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Base of coracoid process fracture with acromioclavicular dislocation in a child

Base of coracoid process fracture with acromioclavicular dislocation in a child Fracture of the coracoid process is a rare injury. It can be easily missed when associated with other injuries to the shoulder girdle, for instance, acromioclavicular joint (ACJ) dislocation. Clinical attention is easily drawn to the more obvious ACJ dislocation, hence, the need for further radiological evaluation. We report an unusual case of fracture of the base of coracoid process associated with a true acromioclavicular joint dislocation in a 12 year old boy, with no separation of the epiphyseal plate, as one might expect. Treatment also remains controversial. Our patient underwent open reduction internal fixation of the acromioclavicular joint and coracoid process. He subsequently made an uneventful progress with pain free full range of shoulder movement at 5 months, and was discharged at 9 months. Introduction the base of his coracoid process (Figures 2, 3). A three Coracoid fracture is an uncommon injury, accounting for dimensional CT scan reconstruction showed a spatial only 2% to 13% of all scapular fractures and approxi- view of the coracoid process fragment (Figures 4, 5) mately 1% of all fractures [1-3]. Acromioclavicular joint He underwent surgical intervention with reduction and dislocation is a very rare injury in a child below the age fixation of the acromioclavicular joint with two threaded of thirteen [4]. We report an interesting case of fracture half pins and screw fixation of the base of coracoid frac- of the coracoid process associated with acromioclavicular ture (Figure 6). Intraoperatively, his coracoclavicular and joint dislocation in a child. He underwent open reduction coracoacromial ligaments were intact and attached to the internal fixation of the acromioclavicular joint and cora- fracture fragment; but he had a disrupted acromioclavi- coid process. He subsequently made a good progress cular capsule. Post-operatively, a shoulder immobiliser with pain free full range of shoulder movement. was applied; and he started intermittent graded right shoulder movement. The threaded pins were removed Case presentation four weeks later (Figure 7). At 3 months follow-up, the A twelve year old boy came off a rope swing from four patient had a good range of movement of his right metres, landed on his right shoulder and sustained an shoulder, with occasional clicking on abduction. He was isolated injury to his right shoulder girdle. He com- advised to continue with shoulder exercises and avoid plained of pain and swelling. Clinically, he had a promi- strenuous activity. His radiograph showed that position nent lateral clavicle associated with swelling, marked was maintained. At 5 months, he had full active pain free bruising and tenderness over his right shoulder and scap- range of movement with resolution of clicking on abduc- ular area. His range of motion was restricted. He had no tion of his right shoulder. At 9 months follow-up, he had evidence of a brachial plexus injury, and had no vascular gone to normal activities, and was discharged from clinic. compromise. His initial radiographs showed a widely displaced Discussion acromioclavicular joint with possible coracoid process An isolated coracoid fracture can occur by direct trauma fracture (Figure 1). He had a computed tomography to the shoulder girdle. It is suggested that an avulsion (CT) scan, which confirmed the associated fracture at fracture of the coracoid could be caused by the sudden and violent contraction of the conjoined tendon [5] of * Correspondence: pritjett4eva@yahoo.co.uk the short head of the biceps, coracobrachialis and pec- Department of Trauma and Orthopaedics, Sunderland Royal Hospital, toralis minor or by the acromioclavicular ligaments. The Sunderland SR4 7TP, UK © 2010 Jettoo et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Jettoo et al. Journal of Orthopaedic Surgery and Research 2010, 5:77 Page 2 of 4 http://www.josr-online.com/content/5/1/77 Figure 1 Radiograph showing a standard anteroposterior view Figure 3 Axial CT image with a fracture of the base of coracoid of the right shoulder with dislocation of the acromioclavicular process. joint and fracture of base of coracoid process. coracoid base and the upper quarter of the glenoid or latter mechanism is believed to account for fracture pat- through the tip of the coracoid process [7]. terns seen in children. Epiphyseal separation of the coracoid process with A coracoid fracture can be isolated or associated with concomitant acromioclavicular sprain has also been an injury complex, including any of acromiclavicular reported in adolescents [6]. In the developing skeleton, disruption, clavicular fracture, acromial fracture, scapu- the epiphyseal plate is weaker than the coracoclavicular lar spine fracture or glenoid fracture [2,3]. ligaments. Interestingly, we describe a rare injury in this Fracture sites described in adults are the base of the twelve year old boy with an avulsion fracture of base of process, including the upper region of the glenoid, the coracoid with acromioclavicular dislocation. There was middle portion and the tip. no epiphyseal plate separation, as one might expect in The coracoid is thought to have two main ossification this age group (Figures 5 &6), but the base of the cora- centres, one at the base of the process, and an accessory coid was avulsed, an injury usually seen in patients in ossification centre at its tip [6]. Avulsion injuries in chil- the second or third decade of life [6]. Intra-operatively, dren result in fracture at the epiphyseal base of the we found intact coracoclavicular (conoid and trapezoid) and corocoacromial ligaments, which reflects the elasti- city and resiliency of the ligaments in the younger child, Figure 2 Axial CT image of the right shoulder with an intact Figure 4 Three-dimensional reconstructions of the CT scan epiphyseal plate of the coracoid process. give a spatial view of the coracoid fracture fragment. Jettoo et al. Journal of Orthopaedic Surgery and Research 2010, 5:77 Page 3 of 4 http://www.josr-online.com/content/5/1/77 Figure 5 Three-dimensional reconstructions of the CT scan show Figure 7 Post-operative radiograph after removal of threaded a base of coracoid fracture with an intact epiphyseal plate. pins, with reduction of acromioclavicular joint maintained. Albeit rare, a coracoid process fracture is an injury but there was disruption of the acromioclavicular joint that can be missed, when combined with an acromiocla- capsule. vicular joint dislocation. Clinical attention is easily The treatment of this type of injury is rather contro- drawn to the more obvious ACJ dislocation, hence, the versial. Both operative and non-operative treatment need for further radiological evaluation. We seek to methods [7-9] have been reported. In an injury complex, draw attentiontothisrareinjurycomplex in atwelve involving small bony avulsion fracture of the angle of year old, and present the good outcome with surgical the coracoid process, some adopt a treatment principle intervention. similar to that developed for grade III acromioclavicular joint disruptions [10]. In this child, we opted for surgical Consent intervention to allow early postoperative rehabilitation Written informed consent was obtained from the patient with mobilisation exercises. We proceeded with open for publication of this case and any accompanying reduction and internal fixation of both sites with this images. A copy of the written consent is available for displaced base of coracoid fracture to avoid the adverse review by the Editor-in-Chief of this journal. long-term effects of an acromioclavicular dislocation and a non union of the coracoid process. List of abbreviations ACJ: acromioclavicular joint. Authors’ contributions PJ conceived the idea and co-wrote the paper. GdeK performed the surgery and contributed to the discussion. SE assisted with the radiology and contributed to the discussion. All authors have read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 19 June 2010 Accepted: 18 October 2010 Published: 18 October 2010 References 1. Ada JR, Miller ME: Scapular fractures: analysis of 113 cases. ClinOrthop 1991, 269:174-80. 2. Eyres KS, Brooks A, Stanley D: Fractures of the coracoid process. JBone Joint Surg Br 1995, 77:425-8. 3. Ogawa K, Yoshida A, Takahashi M, et al: Fractures of the coracoid process. J Bone Joint Surg Br 1997, 79:17-9. 4. Black GB, McPherson JA, Reed MH: Traumatic pseudodislocation of the acromioclavicular joint in children. A fifteen year review. Am J Sports Med Figure 6 Post-operative radiograph anteroposterior of the 1991, 19:644-6. right shoulder. Jettoo et al. Journal of Orthopaedic Surgery and Research 2010, 5:77 Page 4 of 4 http://www.josr-online.com/content/5/1/77 5. Rounds RC: Isolated fracture of the coracoid process. J Bone Joint Surgery [Am] 1949, 31:662. 6. Montgomery SP, Loyd RD: Avulsion fracture of the coracoid epiphysis with acromioclavicular separation. Report of two cases in adolescents and review of the literature. J Bone Joint Surg 1977, 59 A:963. 7. Green NE, Swiontkowski MF: Fractures and dislocations about the shoulder. Skeletal Trauma in Children Saunders, 4 2008, 3:292. 8. Martin-Herrero T, Rodriquez-Merchan C, Munuera-Martinez L: Fractures of the coracoid process: Presentation of seven cases and review of the literature. J Trauma 1990, 30:1597-1599. 9. Lasda NA, Murray DG: Fracture separation of the coracoid process associated with acromioclavicular dislocation: Conservative treatment-A case report and review of the literature. Clin Orthop Relat Res 1975, 108:165-167. 10. Rockwood CA, Matsen FA III, Wirth MA, Lipitt SB: Fractures of the scapula. The shoulder Saunders, 4 2009, 1:p360. doi:10.1186/1749-799X-5-77 Cite this article as: Jettoo et al.: Base of coracoid process fracture with acromioclavicular dislocation in a child. Journal of Orthopaedic Surgery and Research 2010 5:77. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Orthopaedic Surgery and Research Springer Journals

Base of coracoid process fracture with acromioclavicular dislocation in a child

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Springer Journals
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Copyright © 2010 by Jettoo et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Orthopedics; Surgical Orthopedics
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1749-799X
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10.1186/1749-799X-5-77
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20955595
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Abstract

Fracture of the coracoid process is a rare injury. It can be easily missed when associated with other injuries to the shoulder girdle, for instance, acromioclavicular joint (ACJ) dislocation. Clinical attention is easily drawn to the more obvious ACJ dislocation, hence, the need for further radiological evaluation. We report an unusual case of fracture of the base of coracoid process associated with a true acromioclavicular joint dislocation in a 12 year old boy, with no separation of the epiphyseal plate, as one might expect. Treatment also remains controversial. Our patient underwent open reduction internal fixation of the acromioclavicular joint and coracoid process. He subsequently made an uneventful progress with pain free full range of shoulder movement at 5 months, and was discharged at 9 months. Introduction the base of his coracoid process (Figures 2, 3). A three Coracoid fracture is an uncommon injury, accounting for dimensional CT scan reconstruction showed a spatial only 2% to 13% of all scapular fractures and approxi- view of the coracoid process fragment (Figures 4, 5) mately 1% of all fractures [1-3]. Acromioclavicular joint He underwent surgical intervention with reduction and dislocation is a very rare injury in a child below the age fixation of the acromioclavicular joint with two threaded of thirteen [4]. We report an interesting case of fracture half pins and screw fixation of the base of coracoid frac- of the coracoid process associated with acromioclavicular ture (Figure 6). Intraoperatively, his coracoclavicular and joint dislocation in a child. He underwent open reduction coracoacromial ligaments were intact and attached to the internal fixation of the acromioclavicular joint and cora- fracture fragment; but he had a disrupted acromioclavi- coid process. He subsequently made a good progress cular capsule. Post-operatively, a shoulder immobiliser with pain free full range of shoulder movement. was applied; and he started intermittent graded right shoulder movement. The threaded pins were removed Case presentation four weeks later (Figure 7). At 3 months follow-up, the A twelve year old boy came off a rope swing from four patient had a good range of movement of his right metres, landed on his right shoulder and sustained an shoulder, with occasional clicking on abduction. He was isolated injury to his right shoulder girdle. He com- advised to continue with shoulder exercises and avoid plained of pain and swelling. Clinically, he had a promi- strenuous activity. His radiograph showed that position nent lateral clavicle associated with swelling, marked was maintained. At 5 months, he had full active pain free bruising and tenderness over his right shoulder and scap- range of movement with resolution of clicking on abduc- ular area. His range of motion was restricted. He had no tion of his right shoulder. At 9 months follow-up, he had evidence of a brachial plexus injury, and had no vascular gone to normal activities, and was discharged from clinic. compromise. His initial radiographs showed a widely displaced Discussion acromioclavicular joint with possible coracoid process An isolated coracoid fracture can occur by direct trauma fracture (Figure 1). He had a computed tomography to the shoulder girdle. It is suggested that an avulsion (CT) scan, which confirmed the associated fracture at fracture of the coracoid could be caused by the sudden and violent contraction of the conjoined tendon [5] of * Correspondence: pritjett4eva@yahoo.co.uk the short head of the biceps, coracobrachialis and pec- Department of Trauma and Orthopaedics, Sunderland Royal Hospital, toralis minor or by the acromioclavicular ligaments. The Sunderland SR4 7TP, UK © 2010 Jettoo et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Jettoo et al. Journal of Orthopaedic Surgery and Research 2010, 5:77 Page 2 of 4 http://www.josr-online.com/content/5/1/77 Figure 1 Radiograph showing a standard anteroposterior view Figure 3 Axial CT image with a fracture of the base of coracoid of the right shoulder with dislocation of the acromioclavicular process. joint and fracture of base of coracoid process. coracoid base and the upper quarter of the glenoid or latter mechanism is believed to account for fracture pat- through the tip of the coracoid process [7]. terns seen in children. Epiphyseal separation of the coracoid process with A coracoid fracture can be isolated or associated with concomitant acromioclavicular sprain has also been an injury complex, including any of acromiclavicular reported in adolescents [6]. In the developing skeleton, disruption, clavicular fracture, acromial fracture, scapu- the epiphyseal plate is weaker than the coracoclavicular lar spine fracture or glenoid fracture [2,3]. ligaments. Interestingly, we describe a rare injury in this Fracture sites described in adults are the base of the twelve year old boy with an avulsion fracture of base of process, including the upper region of the glenoid, the coracoid with acromioclavicular dislocation. There was middle portion and the tip. no epiphyseal plate separation, as one might expect in The coracoid is thought to have two main ossification this age group (Figures 5 &6), but the base of the cora- centres, one at the base of the process, and an accessory coid was avulsed, an injury usually seen in patients in ossification centre at its tip [6]. Avulsion injuries in chil- the second or third decade of life [6]. Intra-operatively, dren result in fracture at the epiphyseal base of the we found intact coracoclavicular (conoid and trapezoid) and corocoacromial ligaments, which reflects the elasti- city and resiliency of the ligaments in the younger child, Figure 2 Axial CT image of the right shoulder with an intact Figure 4 Three-dimensional reconstructions of the CT scan epiphyseal plate of the coracoid process. give a spatial view of the coracoid fracture fragment. Jettoo et al. Journal of Orthopaedic Surgery and Research 2010, 5:77 Page 3 of 4 http://www.josr-online.com/content/5/1/77 Figure 5 Three-dimensional reconstructions of the CT scan show Figure 7 Post-operative radiograph after removal of threaded a base of coracoid fracture with an intact epiphyseal plate. pins, with reduction of acromioclavicular joint maintained. Albeit rare, a coracoid process fracture is an injury but there was disruption of the acromioclavicular joint that can be missed, when combined with an acromiocla- capsule. vicular joint dislocation. Clinical attention is easily The treatment of this type of injury is rather contro- drawn to the more obvious ACJ dislocation, hence, the versial. Both operative and non-operative treatment need for further radiological evaluation. We seek to methods [7-9] have been reported. In an injury complex, draw attentiontothisrareinjurycomplex in atwelve involving small bony avulsion fracture of the angle of year old, and present the good outcome with surgical the coracoid process, some adopt a treatment principle intervention. similar to that developed for grade III acromioclavicular joint disruptions [10]. In this child, we opted for surgical Consent intervention to allow early postoperative rehabilitation Written informed consent was obtained from the patient with mobilisation exercises. We proceeded with open for publication of this case and any accompanying reduction and internal fixation of both sites with this images. A copy of the written consent is available for displaced base of coracoid fracture to avoid the adverse review by the Editor-in-Chief of this journal. long-term effects of an acromioclavicular dislocation and a non union of the coracoid process. List of abbreviations ACJ: acromioclavicular joint. Authors’ contributions PJ conceived the idea and co-wrote the paper. GdeK performed the surgery and contributed to the discussion. SE assisted with the radiology and contributed to the discussion. All authors have read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 19 June 2010 Accepted: 18 October 2010 Published: 18 October 2010 References 1. Ada JR, Miller ME: Scapular fractures: analysis of 113 cases. ClinOrthop 1991, 269:174-80. 2. Eyres KS, Brooks A, Stanley D: Fractures of the coracoid process. JBone Joint Surg Br 1995, 77:425-8. 3. Ogawa K, Yoshida A, Takahashi M, et al: Fractures of the coracoid process. J Bone Joint Surg Br 1997, 79:17-9. 4. Black GB, McPherson JA, Reed MH: Traumatic pseudodislocation of the acromioclavicular joint in children. A fifteen year review. Am J Sports Med Figure 6 Post-operative radiograph anteroposterior of the 1991, 19:644-6. right shoulder. Jettoo et al. Journal of Orthopaedic Surgery and Research 2010, 5:77 Page 4 of 4 http://www.josr-online.com/content/5/1/77 5. Rounds RC: Isolated fracture of the coracoid process. J Bone Joint Surgery [Am] 1949, 31:662. 6. Montgomery SP, Loyd RD: Avulsion fracture of the coracoid epiphysis with acromioclavicular separation. Report of two cases in adolescents and review of the literature. J Bone Joint Surg 1977, 59 A:963. 7. Green NE, Swiontkowski MF: Fractures and dislocations about the shoulder. Skeletal Trauma in Children Saunders, 4 2008, 3:292. 8. Martin-Herrero T, Rodriquez-Merchan C, Munuera-Martinez L: Fractures of the coracoid process: Presentation of seven cases and review of the literature. J Trauma 1990, 30:1597-1599. 9. Lasda NA, Murray DG: Fracture separation of the coracoid process associated with acromioclavicular dislocation: Conservative treatment-A case report and review of the literature. Clin Orthop Relat Res 1975, 108:165-167. 10. Rockwood CA, Matsen FA III, Wirth MA, Lipitt SB: Fractures of the scapula. The shoulder Saunders, 4 2009, 1:p360. doi:10.1186/1749-799X-5-77 Cite this article as: Jettoo et al.: Base of coracoid process fracture with acromioclavicular dislocation in a child. Journal of Orthopaedic Surgery and Research 2010 5:77. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

Journal

Journal of Orthopaedic Surgery and Research – Springer Journals

Published: Oct 18, 2010

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