Objectives Coracoid Fractures in Football: Evaluation and Management Discuss operative and non-operative management of coracoid fractures Chris Warrell, M.D. Orthopaedic Sports Medicine Fellow Andrews Institute April 27, 2017 Objectives Put coracoid fractures on your radar Discuss common associated injuries Review recent NFL experience Generate thought, discussion Introduction Rare injury 1% of all fractures, 5% of shoulder fractures? increasing Reported in trauma literature No comparative studies Little-to-no information about athletes No guidelines for treatment or return to play EyresKS, Brooks A, Stanley D. Fractures of the coracoid process. JBJS [Br] 1995;77-B:425-8 Anatomy Anatomy 1
Anatomy Classification Attachments Eyres(I-V) & Ogawa (I & II) EyresKS, Brooks A, Stanley D. Fractures of the coracoid process. JBJS [Br] 1995;77-B:425-8 Direct impact to anterolateral shoulder Similar to acromioclavicular separation Previous Surgery Growing risk? Previous Surgery Growing risk? 2
Associated Injuries Superior Shoulder Suspensory Complex (SSSC) Associated Injuries Less Common Subscapularis injury* Shoulder instability Neurologic injury Suprascapular nerve Brachial plexus Glenoid fracture Rotator cuff tear Hill BW, Jacobson AR, AnavianJ et al. Surgical management of coracoid fractures: Technical Tricks and Clinical Experience. J OrthopTrauma 2014;28:e114-122 Evaluation High index of suspicion Exam Tenderness Biceps tests Speed s Yergeason s Cross-body adduction Standard shoulder X-ray series AP, Axillary, Scapular-Y Special X-ray views Cephalad Tilt / Serendipity View Computed Tomography (CT) Gold standard 3D recon ProtassJJ, StapfliFV, OsmerJC. Coracoid process fracture diagnosis in acromioclavicular separation. Radiology. 1975;116:61-64 ProtassJJ, StapfliFV, OsmerJC. Coracoid process fracture diagnosis in acromioclavicular separation. Radiology. 1975;116:61-64 3
Magnetic Resonance (MRI) Not necessary for fracture diagnosis Helpful for diagnosis of associated injuries Management Overview All information from trauma literature No comparative studies Heterogeneous treatment Conflicting results Good and bad outcomes with nonoperative tx Little-to-no information on athletes Better outcomes with early diagnosis ProtassJJ, StapfliFV, OsmerJC. Coracoid process fracture diagnosis in acromioclavicular separation. Radiology. 1975;116:61-64 Hill BW, Jacobson AR, AnavianJ et al. Surgical management of coracoid fractures: Technical Tricks and Clinical Experience. J OrthopTrauma 2014;28:e114-122 AnavianJ, WijdicksCA, Schroder LK, et al. Surgery for scapula process fractures. ActaOrthopaedica2009;80(3):344-350 Management Nonoperative Indications Minimally displaced Type I fractures All Type II fractures No additional displaced injuries of the SSSC Sling or shoulder immobilizer x 4-6 weeks Similar protocol to AC/Clavicle fx Close follow-up with imaging Consider repeat advanced imaging at 2-4 weeks Hill BW, Jacobson AR, AnavianJ et al. Surgical management of coracoid fractures: Technical Tricks and Clinical Experience. J OrthopTrauma 2014;28:e114-122 AnavianJ, WijdicksCA, Schroder LK, et al. Surgery for scapula process fractures. ActaOrthopaedica2009;80(3):344-350 Management Operative Indications Painful nonunion Type I with >1cm displacement Multiple displaced injuries of SSSC Open reduction internal fixation Screw(s) Injured Week 1 of 2016 NFL Regular Season Direct impact to non-throwing shoulder Stayed in game Initially diagnosed with shoulder sprain 4
5 weeks out 12 weeks out Placed on Injured Reserve Cleared to return to play Week 13 of Regular Season (12/1/16) Did not return during 2016 season Currently a free agent Injured Week 3 of 2016 NFL Preseason Awkward fall ; Landed on elbow, jammed shoulder Removed from game Initially diagnosed with shoulder sprain 5
4 weeks out 12 weeks out Placed on Injured Reserve Cleared to return to play Week 12 of Regular Season (11/27/17) Did not return during 2016 season Currently a free agent 6
Summary Rare injury, potentially growing incidence Associated injuries common High index of suspicion needed for diagnosis Advanced imaging necessary Early diagnosis associated with improved outcomes Further study needed to guide management in contact athletes Resources Hill BW, Jacobson AR, Anavian J, et al. Surgical management of coracoid fractures: technical tricks and clinical experience. J OrthopTrauma. 2014;28(5):e114-122. Kawasaki Y, Hirano T, Miyatake K, et al. Safety screw fixation technique in a case of coracoid base fracture with acromioclavicular dislocation and coracoid base cross-sectional size data from a computed axial tomography study. Arch OrthopTrauma Surg.2014;134(7):913-918. Terra BB, EinismanB, de FigueiredoEA, et al. Anatomic study of the coracoid process: safety margin and practical implications. Arthroscopy. 2013;29(1):25-30. VaientiE, PogliacomiF. Delayed diagnosis of isolated coracoid process fractures: results of 9 cases treated conservatively. Acta Biomed.2012;83(2):138-146. Ogawa K, Matsumura N, Ikegami H. Coracoid fractures: therapeutic strategy and surgical outcomes. J Trauma Acute Care Surg. 2012;71(2):E20-26. DiPaolaM, MarchettoP. Coracoid process fracture with acromioclavicular joint separation in an American football player: a case report and literature review. Am J Orthop. 2009;38(1):37-39. Anavian J, WijdicksCA, Schroder LK, et al. Surgery for scapula process fractures: good outcomes in 26 patients. Acta Orthop. 2009;80(3):344-350. ThamA, Purchase R, Kelly JD 4 th. The relation of the coracoid process to the glenoid: an anatomic study. Arthroscopy. 2009;25(8):846-848. Salzmann GM, Paul J, SandmannGH, et al. The coracoid insertion of the coracoclavicular ligaments: an anatomic study. Am J Sports Med. 2008;36(12):2392-2397. Resources Pan WJ, TeoYS, Chang HC, et al. The relationship of the lateral cord of the brachial plexus to the coracoid process during arthroscopic coracoid surgery: a dynamic cadaveric study. Am J Sports Med. 2008;36(10):1998-2001. Rios CG, ArcieroRA, MazzoccaAD. Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments. Am J Sports Med. 2007;35(5):811-817. Lo IK, Burkhart SS, PartenPM. Surgery about the coracoid: neurovascular structures at risk. Arthroscopy. 2004;20(6):591-595. EyresKS, Brooks A, Stanley D. Fractures of coracoid process. J Bone Joint SurgBr. 1995 May;77(3):425-8. Martin-Herrero T, Rodriguez-MerchanC, Munuera-Martinez L. Fractures of the coracoid process: presentation of seven cases and review of the literature. J Trauma. 1990;30(12)1597-1599. ProtassJJ, StapfliFV, OsmerJC. Coracoid process fracture diagnosis in acromioclavicular separation. Radiology. 1975;116:61-64 7