What is the recommended treatment for a 13-year-old with a displaced, comminuted fracture of the coracoid process base/body with cortical disruption, angulation, and lack of healing, and no acute thoracic or abdominal abnormalities?

Surgical Fixation is Recommended

For a 13-year-old with a displaced, comminuted coracoid fracture showing no healing, surgical intervention is indicated, preferably using arthroscopic-assisted reduction and internal fixation with suture anchors or screws. This fracture pattern meets established surgical criteria: displacement with cortical disruption, angulation, and documented nonunion 1.

Rationale for Surgical Management

The key surgical indications for coracoid fractures are:

• Displacement >1 cm
• Painful nonunion (which this patient has developed)
• Disruption of the superior shoulder suspensory complex 1, 2

Your patient meets at least two of these criteria with the displaced, comminuted fracture showing no healing. Conservative management has clearly failed, as evidenced by the lack of healing at the fracture site.

Recommended Surgical Approach

Arthroscopic-Assisted Technique (Preferred)

The most contemporary approach for this age group is arthroscopic reduction with suture anchor fixation 3, 4. This technique offers several advantages in a 13-year-old:

• Minimally invasive with smaller incisions and reduced soft tissue disruption 2, 5
• Direct visualization of the fracture site through arthroscopy 4
• Successful outcomes in adolescents: A 15-year-old rock climber with failed conservative treatment achieved expeditious and durable improvement with this technique 3
• Allows debridement of the nonunion site before fixation 4

Technical Considerations

The surgical technique should include:

• Arthroscopic debridement of the nonunion site
• Reduction under direct visualization
• Fixation with either:
  • Suture anchors (particularly suitable for younger patients with good bone quality) 3, 6
  • Cannulated screws for larger fragments 5
  • Combination approaches depending on fragment size and comminution 7

Alternative: Open Reduction Internal Fixation

If the comminution is severe or arthroscopic visualization is inadequate, open reduction through Langer's lines provides direct exposure for anatomic reduction 7. Implant selection (interfragmentary screws vs. buttress plate) depends on fragment size and degree of comminution 7.

Critical Pitfalls to Avoid

• Missing associated injuries: Carefully evaluate for acromioclavicular joint disruption or other superior shoulder suspensory complex injuries, as these commonly occur together and require simultaneous treatment 2, 5, 8
• Inadequate imaging: The coracoid fracture can be missed on standard AP radiographs 9, 8. Ensure axillary or scapula-Y views were obtained initially
• Underestimating displacement: Radiographs should be performed upright, as supine imaging can underrepresent malalignment 9

Postoperative Protocol

• Immobilization: 6-8 weeks in a sling 5
• Progressive rehabilitation after immobilization period
• Potential implant removal may be needed as a secondary procedure 5
• Monitor for stiffness and antirotation instability during recovery 5

Why Not Conservative Management?

Conservative treatment is appropriate for minimally displaced coracoid fractures 1, but your patient has already demonstrated failure of nonoperative management with persistent nonunion. The combination of displacement, comminution, angulation, and lack of healing makes continued conservative treatment futile and risks chronic pain and functional impairment 1.