Good Clinical Outcome following Non-operative Treatment of Concomitant Fractures of Coracoid Process and Distal End of Clavicle: A Case Report.

INTRODUCTION: A coracoid fracture is a rare orthopaedic condition as it accounts for only 2 - 10 % of all scapular fractures and <0.1% of all fractures. In even rarer cases coracoid fractures are also associated with other bony injuries of the shoulder. There is currently no consensus on the treatment of such injuries. CASE REPORT: We present an unusually rare case of a simultaneous fracture of the coracoid process and the lateral end of clavicle. The patient was treated with shoulder arm sling for 6 weeks followed by physiotherapy. At 6 months follow up the patient was pain free with full range of motion at right shoulder.
CONCLUSION: Concomitant fractures of lateral end clavicle and coracoid process are rare and may not be visible of plain radiographs. CT scan may be indicated if the clinical examination suspects additional injuries of shoulder girdle. We have treated this injury non operatively with a good clinical outcome.

Introduction

Coracoid fractures alone are themselves a rare occurrence amounting to approximately <0.1% of all fractures and even only 5% of all fractures of the shoulder [1-3]. Distal clavicle fractures are also uncommon accounting for less than 1% of all fractures[4,5]. No reliable figures currently exist to determine the prevalence of a simultaneous distal clavicle and coracoid fracture. Also there is no accepted standard of treatment for such a fracture pattern.

Case Report

A 60 year old gardener presented with a history of injury to her shoulder as her arm was pulled by a lawn mower. She presented to the hospital emergency service. The patient did not have any previous injury or degenerative condition to this shoulder prior to this accident.

Physical examination showed swelling and bruising around shoulder, tenderness and restricted movements of the right shoulder. There was no neurovascular deficit in the right arm.

CT and plain radiographs of the shoulder displayed a displaced coracoid fracture and non-displaced fracture of the distal end of clavicle at the time of injury (Fig. 1a-b). After discussion with the patient it was decided to treat non-operatively. The patient was placed in a shoulder arm sling for six weeks and was then referred to physiotherapy.

Figure 1

a- Plain radiograph of the patient showing fracture of the lareal end of clavicle. Some doubtful angulation of the coracoid process is visible but fracture is not appreciated clearly. 1b- CT scan conforms the fracture of lateral end of clavicle and also displace coracoid fracture.

At three months significant fracture consolidation could be seen at both fracture sites (Fig. 2). At six months the patient was pain free and back to working as a gardener with a free range of movement in the right shoulder.

Figure 2

3 months follow up radiographs showing no further displacement of the fracture with early consolidation at the fracture site.

Discussion

When fractures of coracoid and distal clavicle co-exist, misdiagnosis is common because both the fractures may not be seen on standard projections. The Stryker notch view is recommended for detection of these fractures. Furthermore CT imaging is advised if radiographs initially fail to show any bony injuries of the shoulder, but clinical examination suggests otherwise.

The patient described sustaining the injury after her arm was yanked by her lawnmower. The mechanism of injury is probably the result of a resisted flexion of the arm and elbow which led to a forceful pull of the muscles, pectoralis minor and the coracobrachialis, that insert into the coracoid. This has previously been described in two other case studies concomitant coracoid fractures and acromioclavicular dislocation [6,7]. The patient suffered an ipsilateral avulsion of the coracoid which would be considered as a type II according to Ogawa et al and a distal clavicle fracture which would be considered as a type I according to the Neer’s classification.

It is to this day still controversial how to treat coracoid or distal clavicle fractures individually, let alone if they are present concomitantly. Details and consequent treatment methods of coracoid fractures have also yet to be established in literature. Ogawa et al have recommended surgical treatment of coracoid fractures combined with other shoulder injuries, but have otherwise shown similar outcomes between operative and non-operative treatment of coracoid fractures alone. They did however recommend non-operative management of type II fractures as these do not disturb the scapuloclavicular connection [3]. There does not seem to be a general consensus on the treatment of distal clavicle fractures too. Robinson et al have recommended non-operative management of distal clavicle fractures in the middle aged or elderly patients. Out of the 101 patients treated non-operatively with distal clavicle fractures, only in 14% of cases was a delayed reconstructive procedure indicated [8]. Rokito et al compared nonoperative and operative treatment of a total of 30 type II distal clavicle fractures retrospectively and did not reveal any significant difference in terms of UCLA, Constant and ASES scores [9]. On the other hand Haidar et al and Meda et al advocate the use of clavicular hook plates. These studies however did not compare the operative treatment to non- operatively treated control groups [10, 11].

The option of treating a symptomatic nonunion of the distal clavicle was described by Kang et al who achieved 100% bone union in 10 patients following ORIF with an oblique locking T-plate and autogenous bonegraft [12]. Literature on concomitant coracoid and clavicle fractures is indeed very rare. Several authors have published cases of coracoid and acromioclavicular joint injuries. Lasda et al described successful treatment of a concomitant acromioclavicular dislocation and coracoid fracture conservatively [13]. Eleven years later Carr et al further described two cases of concomitant coracoid fracture and acromioclavicular dislocation which were treated conservatively with good results [14]. Recently Duan et al published a case report of operative treatment of an acromioclavicular dislocation in combination with a coracoid fracture which was treated with a hook plate. They described the problem of only partial bone union after 5 months and the additional plate removal that needed to be done 12 months after the initial operation [15].

Only one case report by Ruchelsman however has described the operative treatment of a concomitant lateral clavicle and coracoid fracture. In his case initial non-operative treatment resulted in a non-union. He then proceeded with a open distal clavicle excision and reduction of the coracoclavicular interval with screw fixation achieving an excellent clinical outcome [16]. They commented that high index of suspicion is needed to avoid missing such combination injuries at shoulder girdle and additional radiological investigations should be done if pain at shoulder girdle is persistent.

Conclusion

In view of the sparse and controversial literature available, we believe that the patient should be appropriately informed of both operative and nonoperative options treatment options. In our case the patient preferred nonoperative management which resulted in an excellent clinical result.

Concomitant fractures of lateral end clavicle and coracoid process are rare and may not be visible of plain radiographs. CT scan may be indicated if the clinical examination suspects additional injuries of shoulder girdle. Even in cases with displacement a conservative management will result in a good clinical outcome as seen in our case.