Coracoid Process Fracture Associated With a Distal Clavicle Fracture: A Case Report

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BACKGROUND

The incidence of distal clavicle injuries in the structure of clavicle fractures varies from 10% to 30% [1, 2, 3]. Fractures of the coracoid process are even less common: 3-16% of all scapula fractures [4]. Cases of combined injury of the distal clavicle and the coracoid process are described only in a few publications, which, in turn, indicates the lack of a unified approach to the treatment of this category of patients [5, 6, 7, 8]. Difficulties in selecting a treatment method for a patient are associated with the determination of reasonable limits of the surgical aggression and require balanced approach for trauma surgeon's part.

Aim of the study — to demonstrate positive experience of conservative treatment of the coracoid process fracture combined with hook plate fixation for distal clavicle fracture.

CASE PRESENTATION

A 45-year-old female patient sustained a right shoulder injury in August 2022 as a result of a fall from a ladder on the abducted upper extremity. Physical examination revealed deformity of the right shoulder area, acute pain in the projection of the right acromioclavicular joint, positive piano key symptom. Range of motion in the shoulder joint was severely limited due to a pronounced pain syndrome. X-ray of the right shoulder shows radiologic signs of a closed fracture of the distal part of the right clavicle with displacement of fragments associated with a closed fracture of the coracoid process (Fig. 1).

 

Fig. 1. X-ray of the right acromioclavicular (AC) joint in AP view. Signs of closed fracture of the right distal clavicle with displacement of fragments combined with coracoid process fracture

 

Identical vertical displacement of the central clavicle fragment and the coracoid process allowed to infer indirectly that the coracoclavicular ligaments were intact. In our opinion, the hook plate was and remains the preferred implant for this purpose. On the first day of hospital stay, the patient underwent the surgery: open reduction of fragments, fixation with a hook plate and screws. Based on control X-rays, the final intraoperative decision was made not to fix the coracoid process of the scapula additionally (Fig. 2).

 

Fig. 2. Intraoperative X-ray of the right AC joint in AP view after open manual reduction and fixation of the right distal clavicle with a hook plate. Displacement of fragments is eliminated

 

After the reduction of the clavicle fragments and restoration of anatomical relationships in the acromioclavicular joint, anatomical reduction of the coracoid process occurred due to the restoration of the tendon pull balance of the muscles fixed to the coracoid process. Therefore, it was decided not to additionally fix the coracoid process.

 

Fig. 3. Right shoulder CT scan 3 months after surgery. CT signs of bone union of the distal clavicle and coracoid process

 

Postoperative period was uneventful. The patient was discharged for outpatient treatment on the 5th day after surgery. The right upper extremity was put in a sling for 4 weeks from the date of surgical treatment. Twelve weeks later, the patient underwent a CT scan of the area of surgical intervention, which showed CT signs of bone union of both the distal clavicle and the coracoid process (Fig. 3). Based on clinical tests, instrumental findings, and time elapsed since the surgery, the patient was recommended to have the fixator removed from the right clavicle.

X-rays taken at the time of implant removal also show signs of bone union and absence of subluxation (Fig. 4).

 

Fig. 4. X-ray of the right AC joint in AP view 3 months after surgery. Signs of bone union without subluxation

 

In December 2022, elective removal of the hook plate and screws from the distal part of the right clavicle was performed. Clinical recovery was achieved (Fig. 5).

 

Fig. 5. X-ray of the right AC joint in AP view after implants removal

 

DISCUSSION

There are very few publications that are in one way or another related to fracture of the coracoid process [9, 10, 11]. As a consequence, there is no unified approach to the treatment of this type of fracture.

According to A. Iqbal et al., only three cases of isolated fracture of the coracoid process out of nine presented had surgical treatment options, namely, ligament refixation, open reduction with internal fixation, and, finally, percutaneous screw insertion. In all presented clinical cases, patients were able to return to active sports within 3 to 12 months, regardless of the chosen treatment option [12].

Simultaneous fractures of the distal clavicle and coracoid process are even less frequently described. In a similar clinical case presented by W. Zhang et al. in addition to fixation of the acromioclavicular joint with a hook plate, fixation of the coracoid process with a 3.5 mm cannulated screw was performed. Three months after surgery, the shoulder joint function was restored, and the patient had no complaints [13]. Despite the positive result achieved in the presented case, we would like to note the difference in approaches and different degrees of surgical aggression in the treatment of patients with similar pathology.

M.M. Broekman et al. compiled and analyzed the results of treatment of 37 patients with dislocation of the distal part of the clavicle and fracture of the coracoid process. In 22 cases, the preferred treatment option was surgical, and in 12 cases both the acromioclavicular joint and the coracoid process were fixed, in 9 cases only the acromioclavicular joint was fixed, and in one case only the coracoid process was fixed. As a conclusion, the authors note that even though there is a large sample for such a rare pathology, it is impossible to scientifically justify certain recommendations for the treatment of this category of patients [14].

In our opinion, in cases of satisfactory position of the fragments of the coracoid process, it is possible to get along without its additional fixation, which minimizes the risk of intraoperative complications and overall reduces the extent of surgical intervention.

CONCLUSION

Presented clinical case illustrates treatment result of this type of fractures without fixation of the coracoid process of the scapula with excellent clinical outcome. In our opinion, the use of the hook plate allows to stabilize bone fragments and restore ligament tension, which makes this implant non-alternative for fixation of this type of injuries.

DISCLAIMERS

Author contribution

All authors made equal contributions to the study and the publication.

All authors have read and approved the final version of the manuscript of the article. All authors agree to bear responsibility for all aspects of the study to ensure proper consideration and resolution of all possible issues related to the correctness and reliability of any part of the work.

Funding source. This study was not supported by any external sources of funding.

Disclosure competing interests. The authors declare that they have no competing interests.

Ethics approval. Not applicable.

Consent for publication. Written consent was obtained from the patient for publication of relevant medical information and all of accompanying images within the manuscript.

About the authors

Alexander I. Avdeev

Vreden National Medical Research Center of Traumatology and Orthopedics; Saint Petersburg State Pediatric Medical University

Author for correspondence.
Email: spaceship1961@gmail.com
ORCID iD: 0000-0002-1557-1899
SPIN-code: 2799-2563

Cand. Sci. (Med.), head of reception department, assistant University

Russian Federation, 8, Akademika Baykova st., St. Petersburg, 195427; 2, Litovskaya str., St. Petersburg, 194100

Dmitrii G. Parfeev

Vreden National Medical Research Center of Traumatology and Orthopedics

Email: dgparfeev@rniito.ru
ORCID iD: 0000-0001-8199-7161

Cand. Sci. (Med.), head of trauma and orthopedic Department N 1

Russian Federation, 8, Akademika Baykova st. Saint Petersburg, 195427

Danil D. Parshin

Saint Petersburg State Pediatric Medical University

Email: parshindanil1997@gmail.com
ORCID iD: 0009-0002-0010-1437

Clinical resident

Russian Federation, 2, Litovskaya str., St. Petersburg, 194100

Ekaterina V. Sinitsyna

Saint Petersburg State Pediatric Medical University

Email: katerin_tomtit@mail.ru
ORCID iD: 0009-0002-9798-7886

Clinical resident

Russian Federation, 2, Litovskaya str., St. Petersburg, 194100

References

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