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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 26-28

A rare combination of acromion and coracoid base fracture: An unusual injury managed conservatively


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission24-Apr-2020
Date of Acceptance16-Jul-2021
Date of Web Publication21-Aug-2021

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani 263139, Uttarakhand.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijors.ijors_6_20

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  Abstract 

The acromion and coracoid process fractures are uncommon injuries and may be missed in cases of bad quality radiographs or inappropriate patient positioning during radiography. The complex shoulder region anatomy calls for careful observation and clinical suspicion to rule out these injuries. Concomitant coracoid and acromion process fracture is a rare pattern of injury. We report a case of minimally displaced acromion process fracture with undisplaced fracture of base of the coracoid process. Conservative management was done and a satisfactory outcome was noted in the mean follow-up of 9 months on using the DASH score.

Keywords: Acromion process, coracoid process, fracture, scapula, shoulder girdle


How to cite this article:
Dharmshaktu GS, Adhikari N, Mourya P. A rare combination of acromion and coracoid base fracture: An unusual injury managed conservatively. Int J Orthop Surg 2021;29:26-8

How to cite this URL:
Dharmshaktu GS, Adhikari N, Mourya P. A rare combination of acromion and coracoid base fracture: An unusual injury managed conservatively. Int J Orthop Surg [serial online] 2021 [cited 2021 Dec 8];29:26-8. Available from: https://www.ijos.in/text.asp?2021/29/1/26/324279




  Introduction Top


Coracoids fracture is a rare injury and is usually found along with other injuries of the shoulder girdle.[1] These constitute only 1% of all injuries and 2%–13% of scapula fractures.[2] A careful radiological examination is warranted to diagnose these injuries which may be easily missed. Some of these fractures may also be fatigue fractures especially in athletes as one systematic review of these injuries in sportspersons revealed six cases of fatigue injuries out of 21 cases in total.[3] Fracture of acromion process and coracoids process in combination is a rare injury.[4] We report a case of minimally displaced acromion process fracture with undisplaced fracture of base of the coracoid process.


  Case Report Top


A middle-aged female patient presented to us with a history of fall from a tree, a day back leading to left shoulder region injury and abrasions over left leg along with pain and limitation of shoulder movement. There was no open wound over the shoulder region and the neurovascular status of the left upper extremity was intact. The anteroposterior view radiograph of the shoulder showed normal glenohumeral joint and proximal humerus but there was suggestion of coracoids base fracture [Figure 1]. The computerized tomography (CT) scan of the shoulder was advised to better appreciate the injury. The CT scan with three-dimensional reconstruction clearly delineated the fracture of coracoid base that was slightly displaced but appeared to be joined to the rest of scapula bone with intact bone margins and was not completely separated. The minimally displaced fracture of the acromion process was also noted on the CT scan [Figure 2]. The patient was explained all treatment options with pros and cons of each methods and she chose conservative management of the injury. She was given shoulder immobilizer and strict limitation of the shoulder movement for four weeks followed by supervised physiotherapy of shoulder muscles. The fracture started uniting in 1 month follow-up radiograph [Figure 3]A and completely united in the follow-up radiograph at 5 months [Figure 3]B. The patient had marked clinical improvement and was performing activities of daily living (ADL) without discomfort and pain at the follow-up of 8 months. There were no remote complications of the injury noted.
Figure 1: Radiograph showing left-side coracoid fracture at the base. There is mild acromioclavicular joint luxation, whereas glenoid and proximal humerus remains intact

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Figure 2: CT images showing fracture at the coracoid base (A) that is not completely separated from the scapula. The presence of another minimal displaced fracture of acromion process also noted and marked by arrows (B)

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Figure 3: Radiograph at 1 month (A) and 5 month (B) follow-up showing united fracture. The above radiograph has erroneous marking of right side

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  Discussion Top


Many of these fractures are overlooked and neglected owing to complex radiological anatomy, overlapping of bones, inappropriate posture during emergency radiography, and additional life-threatening injuries taking precedence. Correct radiological imaging like central X-ray beam angled 25° cephalad or an axillary lateral view are useful in better identification of these fractures.[4] Additional CT can be used to confirm the diagnosis in doubtful cases or those requiring fixation. There is however a short report suggesting the usefulness of ultrasonography (USG) also in diagnosing these fractures.[5] A good fluoroscopic assistance offering biplanar visualization using specific methods may prove beneficial in treating these fractures accurately or even percutaneously.[6] In one report CT-guided percutaneous screw fixation has also been described.[7]

Conservative management can be done in many cases with good outcome as was seen in a series of nine cases.[8] Our case chose conservative treatment and it also worked as the fracture was not completely separated; patient was compliant to period of rest and she was housewife requiring no hard manual labor work. Surgery is also done for these fractures with god outcome in selected cases.[9],[10] Results of surgery in cases with or without injury to superior shoulder suspensory complex (SSSC) were satisfactory if the reconstruction is good. The current report highlights rare combination of acromion and coracoid injury and describes conservative management as viable option in selected cases with good treatment compliance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ogawa K, Yoshida A, Takahashi M, Ui M Fractures of the coracoids process. J Bone Joint Surg B 1997;79:17-9.  Back to cited text no. 1
    
2.
Ada JR, Miller ME Scapular fractures: Analysis of 113 cases. Clin Orthop Relat Res 1991;269:174-80.  Back to cited text no. 2
    
3.
Knapik DM, Patel SH, Wetzel RJ, Voos JE Prevalence and management of coracoid fracture sustained during sporting activities and time to return to sport: A systematic review. Am J Sports Med 2018;46:753-8.  Back to cited text no. 3
    
4.
Lim KE, Wang CR, Chin KC, Chen CJ, Tsai CC, Bullard MJ Concomitant fracture of the coracoid and acromion after direct shoulder trauma. J Orthop Trauma 1996;10:437-9.  Back to cited text no. 4
    
5.
Botchu R, Lee KJ, Bianchi S Radiographically undetected coracoid fractures diagnosed by sonography: Report of seven cases. Skeletal Radiol 2012;41:693-8.  Back to cited text no. 5
    
6.
Bhatia DN Orthogonal biplanar fluoroscopy-guided percutaneous fixation of a coracoids base fracture associated with acromioclavicular joint dislocation. Tech Hand Upper Extremity Surg 2012;16:56-9.  Back to cited text no. 6
    
7.
Thompson G, Heever AVD Coracoid stress fracture in an elite fast bowler: Description of a technique for CT-guided percutaneous screw fixation of coracid fractures. Skelet Radiol 2019;48: 1611-6.  Back to cited text no. 7
    
8.
Vaienti E, Pogliacomi F Delayed diagnosis of isolated coracoid process fractures: Results of 9 cases treated conservatively. Acta Biomed 2012;83:138-46.  Back to cited text no. 8
    
9.
Anavian J, Wijdicks CA, Schroder LK, Vang S, Cole PA Surgery for scapula process fractures: Good outcome in 26 patients. Acta Orthop 2009;80:344-50.  Back to cited text no. 9
    
10.
Spormann C, Holzach P, Ryf C Open reduction and internal fixation of isolated fractures of the coracoids process: Presentation of three cases and review of the literature. Swiss Surg 1998;4:198-202.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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