Coracoid Process Avulsion Fracture at the Coracoclavicular Ligament Attachment Site in an Osteoporotic Patient with Acromioclavicular Joint Dislocation

Acromioclavicular dislocation associated with fracture of the coracoid process: a series of cases and review of the literature

PURPOSE

Complete acromioclavicular (AC) dislocation associated with fracture of the coracoid process (CP) is uncommon. The strong coracoclavicular ligaments, instead of rupture, may avulse the CP near its base, and with disruption of the AC joint may allow complete dislocation of the clavicle. We report ten cases, one of the largest series in literature, and reviewed the findings and treatment previous reported cases, to allow potential readers to establish the most appropriate treatment.

METHODS

We have prospectively collected those cases in which we had identified an association of an AC dislocation with a fracture of the CP, as well as retrospectively reviewed the records that were coded as AC dislocations and CP fracture looking for this association in the senior author institutions. A literature search was completed on PubMed, Web of Science and Scholar Google, using a sensitive search strategy.

RESULTS

We have collected a total of ten patients with the association of a CP fracture to an AC dislocation in a period of twenty-five years. A review of the cases reported in literature shows a great variability in treatment methods from conservative to more surgically in recent years.

CONCLUSIONS

When an AC dislocation is identified by clinical examination and X-rays, one should be aware of a possible fracture of the CP. It is possible this association to be more frequent than shown in literature because of the CP fracture can easily be missed out or mistaken with an unfussed epiphysis in routine anteroposterior radiography. Multiple approaches have been opted for by surgeons to deal with this combined injury and are the basis of this review.

Ipsilateral concomitant fractures of the clavicle and coracoid process of the scapula: incidence, characteristics, and outcomes

BACKGROUND

Clavicle fractures associated with ipsilateral coracoid process fractures are very rare, with limited literature reporting only a few cases. This study reports on 27 patients with ipsilateral concomitant fractures of the clavicle and coracoid process who were followed for more than 12 months.

MATERIAL AND METHODS

This retrospective study reviewed the charts of skeletally mature patients with traumatic ipsilateral clavicle and coracoid process fractures treated at the authors' institution. Each patient was regularly followed post-treatment. Radiographs assessed bone union and implant integrity, while clinical evaluations included the Constant-Murley score for shoulder function; disability of the arm, shoulder, and hand (DASH) questionnaire for upper limb function; and visual analog scale score for pain. Complications were also recorded.

RESULTS

From October 2012 to February 2023, 40 patients were diagnosed with ipsilateral fractures of the clavicle and coracoid process of the scapula, accounting for 1.4% (40/2877) of all clavicle fractures and 5.2% (40/786) of all scapular fractures. This study included 27 patients with follow-up exceeding 12 months: 6 had medial-third clavicle fractures, 12 had middle-third fractures, and 9 had distal-third fractures. According to Eyres' classification, the coracoid fractures included two type I, five type II, eight type III, seven type IV, and five type V fractures. Twenty-two patients received operative treatment, with clavicle fractures fixed with internal plating and 11 coracoid fractures with internal fixation. Bone union was achieved in all patients. The mean Constant-Murley score was 91.2 ± 9.4 and the mean DASH score was 6.4 ± 7.6. Five patients reported mild shoulder pain and five patients developed complications.

CONCLUSIONS

Ipsilateral concomitant fractures of the clavicle and coracoid process can occur at various clavicle locations, with shaft and medial fractures more common than previously thought. Displaced fractures can be effectively managed with operative treatment, and coracoid process fixation may not be necessary if satisfactory indirect reduction is achieved after clavicle fixation.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Fractures of the coracoid process: a systematic review

Background

Although fracture of the coracoid process (CF) used to be considered rare, it is now more commonly encountered due to increased awareness and advances in imaging methods. This review aimed to analyze reported cases of CF to determine its mechanism and appropriate treatment.

Methods

PubMed and Scopus were searched using the terms "scapula fracture" and "coracoid fracture." The inclusion criteria were English full-text articles concerning CF that described patient characteristics with appropriate images. The exclusion criteria included cases without appropriate images and those with physeal injury or nonunion. Citation tracking was conducted to find additional articles and notable full-text articles in other languages. Fractures were mainly classified using Ogawa's classification.

Results

Ninety-seven studies were identified, including 197 patients (131 men, 33 women; average age 37.0±16.9 years). CF was classified as type I in 77%, type II in 19%, and avulsion fracture at the angle in 5%. Concurrent shoulder girdle injuries included acromioclavicular injury in 33%, clavicular fracture in 17%, acromion or lateral scapular spine fracture in 15%, and anterior shoulder instability in 11%. Among patients with type I CF, 69% had multiple disruptions of the superior shoulder suspensory complex. Conservative treatment was applied in 71% of isolated type I CF, while surgical treatment was applied in 76% of type I CF with multiple disruptions. Although the evaluation methods varied, 60% of patients were followed up for more than 6 months, and the outcomes were generally satisfactory for both conservative and surgical treatments.

Conclusion

CF occurred commonly in the age group with higher social activity. The most common fracture type was type I. The possible mechanism of CF is violent traction of the attached muscles, except for avulsion fracture at the angle. Type I CF with multiple disruptions of the superior shoulder suspensory complex requires surgical treatment, whereas conservative care is recommended for isolated type I and type II CFs.

Insufficiency avulsion fracture of the femoral attachment of the posterior cruciate ligament of the knee joint

Multiple ligaments are involved in avulsion injuries of the knee joint, including both anterior and posterior cruciate ligaments; however, avulsion injury of the posterior cruciate ligament is less frequently encountered than the anterior counterpart. Furthermore, avulsion of the femoral side of the posterior cruciate ligament is far less common than the tibial one.Femoral attachment avulsion fracture of the posterior cruciate ligaments has been reported in literature in adolescents, rarely in adulthood, and never before in elderly patients, showing an inverse relationship with advancement in patient age. The case presented here shows femoral attachment avulsion fracture of the posterior cruciate ligament in an elderly patient with secondary osteoporosis.

Avulsion Fracture of the Coracoid Process at the Coracoclavicular Ligament Insertion: A Report of Three Cases

Avulsion fracture at the site of attachment of the coracoid process of the coracoclavicular ligament (CCL) is extremely rare. We presented three adult cases of this unusual avulsion fracture associated with other injuries. Case  1 was a 25-year-old right-handed male with a left distal clavicular fracture with an avulsion fracture of the coracoid attachment of the CCL; this case was treated surgically and achieved an excellent outcome. Case  2 was a 39-year-old right-handed male with dislocation of the left acromioclavicular joint with two avulsion fractures: one at the posteromedial surface of the coracoid process at the attachment of the conoid ligament and one at the inferior surface of the clavicle at the attachment site of the trapezoid ligament; this case was treated conservatively, and unfavorable symptoms such as dull pain at rest and sharp pain during some daily activities remained. Case  3 was a 41-year-old right-handed female with a right distal clavicular fracture with an avulsion fracture of the coracoid attachment of the conoid ligament; this case was treated conservatively, and the distal clavicular fracture became typical nonunion. These three cases corresponded to type I fractures according to Ogawa's classification as the firm scapuloclavicular connection was destroyed and also to double disruption of the superior shoulder suspensory complex. We recommend surgical intervention when treating patients with this type of acute or subacute injury, especially in those engaging in heavy lifting or overhead work.