J Emerg Crit Care Med. Vol. 19, No.

1, 2008 8
Received: November 15, 2006 Accepted for publication: February 2, 2007
From the Department of
1
Emergency Medicine,
2
Department of Orthopedic Surgery
Far-Eastern Memorial Hospital, Taipei, Taiwan
Address for reprints: Dr. Jwo-Luen Pao, Department of Orthopedic Surgery, Far-Eastern Memorial Hospital
21 Section 2, Nanya South Road, Panchiao 220, Taipei, Taiwan (R.O.C.)
Tel: (02)89667000 ext 1125 Fax: (02)89660454
E-mail: sun6168kimo@yahoo.com.tw
Introduction
Cor acoi d f r act ur e i s a r ar e or t hopedi c
condition, accounting for only 2% to 13% of all
scapular fractures and approximately 0.1% of all
fractures
(1-4)
. It is usually the result of a direct
trauma or by avulsion of the biceps tendon
(2,5)
.
The fracture is often neglected but can be detected
using careful evaluations
(6-8)
. We present an unusual
case of fracture of the cocracoid process and the
acromion simultaneously.
Case Report
A 25-year-old male motorcyclist presented
with severe right shoulder pain after a collision
with a car and was brought to our hospital for
emergency service. The patient did not have any
history of trauma to his right shoulder prior to
this accident. He sustained a direct blow to the
anterolateral point of the right shoulder. Physical
examination revealed gross swelling, bruising,
Concomitant Fracture of the Coracoid Process and the
Acromion: Report of a Case
MAU-SHENG LIN
1,2
, JWO-LUEN PAO
2
, KUANG-CHAU TSAI
1
A 25-year-old male motorcyclist presented with severe right shoulder pain after a collision with a car.
Physical examination revealed gross swelling, bruising, tenderness and restricted range of motion of his
right shoulder. Coracoid and acromial fractures were noted. Open reduction and internal fxation were
performed. We arranged progressive rehabilitation programs for functional recovery of the shoulder. The
recovery was favorable at 1 year of follow-up.
Key words: acromial fracture, coracoid fracture
tenderness and restricted range of motion over
his right shoulder. No neurovascular defcits were
detected. A displaced coracoid fracture and a
nondisplaced acromial fracture were noted on the
anteroposterior radiograph of the right shoulder
(Fig. 1). Open reduction and internal fxation with
a malleolar screw and washer through the direct
muscle splitting approach were performed under
general anesthesia the day after admission. During
the frst 2 weeks after surgery, he was permitted
to perform circular and pendulum exercises.
Progressive passive and active shoulder movements
were started after 2 weeks and the patient regained
full range of motion after 6 weeks (Fig. 2).
The patient maintained good muscle power and
achieved functional recovery at 1 year of follow-up
without any complaints.
Discussion
Coracoid fracture is an uncommon injury and
has been addressed only in limited series
(1-5,8-10)
.
9 Concomitant fracture of the coracoid process and the acromion
Fig. 1 Anteroposterior view of right shoulder after trauma
There is a displaced coracoid fracture and an undisplaced acromial fracture
Fig. 2 Scapular lateral view of right shoulder after 6 weeks
J Emerg Crit Care Med. Vol. 19, No. 1, 2008 10
Ogawa et al. classified the fractures into those
in front of and those behind the coracoclavicular
ligaments
(3,11)
. These fractures are usually caused
by a direct injury or violent contraction of the
biceps tendon
(2,4,11)
. They may be isolated and
can also occur with associated injuries, such as
acromiclavicular separation, clavicular fracture,
superior scapular fracture, acromial fracture, scapular
spine fracture, shoulder dislocation, rotator cuff tear, or
glenoid fracture
(2-5,7-9,11)
. No concurrent musculocutaneous
or axillary nerve injuries have been reported.
Misdiagnosis is common because the fracture
is not readily seen on anteroposterior radiographs
and further views from different projections
are usual l y needed i f i t i s hi ghl y suggest ed
clinically
(4,6-8,11)
. To date this fracture is best seen on
the Stryker notch view
(11)
.
Thes e i nj ur i es can be managed us i ng
conservative or operative means, although most
researchers recommended t he former
(2, 3, 8, 11)
.
We considered that the surgical treatment for
displaced coracoid fractures protects early mo
bilization.
(2,3,11,12)
. In our case, the direct muscle
splitting approach with a minimal incision was
safe and easy to carry out. A short period of sling
protection and supervised exercises may prevent the
limitation of the range of motion of the shoulder.
Recommendat i ons of st art i ng a progressi ve
rehabilitation program after the reduction have been
reported starting the fourth week after the operation
(2)
.
We found advanced the physiotherapy by 1 week was
adequate in this patient. The patient probably benefted
from the rigid link between the clavicle and scapula
through the stabilization of the coracoid fracture.
In conclusion, emergency physicians should
always be aware of the possibility of the coracoid
fract ure and accompani ed i nj uri es. Careful
assessment of t he mechani sm of i nj ury and
cautious physical examinations should diminish the
misjudgments and lead to better prognoses. Surgery
is one of the choices of treatment for coracoid
fractures which also provides relatively good
functional outcomes.
References
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