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A 14-year-old male patient with chronic shoulder pain
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A 14-year-old high school freshman presented to the office with long-standing left shoulder pain. One year prior to presentation he sustained a left proximal humerus fracture in a motorcycle accident, which was treated nonoperatively. After the fracture healed he performed 3 months of physical therapy, but continued to complain of a persistent non-localized pain. He reports difficulty using his left arm with all tasks, has pain that wakes him at night and rates his subjective shoulder value at 30%.
Physical examination of the left shoulder demonstrated lateral scapular winging with an inability to perform a shoulder shrug. His range of motion was 90° of active forward flexion and 100° of passive motion before extreme pain occurred. Active abduction was 90° with passive motion, which became unbearably painful at 105°. He had tenderness over the scapula and acromion, but the most prominent pain existed over the coracoid. Resisted biceps testing produced pain at the level of the coracoid. Isometric Jobes testing demonstrated asymmetric shoulder strength of 5.2 pounds on the left compared to 8.6 pounds on the right. The neurovascular exam was normal. Preoperative American Shoulder and Elbow Surgeons (ASES) shoulder score was 15.1 and the preoperative Constant score was 34.
An electromyographic study was ordered and the results were normal. Imaging studies included an anatomic anterior-posterior and axillary radiograph of the shoulder, a CT of both shoulders and a left shoulder MRI. A subsequent bone scan of the bilateral shoulders was ordered and is also shown.
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Nonunion of previous left coracoid fracture identified
The patient had a nonunion of a previous left coracoid fracture. The initial management at the time of his injury focused on the proximal humerus fracture; however, his persistent pain was attributed to this coracoid nonunion. Subtle widening of the left coracoid physis was evident on CT and it was not readily visible on plain radiographs. MRI of the left shoulder suggested signal increase at the base of the coracoid consistent with edema. A bone scan suggested decreased uptake at the left coracoid, which supports altered physeal activity. After discussion with the patient and his family, the decision was made for operative management of the coracoid nonunion.
Management
The patient received a brachial plexus block and general anesthesia. He was placed in the beach chair position and an incision was made over the coracoid. The coracoid was approached through the deltopectoral interval and the cephalic vein was moved laterally. The coracoid was exposed and measured. Preoperative planning supported use of a 4-mm partially threaded screw that was about 45-mm long. The angle for insertion was measured in the preoperative CT and replicated in the OR using fluoroscopy (Figure 5). A guide wire was placed and its position and trajectory were confirmed using fluoroscopy. A cannulated drill was passed over the guide wire which was followed by placement of a cannulated partially threaded lag screw across the fracture. The drilling and compression across the physis were considered sufficient stimulation for fracture healing.
The patient was maintained in a sling for 1 week postoperatively which allowed no motion of the shoulder or elbow. Motion restriction was used to reduce the forces across the coracoid from the conjoined tendon. He was permitted to begin passive elbow range of motion after 1 week and then advanced to active elbow range of motion and scapular motion after 3 weeks. After 4 weeks, he was permitted active shoulder range of motion and advanced through therapy. After 3 months, all restrictions were removed and the patient reported no pain, had a subjective shoulder value of 100%, an ASES shoulder score of 100 and a Constant score of 83. At the 1-year follow-up, the patient had full range of motion with full and symmetric strength. His final outcome scores were a subjective shoulder value of 100%, ASES score of 100 and a Constant score of 89. Radiographs were obtained at the final follow-up (Figure 6).
Coracoid fractures
Acute fractures of the coracoid process are uncommon and are more frequently associated with traumatic shoulder dislocation. Coracoid fractures in pediatric patients are more rare. Furthermore, it is difficult to decipher a fracture from the normal physis. The coracoid process serves as the insertion for the short head of the biceps tendon, coracobrachialis tendon and pectoralis minor tendon. Its ligamentous attachments include the coracohumeral, coracoclavicular (CC), superior transverse scapular and coracoacromial ligaments. Ogawa and colleagues proposed the most commonly used classification for coracoid fractures, which defined two main fracture types in relation to the CC ligaments. Fractures that are proximal to the CC ligaments disrupt the scapular clavicular connection and are termed type I. Type II fractures occur distal to the CC ligaments and preserve the scapuloclavicular attachments.
Most coracoid fractures can be treated nonoperatively. Fractures that are highly unstable or persistently painful may be treated with open reduction and internal fixation. Additionally, coracoid fractures in athletes or heavy manual laborers may require operative fixation. Guttentag and Rechtine, as well as Goss, reported that nonoperative management was associated with poor outcomes in this functionally demanding population; however, current literature is limited on coracoid fracture fixation in this subgroup. Morioka and colleagues similarly recommended operative fixation in active and high-demand patients, but this series was limited to three patients.
Coracoid fractures may be treated with nonabsorbable sutures for smaller fragments, but larger fragments may require inter-fragmentary screw fixation or cortical lag screws. Some authors even advocate for plate neutralization. Long-term outcomes are limited, but Ogawa and colleagues reported 87% excellent results and Hill and colleagues reported an 84% rate of return to work and physical activities following coracoid fixation.
Surgical indications
A painful nonunion is an indication for surgery; however, the literature is sparse, especially in the pediatric population. A case report by Jettoo and colleagues reported a successful outcome with operative fixation of an acute coracoid base fracture with an associated acromioclavicular dislocation in a 12-year-old. Their patient’s treatment is different than that of our patient because it was done acutely. Their patient demonstrated complete return to activities at 9 months.
Conservative management was not successful in our patient. He experienced pain despite physical therapy and activity modifications for more than 1 year after his initial injury. We eliminated the possibility of neurologic injury with normal EMG findings and his physical exam consistently identified the coracoid as the primary focus of pain. Based on the available recommendations, we believed operative fixation would successfully address his nonunion. Following surgery, our patient demonstrated successful healing and full recovery at his 1-year follow-up.
- References:
- Delgado J, et al. Radiographics. 2016;doi:10.1148/rg.2016160036.
- Goss TP. Am J Orthop (Belle Mead NJ). 1996;25:106-115.
- Guttentag IJ, et al. Orthop Rev. 1998;17:147-158.
- Hill BW, et al. J Orthop Trauma. 2014;doi:10.1097/01.bot.0000435632.71393.bb.
- Jettoo P, et al. J Orthop Surg Res. 2010;doi:10.1186/1749-799X-5-77.
- Morioka T, et al. Case Rep Orthop. 2016;doi:10.1155/2016/1836070.
- Ogawa K, et al. J Bone Joint Surg Br. 1997;79:17-19.
- Ogawa K, et al. J Trauma. 2009;doi:10.1097/TA.0b013e318184205c.
- Ogawa K, et al. J Trauma Acute Care Surg. 2012;72:E20-26.
- For more information:
- Michael T. Freehill, MD, can be reached at University of Michigan, Medsport, Sports Medicine and Shoulder Surgery,Domino’s Farms, 24 Frank Lloyd Wright Dr., Lobby A, PO Box 391, Ann Arbor, MI 48106; email: freehillmd@gmail.com.
- Austin V. Stone, MD, PhD, can be reached at Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157; email: austinvstonemd@gmail.com.
Disclosures: Freehill reports he is a consultant for Smith & Nephew and Mitek, and receives research support from Smith & Nephew and RTI. Stone reports he receives research support from Smith & Nephew.