What is the management approach for a patient with an acromion fracture?

Management of Acromion Fractures

Most acromion fractures should be managed conservatively with sling immobilization, early range-of-motion exercises, and pain control, reserving surgical intervention for displaced fractures, disruption of the superior shoulder suspensory complex, reduced subacromial space, or symptomatic nonunions. 1, 2

Initial Assessment and Diagnosis

• Obtain high-quality imaging including anteroposterior and lateral shoulder radiographs, with CT scan (including 3D reconstructions) for better fracture characterization and surgical planning if displacement is suspected 1
• Evaluate for associated injuries to the superior shoulder suspensory complex (SSSC), including clavicle fractures, coracoclavicular ligament injuries, and glenoid fractures, as these combinations create biomechanical instability requiring surgical stabilization 3, 1, 2
• Assess fracture displacement and subacromial space on imaging, as reduction of the subacromial space increases risk of impingement and rotator cuff injury 2, 4

Common Pitfall

Acromion fractures are frequently missed or diagnosis delayed in polytrauma patients with multiple injuries, leading to symptomatic nonunion, pain, movement restriction, and subacromial impingement 1, 2

Conservative Management (First-Line for Non-Displaced Fractures)

• Apply sling for comfort and may be discarded as early as the patient's pain allows 5
• Initiate pain management with acetaminophen as first-line, adding NSAIDs or opioids for severe pain as needed 5
• Begin range-of-motion exercises including shoulder, elbow, wrist and hand motion within the first postoperative days once pain is controlled 5
• Restrict above chest level activities until fracture healing is evident on follow-up imaging 5
• Avoid overly aggressive physical therapy in the early period as this may increase risk of fixation failure or displacement 5

Expected Outcomes with Conservative Treatment

Conservative management has a relatively high nonunion rate, but nonunions are not always painful or functionally limiting, particularly in elderly or less active patients 1

Surgical Indications

Proceed with open reduction and internal fixation (ORIF) for:

• Displaced fractures with significant fragment separation 1, 2, 4
• Disruption of the superior shoulder suspensory complex (concurrent clavicle, coracoid, or glenoid fractures creating a "floating acromion") 3, 1, 2
• Reduced subacromial space that may cause impingement 2, 4
• Symptomatic nonunions after failed conservative treatment with persistent pain at 4-6 weeks and no callus formation on CT 3, 1
• Active patients who place high functional demands on their shoulders, as they are more likely to require revision for symptomatic nonunions 1

Surgical Technique

• Use a direct posterior approach to the acromion for optimal visualization 4
• Fixation options include:
  • Lateral clavicle plate applied to the lateral spine and acromion (fits remarkably well anatomically) 3
  • Low-profile plating combined with cortical lag screws for stable construct 4
  • Tension band wiring in appropriate fracture patterns 4
• Achieve anatomic reduction to restore subacromial space and prevent impingement 2, 4

Postoperative Rehabilitation

• Provide sling for comfort immediately postoperatively 3
• Begin circumduction exercises at 2 weeks postoperatively 3
• Progress to active movement under supervision of a shoulder physiotherapist after initial healing phase 3
• Implement early physical training and muscle strengthening once initial pain subsides 5
• Continue long-term balance training and fall prevention programs, particularly in elderly patients 5

Complication to Monitor

Frozen shoulder can develop postoperatively but typically resolves with appropriate physiotherapy and complete restoration of shoulder function 3

Secondary Fracture Prevention (Especially in Patients >50 Years)

• Evaluate for osteoporosis with DXA scanning of lumbar spine and hip, as this represents a fragility fracture 5
• Order laboratory workup including ESR, serum calcium, albumin, creatinine, and TSH to identify subclinical disease increasing fracture risk 5
• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) intake to optimize bone healing and reduce future fracture risk by 15-20% 5
• Implement fall prevention strategies including fall risk evaluation and balance training 5

Follow-Up Protocol

• Clinical reassessment at 2 weeks to evaluate pain control and begin early mobilization 3
• Imaging at 4-6 weeks to assess callus formation and healing progress 3, 1
• Monitor for red flags including increasing pain, swelling, loss of function, or neurovascular compromise requiring urgent reassessment 5