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Arthroscopic Treatment of Isolated Fracture of the Posterolateral Angle of the Acromion
Case Report
Arthroscopic Treatment of Isolated Fracture of the Posterolateral Angle of the Acromion Raffaele Russo, M.D., Ph.D., Luigi Vernaglia Lombardi, M.D., Gerardo Giudice, M.D., and Michele Ciccarelli, M.D.
Abstract: Isolated fractures of the acromion are rare. Fracture avulsion of the posterolateral part of the acromion is even more rare. In 1996, a classification of Types I, II, and III was proposed, along with a recommendation for surgical treatment with open reduction and internal fixation for type III fracture. This report describes arthroscopic treatment provided according to a specialized technique that can be used for displaced avulsion fracture of the posterolateral angle of the acromion with reduction of the posterior subacromial space. This injury occurred in a 43-year-old recreational cyclist who injured his right shoulder through a direct blow. The fracture was exposed after the hematoma and the periosteum from the anterolateral portal had been debrided with a motorized shaver. The fracture was reduced by percutaneus pinning, and the position of the fragments was corrected and stabilized with the use of 2 pins—1 anterior and 1 posterior. In the medium part of the lateral fragment, a pin was introduced for implant of the titanium cannulated screw. After 3 weeks, the pins were removed; the screw was taken out after 2 months. Radiographs at 1 year after surgery indicated that bone union had occurred; further physical examination revealed a complete range of motion. The patient was able to return to cycling with no additional problems. Key Words: Arthroscopic—Acromial—Fractures—Osteosynthesis—Sport—Rare.
T
he literature contains few references1-4 to isolated avulsion fractures of the acromial process and no reports on arthroscopic techniques for surgical treatment. These injuries may become displaced, particularly when they are caused by a direct blow from outside forces. Kuhn et al.1 proposed classification into 3 groups. Type I fractures are minimally dis-
From the Department of Orthopaedics and Traumatology, Pellegrini Hospital, Naples, Italy. Address correspondence and reprint requests to Raffaele Russo, M.D., Ph.D., Department of Orthopaedics and Traumatology, Pellegrini Hospital, via Portamedina 41, 80136 Napoli, Italy. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Russo R, Vernaglia Lombardi L, Giudice G, Ciccarelli M. Arthroscopic treatment of isolated fracture of the posterolateral angle of the acromion. Arthroscopy 2007;23: 798.e1-798.e3 [doi:10.1016/j.arthro.2006.03.007]. 0749-8063/07/2307-4693$32.00/0 doi:10.1016/j.arthro.2006.03.007
placed and heal rapidly. Type II fractures are displaced laterally, superiorly, and anteriorly and do not reduce the subacromial space. Treatment is nonoperative. Type III fractures reduce the subacromial space. In these cases, surgical treatment with open reduction and stable internal fixation is indicated. This report describes arthroscopic treatment of a patient with a rare displaced avulsion fracture of the posterolateral angle of the acromion that occurred during recreational cycling. CASE REPORT The patient was a 43-year-old man who had directly injured his right shoulder while cycling recreationally. The accident happened during a steep descent into a curve; he came off his bicycle with the arm in flexion and abduction, causing trauma. Immediately, motion of the shoulder became painful and was impaired. The
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 7 (July), 2007: pp 798.e1-798.e3
798.e1
798.e2
R. RUSSO ET AL. posterior subacromial space. This patient underwent surgical treatment with arthroscopic reduction and fixation of the fracture 2 days after the trauma. Surgical Procedure
FIGURE 1. Radiograph of right shoulder (frontal view). Fracture of the posterolateral angle of the acromion.
patient presented at once to the hospital for examination. Clinical examination revealed swelling and ecchymoses of the posterior part of the shoulder with superficial abrasions. Active and passive motion of the shoulder was restricted and painful. Radiographs and computed tomography (CT) scan of the shoulder revealed a displaced fracture of the posterolateral part of the acromion (Fig 1) as well as reduction of the
The patient was placed into the lateral decubitus position, with the injured arm suspended with the use of a commercially available sterile skin traction setup. Through arthroscopy, the classical posterior portal and intra-articular structures were examined; a normal capsule and ligaments were observed. No traumatic rotator cuff tear or alteration of the glenohumeral cartilage was observed. Examination of the subacromial space revealed a hematoma.2 The fracture was exposed after the hematoma and periosteum had been debrided from the anterolateral portal with a motorized shaver. Greater soft tissue interposition was then noted; if left untreated with the shaver, this would have impaired congruent reduction. The posterolateral fragment was displaced laterally and outside. The fracture was reduced by percutaneus pinning (2 mm), and when the position of the fragments had been corrected, the fracture was stabilized with 2 pins (1.8 mm)—1 anterior and 1 posterior. In the medium part of the lateral fragment, the pin (1.5 mm) was introduced for implant of the titanium cannulated screw (2.5 mm) (Fig 2). The arm was posi-
FIGURE 2. (A) Arthroscopic view shows anatomic reduction with effect of compression (arrow) of cannulated screw. (B) Postoperative radiograph shows the reduction of the fracture with K-wire and cannulated screw.
ARTHROSCOPY FOR FRACTURE OF THE ACROMION
FIGURE 3. Radiograph of the same shoulder 1 year postoperatively shows anatomic reduction and consolidation of fragment.
tioned against the trunk with the abduction system. The percutaneous pins were removed after 3 weeks. Physical therapy was initiated 1 month after the operation was performed. After 3 weeks, therapy was advanced and the arm was mobile at 170°. After 2 months, the cannulated screw was removed through the percutaneous technique with the patient under local anesthesia. Radiograph obtained 1 year after the surgery (Fig 3) indicated that bone union had occurred. The patient reported no pain. Physical examination revealed complete range of motion, and the “swallow-tail sign” of Nishijima used to evaluate deltoid muscle function was negative.3 The patient was permitted to return to cycling and had no additional problems. DISCUSSION Scapular fractures are uncommon and fractures of the acromion are very rare.4-6 The literature reports only a few cases, and these can be divided into 2 groups: fractures that result from a direct and significant force,7 and nondirect stress fractures. The first group was reported by Kuhn et al.1 and Weber et al.,6
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who emphasized open reduction and internal fixation if the fragment is displaced inferiorly. The patient described in the case report was a member of this group. In the second group of fractures, little benefit was derived from nonoperative treatment, as reported by Heyse-Moore and Stoker8 and Rask et al.9 These authors identified the locations and mechanisms of these fractures, which they concluded were caused by sports-related forceful contraction of the deltoid muscle; they believed that indications for treatment included open reduction and internal fixation. We have been unable to find any other reports in the literature on arthroscopic techniques for surgical treatment. We believe that the technique described here was indicated for the treatment of patients with isolated displaced fractures of the acromion and that good outcomes associated with good postsurgical nursing of the patient included a return to recreational sports activities. REFERENCES 1. Kuhn JE, Blasier RB, Carpenter JE. Fractures of the acromion process: A proposed classification system. J Orthop Trauma 1994;8:6-13. 2. Ogawa K, Naniwa T. Fractures of the acromion and the lateral scapular spine. J Shoulder Elbow Surg 1997;8:544-548. 3. Nishijima N, Yamamuno T, Fjio K, Ohba M. The swallow-tail sign: A test of deltoid function. J Bone Joint Surg Br 1995;77: 152-153. 4. Hall RJ, Calvert PT. Stress fracture of the acromion: An unusual mechanism and review of the literature. J Bone Joint Surg Br 1995;77:153-154. 5. Goss TP. The scapula: Coracoid, acromial and avulsion fractures. Am J Orthop 1996;25:106-115. 6. Weber D, Sadri H, Hoffmeyer P. Isolated fracture of posterior angle of the acromion: A case report. J Shoulder Elbow Surg 2000;9:534-535. 7. Goodrich A, Crosland E, Pye J. Acromion fractures associated with posterior shoulder dislocation. J Orthop Trauma 1998;12: 521-522. 8. Heyse-Moore GH, Stoker DJ. Avulsion fractures of the scapula. Skeletal Radiol 1982;9:27-32. 9. Rask MR, Steinberg LH. Fracture of the acromion caused by muscle force: A case report. J Bone Joint Surg Am 1978;60: 1146-1147.
Arthroscopic Treatment of Isolated Fracture of the Posterolateral Angle of the Acromion Raffaele Russo, M.D., Ph.D., Luigi Vernaglia Lombardi, M.D., Gerardo Giudice, M.D., and Michele Ciccarelli, M.D.
Abstract: Isolated fractures of the acromion are rare. Fracture avulsion of the posterolateral part of the acromion is even more rare. In 1996, a classification of Types I, II, and III was proposed, along with a recommendation for surgical treatment with open reduction and internal fixation for type III fracture. This report describes arthroscopic treatment provided according to a specialized technique that can be used for displaced avulsion fracture of the posterolateral angle of the acromion with reduction of the posterior subacromial space. This injury occurred in a 43-year-old recreational cyclist who injured his right shoulder through a direct blow. The fracture was exposed after the hematoma and the periosteum from the anterolateral portal had been debrided with a motorized shaver. The fracture was reduced by percutaneus pinning, and the position of the fragments was corrected and stabilized with the use of 2 pins—1 anterior and 1 posterior. In the medium part of the lateral fragment, a pin was introduced for implant of the titanium cannulated screw. After 3 weeks, the pins were removed; the screw was taken out after 2 months. Radiographs at 1 year after surgery indicated that bone union had occurred; further physical examination revealed a complete range of motion. The patient was able to return to cycling with no additional problems. Key Words: Arthroscopic—Acromial—Fractures—Osteosynthesis—Sport—Rare.
T
he literature contains few references1-4 to isolated avulsion fractures of the acromial process and no reports on arthroscopic techniques for surgical treatment. These injuries may become displaced, particularly when they are caused by a direct blow from outside forces. Kuhn et al.1 proposed classification into 3 groups. Type I fractures are minimally dis-
From the Department of Orthopaedics and Traumatology, Pellegrini Hospital, Naples, Italy. Address correspondence and reprint requests to Raffaele Russo, M.D., Ph.D., Department of Orthopaedics and Traumatology, Pellegrini Hospital, via Portamedina 41, 80136 Napoli, Italy. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Russo R, Vernaglia Lombardi L, Giudice G, Ciccarelli M. Arthroscopic treatment of isolated fracture of the posterolateral angle of the acromion. Arthroscopy 2007;23: 798.e1-798.e3 [doi:10.1016/j.arthro.2006.03.007]. 0749-8063/07/2307-4693$32.00/0 doi:10.1016/j.arthro.2006.03.007
placed and heal rapidly. Type II fractures are displaced laterally, superiorly, and anteriorly and do not reduce the subacromial space. Treatment is nonoperative. Type III fractures reduce the subacromial space. In these cases, surgical treatment with open reduction and stable internal fixation is indicated. This report describes arthroscopic treatment of a patient with a rare displaced avulsion fracture of the posterolateral angle of the acromion that occurred during recreational cycling. CASE REPORT The patient was a 43-year-old man who had directly injured his right shoulder while cycling recreationally. The accident happened during a steep descent into a curve; he came off his bicycle with the arm in flexion and abduction, causing trauma. Immediately, motion of the shoulder became painful and was impaired. The
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 7 (July), 2007: pp 798.e1-798.e3
798.e1
798.e2
R. RUSSO ET AL. posterior subacromial space. This patient underwent surgical treatment with arthroscopic reduction and fixation of the fracture 2 days after the trauma. Surgical Procedure
FIGURE 1. Radiograph of right shoulder (frontal view). Fracture of the posterolateral angle of the acromion.
patient presented at once to the hospital for examination. Clinical examination revealed swelling and ecchymoses of the posterior part of the shoulder with superficial abrasions. Active and passive motion of the shoulder was restricted and painful. Radiographs and computed tomography (CT) scan of the shoulder revealed a displaced fracture of the posterolateral part of the acromion (Fig 1) as well as reduction of the
The patient was placed into the lateral decubitus position, with the injured arm suspended with the use of a commercially available sterile skin traction setup. Through arthroscopy, the classical posterior portal and intra-articular structures were examined; a normal capsule and ligaments were observed. No traumatic rotator cuff tear or alteration of the glenohumeral cartilage was observed. Examination of the subacromial space revealed a hematoma.2 The fracture was exposed after the hematoma and periosteum had been debrided from the anterolateral portal with a motorized shaver. Greater soft tissue interposition was then noted; if left untreated with the shaver, this would have impaired congruent reduction. The posterolateral fragment was displaced laterally and outside. The fracture was reduced by percutaneus pinning (2 mm), and when the position of the fragments had been corrected, the fracture was stabilized with 2 pins (1.8 mm)—1 anterior and 1 posterior. In the medium part of the lateral fragment, the pin (1.5 mm) was introduced for implant of the titanium cannulated screw (2.5 mm) (Fig 2). The arm was posi-
FIGURE 2. (A) Arthroscopic view shows anatomic reduction with effect of compression (arrow) of cannulated screw. (B) Postoperative radiograph shows the reduction of the fracture with K-wire and cannulated screw.
ARTHROSCOPY FOR FRACTURE OF THE ACROMION
FIGURE 3. Radiograph of the same shoulder 1 year postoperatively shows anatomic reduction and consolidation of fragment.
tioned against the trunk with the abduction system. The percutaneous pins were removed after 3 weeks. Physical therapy was initiated 1 month after the operation was performed. After 3 weeks, therapy was advanced and the arm was mobile at 170°. After 2 months, the cannulated screw was removed through the percutaneous technique with the patient under local anesthesia. Radiograph obtained 1 year after the surgery (Fig 3) indicated that bone union had occurred. The patient reported no pain. Physical examination revealed complete range of motion, and the “swallow-tail sign” of Nishijima used to evaluate deltoid muscle function was negative.3 The patient was permitted to return to cycling and had no additional problems. DISCUSSION Scapular fractures are uncommon and fractures of the acromion are very rare.4-6 The literature reports only a few cases, and these can be divided into 2 groups: fractures that result from a direct and significant force,7 and nondirect stress fractures. The first group was reported by Kuhn et al.1 and Weber et al.,6
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who emphasized open reduction and internal fixation if the fragment is displaced inferiorly. The patient described in the case report was a member of this group. In the second group of fractures, little benefit was derived from nonoperative treatment, as reported by Heyse-Moore and Stoker8 and Rask et al.9 These authors identified the locations and mechanisms of these fractures, which they concluded were caused by sports-related forceful contraction of the deltoid muscle; they believed that indications for treatment included open reduction and internal fixation. We have been unable to find any other reports in the literature on arthroscopic techniques for surgical treatment. We believe that the technique described here was indicated for the treatment of patients with isolated displaced fractures of the acromion and that good outcomes associated with good postsurgical nursing of the patient included a return to recreational sports activities. REFERENCES 1. Kuhn JE, Blasier RB, Carpenter JE. Fractures of the acromion process: A proposed classification system. J Orthop Trauma 1994;8:6-13. 2. Ogawa K, Naniwa T. Fractures of the acromion and the lateral scapular spine. J Shoulder Elbow Surg 1997;8:544-548. 3. Nishijima N, Yamamuno T, Fjio K, Ohba M. The swallow-tail sign: A test of deltoid function. J Bone Joint Surg Br 1995;77: 152-153. 4. Hall RJ, Calvert PT. Stress fracture of the acromion: An unusual mechanism and review of the literature. J Bone Joint Surg Br 1995;77:153-154. 5. Goss TP. The scapula: Coracoid, acromial and avulsion fractures. Am J Orthop 1996;25:106-115. 6. Weber D, Sadri H, Hoffmeyer P. Isolated fracture of posterior angle of the acromion: A case report. J Shoulder Elbow Surg 2000;9:534-535. 7. Goodrich A, Crosland E, Pye J. Acromion fractures associated with posterior shoulder dislocation. J Orthop Trauma 1998;12: 521-522. 8. Heyse-Moore GH, Stoker DJ. Avulsion fractures of the scapula. Skeletal Radiol 1982;9:27-32. 9. Rask MR, Steinberg LH. Fracture of the acromion caused by muscle force: A case report. J Bone Joint Surg Am 1978;60: 1146-1147.