Management of High-Energy Displaced Coracoid Process Fractures in Adults
For adults with high-energy displaced coracoid fractures (>5 mm displacement) involving the scapular neck or glenoid, surgical fixation is strongly recommended to restore shoulder mechanics, prevent nonunion, and avoid functional compromise from superior shoulder suspensory complex disruption. 1, 2, 3
Initial Imaging and Assessment
- CT scanning is essential for characterizing the fracture pattern, assessing displacement, evaluating glenoid involvement, and planning surgical approach 4
- Three-dimensional CT reconstruction helps visualize the complex scapular anatomy and fracture configuration, particularly when glenoid or scapular neck extension is present 4
- Standard radiographs frequently miss or underestimate coracoid fractures due to overlying structures 1
Surgical Indications (Your Patient Meets These)
Your patient has clear surgical indications based on multiple criteria:
- Displacement >1 cm (your patient has >5 mm, approaching this threshold) 1, 3
- High-energy mechanism with scapular neck or glenoid involvement represents a double disruption of the superior shoulder suspensory complex, which is an absolute surgical indication 2, 3
- Fractures extending into the glenoid require anatomic reduction to prevent post-traumatic arthritis and restore articular congruity 2
Surgical Approach Selection
The surgical approach depends on fracture location and associated injuries:
- For isolated coracoid base/shaft fractures: Direct anterior approach through Langer's lines provides excellent exposure for anatomic reduction 2
- For fractures extending into the superior glenoid fossa (your patient): Anterior approach allows direct visualization for articular reduction of the glenoid component and indirect reduction of the coracoid 2
- For complex patterns with scapular neck involvement: Consider posterior Judet approach with indirect reduction, or combined anterior-posterior approaches if fracture segments are not in continuity 2
Fixation Technique
Implant selection should be based on fragment size, comminution, and articular involvement:
- Interfragmentary lag screws are preferred for large, simple fragments with adequate bone stock 2, 5
- Buttress plating is indicated for comminuted patterns or when screw fixation alone provides inadequate stability 2
- Cannulated screws under fluoroscopic guidance can simultaneously reduce both the coracoid fracture and any associated acromioclavicular disruption via intact coracoclavicular ligaments 5
- Ensure adequate purchase in both proximal and distal fragments to prevent hardware failure 2
Timing of Surgery
- Surgery should be performed within 24-48 hours when medically feasible, following principles established for other shoulder girdle fractures requiring operative fixation 4
- Delay beyond this window increases soft tissue contracture and makes anatomic reduction more difficult 2
Expected Outcomes
- Surgical fixation of displaced coracoid fractures yields excellent functional outcomes with fracture union in nearly all cases when proper technique is used 2, 3
- All 27 fractures in one surgical series achieved union with full pain-free motion at mean 11-month follow-up 3
- Hardware removal may be required in approximately 10-15% of cases due to prominence causing irritation 3
Critical Pitfalls to Avoid
- Do not treat high-energy displaced fractures with glenoid involvement conservatively—this leads to painful nonunion, impingement, and functional compromise 1, 3
- Do not underestimate fracture displacement on plain radiographs alone—always obtain CT imaging 4, 1
- Do not miss associated injuries to the acromioclavicular joint, rotator cuff, or other components of the superior shoulder suspensory complex, as these may require simultaneous treatment 2, 3
- Ensure adequate soft tissue handling during the anterior approach to avoid neurovascular injury 2