty four of 36 patients had patients. A limitation of the study was in a sling and all patients had an double disruptions of the SSSC. All the lack of validated patient-reported excellent outcome at a mean follow- cases achieved bony union. The Con- outcome measures. up of 37 months. In summary, con- stant score ratio to the intact side at the There is limited evidence to guide servative treatment is indicated for follow-up was 93% 6 7.4% (range, 75 treatment for Ogawa type 2 coracoid type 2 coracoid fractures with good to 100%) on average. Based on these fractures; however, most studies sup- results. Rarely, a displaced type 2 small case series, surgical treatment of port good outcomes with conserva- fracture will lead to subcoracoid

8 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Joseph W. Galvin, DO, et al impingement and surgical treatment 1. Chahla J, Marchetti DC, Moatshe G, et al: reverse total shoulder arthroplasty: A Quantitative assessment of the report of 2 cases. Am J Orthop (Belle Mead, is effective in relieving symptoms. coracoacromial and the coracoclavicular NJ) 2015;44:E469-E472. ligaments with 3-dimensional mapping of the coracoid process anatomy: A cadaveric 16. Dunn JC, Waterman BR: Successful study of surgically relevant structures. nonoperative management of coracoid Summary Arthroscopy 2018;34:1403-1411. fracture associated with suture-button fixation of acromioclavicular separation. 2. McGinnis M, Denton JR: Fractures of the Mil Med 2015;180:e138-e141. Coracoid process fractures are rela- scapula: A retrospective study of 40 tively rare and typically occur because fractured scapulae. J Trauma 1989;29: 17. 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30. Chitre AR, Divecha HM, Hakimi M, 33. Kennedy NI, Ferrari MB, Godin JA, Sanchez subacute and chronic fractures of the Marynissen HAJ: Traumatic isolated G, Provencher MT: Repair of an isolated coracoid process. J Trauma 2009;67: coracoid fractures in the adolescent. Case coracoid fracture with suture anchor 1040-1045. Rep Orthop 2012;2012:371627. fixation. Arthrosc Tech 62017;e1715-9. 37. Hill BW, Jacobson AR, Anavian J, Cole 31. Pedersen V, Prall WC, Ockert B, Haasters 34. Gross TP, Walcott ME: Rockwood and PA: Surgical management of coracoid F: Non-operative treatment of a fracture to ’ Matsen s The Shoulder, ed 5. Philadelphia, fractures: Technical tricks and clinical the coracoid process with PA, Elsevier, 2016. experience. J Orthop Trauma 2014;28: acromioclavicular dislocation in an adolescent. Orthop Rev 2014;6:5499. 35. Goss TP: Double disruptions of the superior e114-e122. shoulder suspensory complex. J Orthop 38. Ogawa K, Matsumura N, Ikegami H: 32. Thomas K, Ng VY, Bishop J: Nonoperative Trauma 1993;7:99-106. management of a sagittal coracoid fracture Coracoid fractures: Therapeutic strategy with a concomitant acromioclavicular joint 36. Ogawa K, Ikegami H, Takeda T, Watanabe and surgical outcomes. J Trauma Acute separation. Int J Shoulder Surg 2010;4:44-47. A: Defining impairment and treatment of Care Surg 2012;72:E20-E26.

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