New System for the Classification of Epiphyseal Separation of the Coracoid Process: Evaluation of Nine Cases and Review of the Literature

Abstract

Objectives and Design. Epiphyseal separation of the coracoid process (CP) rarely occurs in adolescents. In this retrospective case series, we reviewed the data of nine patients treated at our center and those of 28 patients reported in the literature. This injury can be classified into three types according to the injured area: Type I, base including the area above the glenoid; Type II, center including the coracoclavicular ligament (CCL); and Type III, tip with the short head of the biceps and coracobrachialis, as well as the pectoralis minor. Patients/Participants. A total of 37 patients were included in the analysis. Data on sex, age, cause and mechanism of injury, separation type, concomitant injury around the shoulder girdle, treatment, and functional outcomes were obtained. Main Outcome Measurements and Results. Type I is the most common type. The cause of injury and associated injury around the shoulder girdle were significantly different between Type I, II, and III fractures. The associated acromioclavicular (AC) dislocation and treatment were significantly different between Type I and III fractures. Our new classification system reflects the clinical features, imaging findings, and surgical management of epiphyseal separation of the CP. Type I and II fractures are mostly associated with AC dislocation and have an associated injury around the shoulder girdle. Type III fractures are typically caused by forceful resisted flexion of the arm and elbow. Although the latter are best managed surgically, whether conservative or surgical management is optimal for Type I and II fractures remains controversial. Conclusions. We noted some differences in the clinical characteristics depending on the location of injury; therefore, we aimed to examine these differences to develop a new system for classifying epiphyseal separation of the CP. This would increase the clinicians’ awareness regarding this injury and lead to the development of an appropriate treatment.

Presumed Glenoid SLAP Tear in an Adolescent Football Player Belied the Presence of a Coracoid Growth Plate Fracture: A Diagnostic Conundrum

“…Despite these potential diagnostic challenges, coracoid physeal injury should be considered when evaluating a pediatric patient for shoulder pain [ 19 , 20 ]. As demonstrated by the clinical data reported by Mondori et al [ 21 ], simultaneous fracture of the coracoid epiphysis and labral tear is not likely. Of the 37 patients that they describe with epiphyseal separation of the coracoid, none had injury to the glenohumeral labrum.…”

Acromioclavicular Joint Lesions in Adolescents—A Systematic Review and Treatment Guidelines

“…Although concrete management guidelines are lacking, most of the studies in this review chose operative management in cases with soft tissue impingement, buttonholing of the clavicle in the trapezius, excessive displacement of the clavicle and presence of concomitant injuries like coracoid fractures and clavicle fractures [7,16,18,19,22,24,28]. On the other hand, conservative management was suggested for minimally displaced dislocations and voluntary atraumatic dislocation due to their chronic nature and minimal symptoms [26,27].…”

“…On the other hand, conservative management was suggested for minimally displaced dislocations and voluntary atraumatic dislocation due to their chronic nature and minimal symptoms [26,27]. A number of 4 cases with concomitant coracoid fractures were managed conservatively as the patients did not consent to surgery [22]. No case of isolated ACJ dislocation with minimal displacement was reported in the literature.…”

“…Out of the 10 cases of conservative management, 4 did not consent to surgery [22], 3 had minimally displaced stable injuries [15,21,23], 1 case of pseudo-dislocation was reduced successfully under sedation and 2 cases of voluntary dislocation were managed conservatively because of minor symptoms.…”

“…Type 2: Coracoid fracture with ACJ dislocation (Figure 3b) A total of 10 cases were reported, out of which 4 underwent surgery (Table 1) Mondori et al and Jettoo et al suggested operative intervention in all cases due to the instability of the SSSC caused by the combination of injuries [22,25]. Conservative management was conducted in minimally displaced injuries oH.…”