Working Diagnosis:
Fracture at the coracoid base of the left shoulder

Treatment:
The patient was placed in a sling and referred to sports medicine.


One week later the patient was seen by sports medicine. His examination was unchanged, but additional x-rays were obtained of the right shoulder to differentiate suspected findings from a normal variation in a patient of this age. Comparison with the left shoulder confirmed the fracture.
Case Photo #2


Patient was immobilized in a sling and was instructed not to participate in gym or sports activities. The sling was removed at the second visit, x-rays were performed Case Photo #3 and the patient was instructed to introduce gentle range of motion at home. Following the third and final visit, the patient was permitted to return to sports and gym class, given resolution of his pain, improved range of motion on examination and signs of healing on x-ray Case Photo #4 .

Outcome:
Healed fracture and resolution of pain.

Author's Comments:
Coracoid fractures are rare and seen mainly in males. They present in 5% of shoulder fractures and account for roughly 2% to 13% of all scapula fractures and only 2% of all isolated scapula fractures. There is a high incidence of associated injuries with coracoid fractures. These associated injuries included acromioclavicular dislocations, fractures of the superior scapular margin, clavicular and/or acromion fractures, scapular spine fractures, rotator cuff tears, anterior shoulder dislocations, and glenoid rim and proximal humeral fractures.


They are the result of direct impact or avulsion. Coracoid fractures are often overlooked on frontal radiographs of the shoulder, because they are frequently non-displaced and difficult to visualize when projected end on. The axillary radiograph and the anteroposterior cephalic tilt view most reliably show coracoid process fractures.

Coracoid fractures are classified into 5 anatomical types: tip or epiphyseal fracture (type I), mid-process (type II), the base (type III), the superior body of the scapula (type IV), and extension into the glenoid (type V). Rotator cuff tears and anterior shoulder dislocations were only seen with type I fractures, whereas clavicular fractures were only seen in the presence of type II fractures

Most coracoid process fractures are managed nonoperatively with excellent results. However, surgical intervention may be indicated in certain cases. Indications for surgery are:
• ≥ 1 cm of displacement upon radiographic evaluation, despite area of fracture
• Disruption of the superior shoulder suspensory complex
• Painful nonunion
• Concomitant ipsilateral operative scapula fracture with need for surgery

Editor's Comments:
While rare, coracoid fractures should be considered in traumatic cases of shoulder pain. This case illustrates the importance of correlating anatomical knowledge with a thorough physical exam. Direct palpation of the coracoid reproduced pain, suggesting injury to the coracoid. While the fracture was confirmed by contralateral x-rays, it was wise of the treating team to obtain x-rays of the opposite shoulder for comparison as fusion of the physis is generally not complete until 17 years of age.

References:
Alsey, Karl J, Anant N Mahapatra and Julian H Jessop. "Coracoid Fracture in an Adolescent Rugby Player - Case Report and Review of the Literature." Radiography (2012): 301-302.
Camenzind, Roland S and Florian B Imhoff. "Rupture of the Short Head of the Biceps and Coracoid Fractures: Mechanism and Refixation." Operative Techniques in Sports Medicine (2018): 140-146.
Kennedy, Nicholas I, et al. "Repair of an Isolated Coracoid Fracture With Suture and Anchor Fixation." Arthroscopy Techniques (2017): 1715-1719.
Ogawa, Kiyohisa, et al. "Fractures of the Coracoid Process: A Systematic Review." Journal of Shoulder and Elbow Surgery Reviews, Reports and Techniques (2021): 171-178.
Rabbani, Gita R, Stephanie M Cooper and Eva M Escobedo. "An Isolated Coracoid Fracture." Current Problems Diagnostic Radiology (2012): 120-121.

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