Nonunion of the coracoid process: a systematic review.

To assess the ability of plain films and computed tomography scans to show the pattern, displacement, and angulation of scapular neck fractures. To assess the ability of computed tomography to identify concomitant occult shoulder injuries. Masked retrospective radiographic review. Level I trauma center. Three orthopaedic surgeons (two attending physicians and one senior resident) and one musculoskeletal radiology attending physician reviewed the imaging studies of scapula neck fractures in twenty patients treated at our institution. Kappa analysis of agreement of fracture characteristics and benefits of computed tomography for scapular neck fractures. The mean weighted kappa coefficient for interobserver reliability of fracture displacement was 0.49 when the fractures were assessed by plain films alone, 0.15 when they were assessed by computed tomography scans alone, and 0.35 when they were assessed by plain films and computed tomography scans. The mean weighted kappa coefficients for fracture angulation were 0.30, 0.23, and 0.16, respectively. The mean simple kappa coefficients for fracture classification were 0.81, 0.20, and 0.33, respectively. Concomitant injury to the superior shoulder suspensory complex was seen in 57 percent of cases, including nine clavicle fractures, one coracoid fracture, and three acromion process fractures. The coracoid fracture and two of the acromion process fractures were minimally displaced and seen on computed tomography scans only. Scapular neck fracture displacement, angulation, and anatomic classification showed moderate interobserver reliability by plain films but were not enhanced by computed tomography. Computed tomography confused, rather than clarified, the assessment of these characteristics. Computed tomography may be useful to identify associated injuries to the superior shoulder suspensory complex, which can be missed by plain films alone. Routine computed tomography in patients with scapular neck fractures cannot be recommended based on this study. Computed tomography of scapular neck fractures may be useful in selected cases in which intraarticular extension is noted on plain films.

BackgroundThe internal fixation of Ogawa type I coracoid fractures is relatively difficult, and there is no consensus on the fixation method, which is also prone to screw cutout. This study aims to evaluate the biomechanical properties of 5 different screw internal fixation methods for Ogawa type I coracoid process base fracture through biomechanical experiments.HypothesisThe biomechanical effects of the 5 fixation methods are different.MethodsFifteen fresh adult scapula specimens were randomly selected to create models of Ogawa type I coracoid process base fracture. Five fixation methods were used: single hollow screw fixation entirely within the bone (M1), single hollow screw fixation partially exiting below the vertical part of the coracoid process (M2), single hollow screw fixation partially exiting above the vertical part of the coracoid process and extending to the scapular spine (M3), dual hollow screw fixation entirely within the bone (M4), and dual hollow screw fixation combining M1+M3 (M5). All specimens were randomly divided into 5 groups of 3, each corresponding to a fixation method. Biomechanical experiments of compression, tension, and rotation were conducted to assess the stability of each fixation method.ResultsThere was no significant difference in bone mineral density among the groups (P = .873). At the compression end point, M2 sustained the lowest force and M4 the highest, with the ranking M2 < M3 < M1 < M5 < M4; the intergroup difference was statistically significant (P = .022). At the tension end point, M3 sustained the lowest force and M5 the highest, with the ranking M3 < M2 < M1 < M4 < M5; the intergroup difference was statistically significant (P = .019). At the torsion end point, M2 showed the lowest torque and M5 the highest, with the ranking M2 < M3 < M1 < M4 < M5; the intergroup difference was statistically significant (P = .032).ConclusionThe dual-screw fixation methods (M4 and M5) demonstrated the best stability in treating Ogawa type I coracoid process base fracture, with no significant difference between M5 and M4. For single-screw fixation, the entirely intraosseous method (M1) was more stable than the “in-out-in” methods, and the mode with partial downward exit (M2) should be avoided.

The coracoid process is a unique anatomical structure that extends anteriorly from the scapula in a hook-shaped manner, with variations in size, shape, and orientation among individuals. Although uncommon, fractures of the coracoid process may occur and can be difficult to detect on regular X-rays due to their morphology. In this case study, we report on a 46-year-old daily wage worker who presented to the emergency department with left shoulder pain and limited mobility following a traffic collision. Initial X-rays revealed only an acromioclavicular joint dislocation, but further evaluation with a CT scan confirmed a coracoid fracture with minor displacement. Despite the concurrent dislocation, we opted for conservative treatment, and the fracture had completely healed after six weeks of physical therapy. The use of specific shoulder X-ray views, such as the scapula Y or axillary view is recommended to rule out coracoid fractures, while CT scans are considered the gold standard for diagnosis. Treatment options for coracoid fractures may range from non-operative management to surgical repair, depending on the type of fracture. Our case report highlights a rare occurrence of a coracoid process fracture with acromioclavicular joint dislocation treated conservatively.

Introduction:Isolated coracoid fractures are rare and few scattered cases are reported in literature. Coracoid fractures can be missed and the treatment for coracoid process fractures is still controversial. The case presented here is of an isolated coracoid process fracture which was treated surgically.Case Report:A 15-years old male presented after 4 days of injury complaining of persistent pain in the right shoulder following a jerk during bowling. Physical examination revealed tenderness in the left shoulder. There was pain on abduction and external rotation. The neurovascular examination was normal. Osseous avulsion of the distal tip of the coracoid process was confirmed by CT and MRI. The short head of the biceps and coracobrachialis was attached to the avulsed tip, while the pectoralis minor was attached to the coracoid base. The case was managed by open reduction and fixation with a 3.5mm cannulated screw and washer.Conclusion:Isolated coracoid fracture is a rare entity causing impairment of upper limb movement. It can be diagnosed more accurately by MRI scan and CT scan. In case of young highly demanding individuals like athletes surgical management may be a better option as compared to conservative treatment to achieve early use of the extremity, good radiological union and clinical function.

Historically, extra-articular scapular body fractures were treated nonsurgically, but displaced fractures of the glenoid neck can lead to dysfunction. Controversy exists regarding which extra-articular scapular fractures should be treated surgically; however, nonsurgical management of severely displaced scapular body fractures can result in satisfactory outcomes. Inclusion criteria for this study were medial or lateral displacement greater than 2 cm, angular deformity between fracture fragments greater than 45°, or glenopolar angle less than 22°. Functional outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) score, Short Form-36 (SF-36) score, and American Shoulder and Elbow Surgeons (ASES) shoulder score. Radiographs and computed tomography scans were available for all patients. Range of motion (ROM), strength, other injuries, and complications also were recorded. Twelve patients (10 males, 2 females) with a mean age of 45.6 years (range, 29-57 years) underwent follow-up for a mean of 54.1 months (range, 28.2-74.4 months). At latest follow-up, mean DASH score was 8.9 (range, 0-35), mean SF-36 score was 72.2 (range, 57.3-96.1), and mean ASES score was 85.9 (range, 46.7-100). Mean ROM and strength expressed as a percentage of the contralateral side ranged from 88% to 99% and 70% to 93%, respectively. At longest follow-up, 10 patients reported excellent satisfaction with their treatment. There were no radiographic non-unions. One patient with concomitant clavicle and acromion fractures treated surgically had a postoperative infection requiring operative irrigation and debridement. None of the patients required or sought additional treatment. Nonoperative treatment of highly displaced scapular body fractures resulted in good patient satisfaction, satisfactory long-term functional outcomes, and only minor loss of motion and strength. [Orthopedics. 2020;43(3):e177-e181.].

IntroductionScapular anatomical neck fractures are among the most infrequent shoulder girdle fractures. Only seven radiologically confirmed cases of scapular anatomical neck fractures have been documented in the literature to date, of which only one case underwent delayed surgery.Case presentationA 34-year-old male Persian patient with morbid obesity was diagnosed with a scapula anatomical neck fracture after a motor vehicle collision. The radiographic assessment of the patient indicated an increase in the scapular glenopolar angle (73.9°). Due to concurrent chest and head injuries, surgical intervention was deferred until 6 weeks following the injury. The posterolateral limited Dupont–Evrard approach was used because of the patient’s extremely high body mass index. Two plates were utilized to achieve stable fixation of the glenoid neck fracture. Following a 1 year follow-up period, complete fracture union was successfully attained, resulting in a constant score of 79.ConclusionsThe most accurate radiographic indicators of these fractures are a superior fracture line located laterally to the coracoid process, a small inferior spike, and an elevated glenopolar angle. The only tendon attached to the glenoid is the long head of the triceps, making these fractures unstable; therefore, surgery is required in the majority of instances. The small size of the fractured component makes stabilization more difficult. Overall, anatomical scapular neck fractures are extremely uncommon and distinguished from other scapular fractures by their unique radiological and biomechanical characteristics. This case highlights the challenges encountered when managing scapular fractures in patients with morbid obesity. The delayed surgical intervention and the choice of surgical approach tailored to the patient’s specific anatomical and physiological considerations proved to be effective in achieving a favorable outcome.

The Superior Shoulder Suspensory Complex (SSSC) is a bony and soft tissue ring comprising the glenoid process, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the acromioclavicular joint, and the acromion. The SSSC maintains a normal stable relationship between the upper extremity and the axial skeleton. High-energy injury, such as traffic accident or a fall, can cause disruption of the SSSC. Single traumatic disruption of the SSSC is common. However, double disruption of the SSSC is infrequent and surgical management is generally necessary. We have experienced a case of triple fracture involving the coracoid process, the acromion, and the distal end of the clavicle. Such disruption of the SSSC has not been previously reported in our country and only one case has been reported in the Western literature; the authors obtained positive clinical results with surgical treatment. We report here on this case and include a review of the relevant literature.

Introduction:Coracoid fracture occurs with shoulder instability due to direct humeral head impaction. Incidence coracoid fracture with shoulder dislocation is rare amounts to 0.8–2%. We encountered clinical challenge of unique combination of both shoulder instability and coracoid fracture. This technical note will describe the treatment of the same.Case Report:A 23-year-old male suffering from recurrent shoulder dislocation sustained coracoid fracture. Further evaluation showed glenoid defect of 25%. Magnetic resonance study showed on track lesion with Hill-Sach lesion of 9 mm, labral defect anteriorly with no associated rotator cuff tear. The patient was managed with open Latarjet procedure with fracture coracoid fragment with conjoint tendon as graft.Conclusion:Our purpose of reporting this technical note is to provide an option of dealing both instability and coracoid fracture in single sitting and usage of coracoid fractured fragment as an excellent graft of choice in acute presentation. However, certain limitations such as adequacy of graft in size and shape do exist operating surgeon which must be aware of the same.

IntroductionTriple disruption of the superior shoulder suspensory complex (SSSC) is a rare injury which affects 3 or more structures of this ring. This paper aims to report the patient who suffered from this challenging injury and a review of literatures which had similar disruption. CaseA 51-year-old male who sustained right shoulder injuries, which consisted of mid-shaft clavicular fracture, acromion fracture, scapular body fracture, acromioclavicular joint and coracoclavicular joint disruption after a motorcycle accident. He was treated with clavicle and acromion fracture fixation combined with coracoclavicular joint and acromioclavicular joint stabilization. ConclusionTriple or quadruple disruption of the SSSC ring is an extremely rare injury that is caused by high-energy trauma. This injury is often associated with other injuries and aggressive care should be taken for this group of patients. Good preoperative planning and proper surgical fixations are crucial for a satisfactory outcome of shoulder joint function.

Triple rotura del complejo suspensorio del hombro

We report a rare case of a patient experiencing pain and dysfunction attributable to bone fragments from a trauma sustained over two decades prior. A 43-year-old Japanese woman presented with persistent left shoulder pain. Initial radiographs revealed glenohumeral joint osteoarthritis, an unusual finding for her age. Her medical history included a previously overlooked traumatic dislocation of the left acromioclavicular joint over 20 years ago. Computed tomography scans later uncovered bone fragments below the coracoid process without signs of scapular or tuberosity fractures. The fragments were arthroscopically removed, resulting in significant pain relief. The patient's Shoulder Pain and Disability Index score improved from 60 to 9 at the six-month postoperative follow-up. This case underscores the importance of considering historical trauma in patients presenting with atypical shoulder pain and highlights the potential diagnostic value of revisiting a patient's medical history when unusual lesions are discovered.

Background: The purpose of this study was to evaluate the clinical and radiological results after arthroscopically assisted and image intensifier–controlled stabilization of high-grade acromioclavicular (AC) joint separations using the double TightRope technique with the first-generation implant. Hypothesis: The double TightRope technique using the first-generation implant leads to good clinical and radiological results by re-creating the anatomy of the AC joint. Study Design: Case series; Level of evidence, 4. Methods: Thirty-seven consecutive patients (4 women and 33 men; mean age, 38.6 years) who sustained an acute AC joint dislocation grade V according to Rockwood were included in this prospective study. The Subjective Shoulder Value (SSV), the Constant Score (CS), the Taft Score (TS), and a newly developed Acromioclavicular Joint Instability Score (ACJI) were used for final follow-up. Bilateral stress views and bilateral Alexander views were taken to evaluate radiographic signs of recurrent vertical and horizontal AC joint instability. Results: Twenty-eight patients (2 women and 26 men; mean age, 38.8 years [range, 18-66 years]) could be evaluated after a mean follow-up of 26.5 months (range, 20.1-32.8 months). The interval from trauma to surgery averaged 7.3 days (range, 0-18 days). The mean SSV reached 95.1% (range, 85%-100%), the mean CS was 91.5 points (range, 84-100) (contralateral side: mean, 92.6 points), the mean TS was 10.5 points (range, 7-12), and the ACJI averaged 79.9 points (range, 45-100). The final coracoclavicular distance was 13.6 mm (range, 5-27 mm) on the operated versus 9.4 mm (range, 4-15 mm) on the contralateral side (P < .05). Radiographic signs of posterior instability were noted in 42.9% of cases. Patients with evidence of posterior instability had significantly inferior results in the TS and the ACJI (P < .05). Neither coracoid fractures nor early (within 6 weeks postoperatively) loss of reduction due to tunnel malpositioning or implant loosening was observed. Conclusion: The combined arthroscopically assisted and image intensifier–controlled double TightRope technique using implants of the first-generation represents a safe technique and yields good to excellent early clinical results despite the presence of partial recurrent vertical and horizontal AC joint instability.

Background: Anatomic reconstruction of the coracoclavicular (CC) ligaments has become a popular surgical treatment for high-grade acromioclavicular (AC) dislocations, but little has been reported about complications related to these newer surgical techniques. Purpose: We sought to review the complications related to several new techniques for the anatomic reconstruction of the CC ligaments for the treatment of AC separations. Study Design: Case series; Level of evidence, 4. Methods: We conducted a retrospective review of the operative treatment of AC separation utilizing anatomic reconstruction of the CC ligaments by reviewing the case logs of 3 fellowship-trained orthopaedic surgeons at a single academic sports medicine center for the past 5 years using appropriate current procedural terminology codes. The medical records and postoperative radiographs were assessed for complications. Results: Twenty-seven cases of anatomic reconstruction of the CC ligaments were reviewed. All patients had an autograft or allograft ligament reconstruction utilizing either a coracoid tunnel (10 cases) or a loop around the coracoid base (17 cases). Eight complications (80%) were noted in the coracoid tunnel group including 2 coracoid fractures (20%), 5 patients with some loss of reduction (more than 5-mm increased CC interval displacement on subsequent postoperative radiographs) (50%), and 1 patient with an intraoperative failure of the coracoid button fixation (10%). Six patients developed complications in the coracoid loop group (35%) including 3 clavicle fractures (18% within group, 11% overall), 1 patient with loss of reduction (6%), 1 patient with loss of reduction and an infection (6% within group, 4% overall), and 1 patient with adhesive capsulitis postoperatively (6% within group, 4% overall). Conclusion: Newer techniques for the anatomic reconstruction of the CC ligaments may have steep learning curves associated with complications such as coracoid and clavicle fractures. Loss of reduction continues to be associated with the operative treatment of high-grade AC separations. Further refinement of surgical technique and experience with the operative treatment of AC separation is warranted.

Biplanar fixation of acromio-clavicular joint dislocation associated with coracoid process fracture: Case report

Acromioclavicular joint injuries are common cause for shoulder pain among young adults and athletes. There are shift of interest towards anatomical ACJ reconstruction recently owing to perceived biomechanical and clinical advantages. Yet, double tunnels in coracoid process resulting in more complications especially iatrogenic fracture. Arthroscopic and radiographic measurements of base of coracoid process in 42 patients who underwent arthroscopic ACJ reconstruction was obtained. The mean length was then compared to each other and with patient?s demographic data (age, gender, ethnicity and BMI). The data were also compared to previously published studies. The mean arthroscopic measurement of coracoid base width was 19.21?1.38mm. There was significant difference between arthroscopic and radiographic measurement, with the latter having wider length, 22.30?1.48mm. Male subjects were found to have wider coracoid base width as compared to female subjects. There was no significant difference observed in between ethnicity groups and no association found in between age and BMI with regards to coracoid base width. The mean coracoid base width in Malaysian population is smaller as compared to previous studies performed on Caucasian populations. Given the potentially narrower coracoid base width of the Malaysian population, extra precautions are required to minimize the risk of iatrogenic coracoid fractures.