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Coracoid fracture in an adolescent rugby player – Case report and review of the literature
Radiography 18 (2012) 301e302
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Case report
Coracoid fracture in an adolescent rugby player e Case report and review of the literature Karl J. Alsey*, Anant N. Mahapatra a, Julian H. Jessop a Watford General Hospital, Vicarage Road, Watford WD18 0HB, Hertfordshire, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 May 2011 Received in revised form 29 April 2012 Accepted 14 May 2012 Available online 4 July 2012
Coracoid fractures are rare injuries which may be easily missed radiographically. This case report discusses a 14 year old child who sustained a coracoid fracture during a violent tackle whilst playing rugby. The fracture was clearly visible only on the axial view of the shoulder, and was subsequently confirmed by CT scan. This article includes a discussion detailing the anatomy and developmental features of the coracoid process of the scapula, its clinical significance, and radiological assessment of suspected coracoid injury. Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Orthopaedics Trauma Coracoid Fracture
Introduction Coracoid fractures are rare in clinical practice, especially so in adolescents, and may be missed if an incomplete shoulder imaging series is performed. A 14 year old child was tackled violently whilst playing rugby, resulting in immediate anterior shoulder pain. On examination he had a restricted range of motion and tenderness on palpation of the coracoid process. No abnormality could be seen on anteroposterior (AP) and lateral views of the shoulder, but an axial view clearly demonstated a minimally displaced fracture at the base of the coracoid (it is the standard practice of our institution to perform three views to assess the coracoid) Figs. 1e3. The fracture was subsequently confirmed by CT scan Figs. 4 and 5. We elected to treat our patient with sling immobilisation for 4 weeks, which resulted in an excellent outcome with recovery of a full pain-free range of motion.
facilitate muscular action. Its lateral aspect provides attachment for the tendons of the short head of biceps brachii and coracobrachialis (which together form the conjoined tendon), and its medial aspect gives attachment to the pectoralis minor muscle. The coracoclavicular ligaments (conoid and trapezoid) and coracoacromial ligaments attach to its superior aspect. The coracoid is an important anatomical landmark, palpable through the deltopectoral groove, and has been called the “lighthouse of the shoulder”1 for its ability to guide surgeons away from
Discussion The coracoid process is a forward facing projection on the supero-anterior part of the scapula, which acts both to stabilise the shoulder girdle (through its ligamentous attachments) and
* Corresponding author. Tel.: þ44 (0) 1923 244366; fax: þ44 (0) 1242674252. E-mail addresses: [email protected] (K.J. Alsey), anant.mahapatra@ whht.nhs.uk (A.N. Mahapatra), [email protected] (J.H. Jessop). a Tel.: þ44 (0) 1923 244366.
Figure 1. AP radiograph of shoulder, demonstrating no abnormality.
1078-8174/$ e see front matter Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.radi.2012.05.002
302
K.J. Alsey et al. / Radiography 18 (2012) 301e302
Figure 4. Axial CT scan of shoulder, demonstrating the coracoid base fracture.
Figure 2. Lateral radiograph of the scapula, demonstrating no abnormality.
Figure 5. Sagittal CT scan of shoulder, demonstration the coracoid base fracture.
from a normal epiphyseal plate is not simple radiographically, but requires clinical correlation. In the case of our patient the asymmetrical separation at the fracture site was diagnostic. In clinical practice the important factors are degree of displacement of the fracture and associated injuries such as acromioclavicular separation, because these determine the need for operative management.3e5 References Figure 3. Axial radiograph of shoulder, demonstrating the coracoid base fracture.
the medially placed subclavian artery, vein and brachial plexus into a safe lateral zone. During development the coracoid has both an epiphyseal plate near to its base and and an apophysis at its tip. Both the epiphseal plate and apophysis of the coracoid process fuse at approximately 17 years of age.2 Differentiating a symmetrically and minimally displaced fracture or Salter Harris I epiphyseal injury at the base of the coracoid
1. Matsen FA, Thomas SC, Rockwood CA. Anterior glenohumeral instability. In: The shoulder. Philadelphia: WB Saunders; 1990. p. 336e67. 2. Flecker H. Roentgenographic observations of the times of appearance of epiphyses and their fusion with the diaphyses. Journal of Anatomy 1932;67:118e66. 3. Jettoo P, de Kiewert G, England S. Base of coracoid fracture with acromioclavicular dislocation in a child. Journal of Orthopaedic Surgery and Research 2010;5:77. 4. Eyres K, Brooks A, Stanley D. Fractures of the coracoid process. Journal of Bone and Joint Surgery 1995;77-B:425e8. 5. Montgomery S, Loyd D. Avulsion fracture of the coracoid epiphysis with acromioclavicular separation. Journal of Bone and Joint Surgery (Am) 1977;59-A:963e5.
Contents lists available at SciVerse ScienceDirect
Radiography journal homepage: www.elsevier.com/locate/radi
Case report
Coracoid fracture in an adolescent rugby player e Case report and review of the literature Karl J. Alsey*, Anant N. Mahapatra a, Julian H. Jessop a Watford General Hospital, Vicarage Road, Watford WD18 0HB, Hertfordshire, United Kingdom
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 May 2011 Received in revised form 29 April 2012 Accepted 14 May 2012 Available online 4 July 2012
Coracoid fractures are rare injuries which may be easily missed radiographically. This case report discusses a 14 year old child who sustained a coracoid fracture during a violent tackle whilst playing rugby. The fracture was clearly visible only on the axial view of the shoulder, and was subsequently confirmed by CT scan. This article includes a discussion detailing the anatomy and developmental features of the coracoid process of the scapula, its clinical significance, and radiological assessment of suspected coracoid injury. Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Keywords: Orthopaedics Trauma Coracoid Fracture
Introduction Coracoid fractures are rare in clinical practice, especially so in adolescents, and may be missed if an incomplete shoulder imaging series is performed. A 14 year old child was tackled violently whilst playing rugby, resulting in immediate anterior shoulder pain. On examination he had a restricted range of motion and tenderness on palpation of the coracoid process. No abnormality could be seen on anteroposterior (AP) and lateral views of the shoulder, but an axial view clearly demonstated a minimally displaced fracture at the base of the coracoid (it is the standard practice of our institution to perform three views to assess the coracoid) Figs. 1e3. The fracture was subsequently confirmed by CT scan Figs. 4 and 5. We elected to treat our patient with sling immobilisation for 4 weeks, which resulted in an excellent outcome with recovery of a full pain-free range of motion.
facilitate muscular action. Its lateral aspect provides attachment for the tendons of the short head of biceps brachii and coracobrachialis (which together form the conjoined tendon), and its medial aspect gives attachment to the pectoralis minor muscle. The coracoclavicular ligaments (conoid and trapezoid) and coracoacromial ligaments attach to its superior aspect. The coracoid is an important anatomical landmark, palpable through the deltopectoral groove, and has been called the “lighthouse of the shoulder”1 for its ability to guide surgeons away from
Discussion The coracoid process is a forward facing projection on the supero-anterior part of the scapula, which acts both to stabilise the shoulder girdle (through its ligamentous attachments) and
* Corresponding author. Tel.: þ44 (0) 1923 244366; fax: þ44 (0) 1242674252. E-mail addresses: [email protected] (K.J. Alsey), anant.mahapatra@ whht.nhs.uk (A.N. Mahapatra), [email protected] (J.H. Jessop). a Tel.: þ44 (0) 1923 244366.
Figure 1. AP radiograph of shoulder, demonstrating no abnormality.
1078-8174/$ e see front matter Ó 2012 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.radi.2012.05.002
302
K.J. Alsey et al. / Radiography 18 (2012) 301e302
Figure 4. Axial CT scan of shoulder, demonstrating the coracoid base fracture.
Figure 2. Lateral radiograph of the scapula, demonstrating no abnormality.
Figure 5. Sagittal CT scan of shoulder, demonstration the coracoid base fracture.
from a normal epiphyseal plate is not simple radiographically, but requires clinical correlation. In the case of our patient the asymmetrical separation at the fracture site was diagnostic. In clinical practice the important factors are degree of displacement of the fracture and associated injuries such as acromioclavicular separation, because these determine the need for operative management.3e5 References Figure 3. Axial radiograph of shoulder, demonstrating the coracoid base fracture.
the medially placed subclavian artery, vein and brachial plexus into a safe lateral zone. During development the coracoid has both an epiphyseal plate near to its base and and an apophysis at its tip. Both the epiphseal plate and apophysis of the coracoid process fuse at approximately 17 years of age.2 Differentiating a symmetrically and minimally displaced fracture or Salter Harris I epiphyseal injury at the base of the coracoid
1. Matsen FA, Thomas SC, Rockwood CA. Anterior glenohumeral instability. In: The shoulder. Philadelphia: WB Saunders; 1990. p. 336e67. 2. Flecker H. Roentgenographic observations of the times of appearance of epiphyses and their fusion with the diaphyses. Journal of Anatomy 1932;67:118e66. 3. Jettoo P, de Kiewert G, England S. Base of coracoid fracture with acromioclavicular dislocation in a child. Journal of Orthopaedic Surgery and Research 2010;5:77. 4. Eyres K, Brooks A, Stanley D. Fractures of the coracoid process. Journal of Bone and Joint Surgery 1995;77-B:425e8. 5. Montgomery S, Loyd D. Avulsion fracture of the coracoid epiphysis with acromioclavicular separation. Journal of Bone and Joint Surgery (Am) 1977;59-A:963e5.