What is the treatment for an old acromion fracture?

Treatment for Old Acromion Fractures

The treatment of old acromion fractures requires a balanced approach between operative and non-operative management, with surgical intervention recommended for displaced fractures that reduce the subacromial space or disrupt the superior shoulder suspensory complex. 1, 2

Initial Assessment

• Evaluate fracture displacement (>2-3mm step-off or >1-4mm displacement indicates potential need for surgery)
• Check integrity of the extensor mechanism
• Assess for articular surface disruption
• Evaluate for reduction of subacromial space
• Determine patient's activity level and functional demands

Treatment Algorithm

Non-operative Management

• Appropriate for:

  • Non-displaced fractures (<2mm displacement)
  • Elderly or less active patients with minimal symptoms
  • Patients with high surgical risk
  • Intact superior shoulder suspensory complex

• Non-operative treatment includes:

  • Pain management with appropriate analgesics
  • Activity modification
  • Physical therapy for range of motion and strengthening
  • Regular radiographic follow-up to monitor for displacement

Surgical Management

• Indicated for:

  • Displaced fractures (>2mm)
  • Persistent symptomatic non-unions
  • Reduction of subacromial space
  • Disruption of superior shoulder suspensory complex
  • Active patients with higher functional demands

• Surgical options:

  • Open reduction and internal fixation (ORIF) with plates and screws 3, 4
  • Cannulated screw fixation for simpler fractures 5
  • Fragment excision (only for small fragments or after failed fixation) 6
  • Local bone grafting for non-unions 4

Rehabilitation Protocol

• Early phase (0-4 weeks):

  • Protected motion with limited abduction
  • Pain control
  • Pendulum exercises

• Intermediate phase (4-8 weeks):

  • Begin gentle passive range of motion exercises
  • Progress to active-assisted range of motion as tolerated

• Advanced phase (8-12 weeks):

  • Advance to strengthening exercises after radiographic evidence of healing
  • Focus on rotator cuff and periscapular strengthening

Follow-up and Monitoring

• Clinical and radiographic follow-up at 2-week intervals initially
• Monitor for:
  • Fracture healing
  • Pain levels
  • Range of motion progress
  • Functional improvement
  • Potential complications (subacromial impingement, rotator cuff injury)

Special Considerations

• For patients over 50 years, evaluate for risk of subsequent fractures 7
• Consider calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 1
• Implement fall prevention strategies for elderly patients
• Consider orthogeriatric comanagement for elderly patients with multiple fractures 7

Potential Complications

• Symptomatic non-union (relatively high with conservative treatment) 2
• Subacromial impingement 5
• Rotator cuff injury 5
• Movement restriction 5
• Persistent pain 2
• Hardware irritation requiring removal (with surgical fixation) 6

The literature suggests that while non-union rates with conservative treatment are relatively high, they are not always painful or functionally limiting, especially in elderly or less active patients. However, for active patients with displaced fractures, surgical fixation is more likely to provide satisfactory outcomes and avoid the need for revision of symptomatic non-unions 2.