When is a coracoid fracture (fx) surgically treated?

From the Guidelines

A coracoid fracture is considered for surgical intervention when it results in disruption of the coracoclavicular ligament complex, as suggested by the American Academy of Orthopaedic Surgeons clinical practice guideline summary 1. When considering the management of a coracoid fracture, several factors come into play, including the degree of displacement, the involvement of the base of the coracoid, association with other shoulder injuries, and the impact on the patient's quality of life due to pain and functional limitation.

• Key considerations for surgical intervention include:
  • Displacement of the fracture, particularly when it affects the attachments of crucial stabilizing structures
  • Association with other injuries such as acromioclavicular joint dislocations or glenoid fractures
  • Persistent symptoms despite conservative management
• The goal of surgery is to restore anatomical alignment, ensure proper healing, and prevent long-term complications such as malunion, nonunion, or chronic shoulder instability, thereby improving morbidity, mortality, and quality of life outcomes.
• The surgical approach typically involves open reduction and internal fixation, with post-operative care focusing on immobilization followed by progressive rehabilitation to restore normal shoulder function, as indicated by the most recent clinical practice guidelines 1.

From the Research

Indications for Surgical Intervention

• Displaced fractures (>1 cm) 2
• Fractures that have progressed to a painful nonunion 2
• Fractures associated with the disruption of the superior shoulder suspensory complex 2, 3
• Ogawa type I fractures with associated disruptions of the SSSC 3

Surgical Management

• Direct approach through Langer's lines for simple fractures through the shaft or base of the coracoid 4
• Anterior approach for fractures that extend into the superior glenoid fossa 4
• Posterior Judet approach or a separate anterior approach for complex glenoid or scapula neck/body fractures 4
• Implant selection based on the size of the fragment, the degree of comminution, and the degree of articular involvement 4

Specific Surgical Techniques

• Fixation with a cannulated screw under fluoroscopic guidance for displaced fracture of the coracoid process associated with acromioclavicular dislocation 5
• Safety screw fixation technique using a guidewire inserted into the circle of the coracoid base under fluoroscopic guidance 6