Download Corrective Osteotomy for Ipsilateral Distal Clavicular and Coracoid

n Case Report
Corrective Osteotomy for Ipsilateral Distal
Clavicular and Coracoid Malunions
Atsushi Yoshida, MD
abstract
Malunion after double disruption injuries of the superior shoulder suspensory
complex accompanied by shoulder pain and dysfunction has been reported infrequently. A 37-year-old man had a double disruption injury (fractures of the distal
clavicle and the base of the coracoid process). Conservative treatment resulted in
malunion. Twelve months after the injury, pain continued in the coracoclavicular
interval, and there was only 125° forward shoulder elevation. Radiographs showed
50° inferior angulation of the distal clavicle and elongated base of the coracoid
process. Corrective osteotomy was required; however, the concomitant malunion
of the coracoid prevented correction of the deformity with osteotomy of the distal clavicle alone. Therefore, osteotomy of the coracoid was performed. Twelve
months postoperatively, successful bone union resulted in loss of pain. Forward
elevation had recovered to 160°. Distal clavicular fractures with concomitant coracoid fractures are often significantly displaced, which disrupts physiologic coupling of clavicular and scapular motion and limits forward elevation. In the case of
such malunions, excessive movement at the clavicle-scapula junction during mobilization causes pain in the coracoclavicular interval. Correction of this deformity
requires osteotomy of both the clavicular and coracoid malunions. [Orthopedics.
2015; 38(8):e742-e745.]
The author is from the Department of Orthopaedic Surgery, National Hospital Organization Saitama
National Hospital, Saitama, Japan.
The author has no relevant financial relationships to disclose.
The author thanks Yasushi Morisawa, MD, who helped perform the surgery and the postoperative
follow-up.
Correspondence should be addressed to: Atsushi Yoshida, MD, Department of Orthopaedic Surgery,
National Hospital Organization Saitama National Hospital, 2-1 Suwa, Wako, Saitama 351-0102, Japan
([email protected]).
Received: September 26, 2014; Accepted: February 3, 2015.
doi: 10.3928/01477447-20150804-92
e742
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n Case Report
T
he superior shoulder suspensory
complex, which is composed of
2 struts of the clavicle and the
lateral scapular body that support a ring
consisting of the glenoid process, coracoid process, distal clavicle, and acromial
process, maintains a normal, stable relationship between the upper extremity and
the axial skeleton.1 When this complex
sustains double disruptions in which its
connection breaks in 2 places, its structure becomes unstable. These conditions
are associated with a high rate of nonunion or malunion. Various combinations
of injuries can cause double disruptions,
including fractures of the distal clavicle
and coracoid. To the author’s knowledge,
there have been no previous reports of
malunion accompanied by dysfunction
caused by this combination of injuries.
This report describes a case of concomitant distal clavicle and coracoid fractures
and successful surgical management of
the resulting malunion with double disruption.
Figure 1: Preoperative anteroposterior (A) and 20° oblique (B) radiographs showing malunion 12 months
after distal clavicular and coracoid fractures.
Case Report
A 37-year-old right-hand–dominant
man who worked as a computer programmer had left-sided ipsilateral fractures of the distal clavicle and base of
the coracoid process as well as left rib
fractures after a fall down stairs. He had
no other health problems. He was treated
conservatively by a local physician, and
fracture union occurred. Despite intensive physiotherapy, he had pain and limited forward shoulder elevation. He was
referred to the author’s institution 12
months after the injury because of lack
of improvement.
On admission, motion induced pain in
the coracoclavicular interval. The angle of
active and passive forward elevation was
limited to 125° for the left arm. However,
there were no remarkable limits in external rotation of 70° and internal rotation to
T8 compared with the contralateral right
shoulder, which showed forward elevation
of 170°, external rotation of 80°, and in-
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Figure 2: Preoperative sagittal oblique computed tomography scan (A) and T2-weighted magnetic resonance imaging scan (B) showing fracture union of the coracoid and an intact coracoclavicular ligament
(arrowhead).
ternal rotation to T7. Radiography showed
50° of inferior angulation of the distal
third of the clavicle in relation to the middle third and elongation of the coracoid at
its base (Figure 1). Computed tomography scan confirmed fracture union, and no
coracoclavicular ligament tear was seen on
magnetic resonance imaging scan (Figure
2), suggesting that the pain and limited
forward shoulder elevation resulted from
malunion with double disruption of the superior shoulder suspensory complex. Corrective osteotomy was performed.
A saber-cut incision was performed,
and the clavicular malunion was exposed.
Osteotomy of the distal clavicle was performed upward along the convex malunion, perpendicular to the distal clavicle, with a micro-bone saw. The sharp
upper end of the proximal fragment was
impacted into the distal fragment to correct the upward convex deformity. However, the proximal fragment impinged on
the elongated coracoid with malunion,
so the correction was incomplete. The
deltoid muscle was then detached from
the anterior clavicular border, exposing
the anterior coracoid base with blunt dissection between the conjoint tendon and
the pectoralis minor.2 The posterior cora-
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n Case Report
Figure 3: Postoperative anteroposterior radiograph showing the osteotomy site fixed by a clavicular hook plate and a cannulated cancellous
screw.
coid base was exposed with a trapeziussplitting approach in which the trapezius
is divided and the supraspinatus muscle
is moved posteriorly en bloc.3 The entire
coracoid base was exposed by connecting the anterior and posterior coracoid
subperiosteally to protect the neurovascular bundle, particularly the suprascapular nerve. An additional shortening osteotomy was performed at the base of the
coracoid process with a curved chisel,
partially resecting the osteotomy section
with a rongeur from the posterior side of
the coracoid. This maneuver completely
corrected the distal clavicle malposition.
The clavicular osteotomy site was fixed
with a clavicular hook plate, which was
necessary in this case because the distal clavicular fragment was too short to
maintain the corrected position without
the transacromial fixation provided by
the hook. The coracoid osteotomy site
was then fixed by inserting a cannulated
cancellous screw from the coracoid to the
neck of the scapula (Figure 3). The patient was placed in an arm sling for the
first 3 weeks, with active range of motion of only the elbow, wrist, and hand
allowed. Then passive and active range
of motion exercises were begun, with
forward elevation limited to 90° and external and internal rotation to tolerance,
and continued until the plate and screws
were removed.
Bone union occurred, and the plate
and screws were removed 6 months after
surgery, followed by full range of motion
exercises focusing on forward elevation.
At the latest follow-up, 12 months after
corrective osteotomy and 6 months after
plate and screw removal, the patient had
no pain. The forward elevation angle had
recovered to 160° without postoperative
changes in external rotation of 70° and
internal rotation to T8 (Figure 4).
Discussion
Previous reports discussed shoulder
malunions accompanied by pain and
dysfunction that resulted in double disruptions, called a “floating shoulder.”4-6
The limited forward shoulder elevation
in these reports resulted from a markedly deformed scapular neck. However,
patients with markedly short malunions
in isolated clavicle shaft fractures can
have scapular malposition.7 Shoulder
elevation is limited by anterior tilt malpositioning resulting from a decreased
Figure 4: Final anteroposterior (A) and 20° oblique (B) radiographs 12 months after corrective osteotomy
showing complete correction of the malunion after removal of the plate and screws.
e744
posterior tilt angle of the scapula during
arm elevation.8 Floating shoulder malunions are believed to cause dysfunction
because of the combination of clavicular
and scapular deformities.
Isolated fractures of the distal clavicle
or coracoid without coracoclavicular and
acromioclavicular ligament injury do not
result in major fracture displacement.
In the current case, the distal clavicular
fracture caused loss of stability because
of the coracoclavicular ligament injury
from the coracoid fracture, with marked
angular displacement. Inman et al9 noted
that excursion of the scapulothoracic
joint during maximum shoulder elevation was 30° at the sternoclavicular joint,
with 40° of posterior axial rotation of
the clavicle. That is, the motions of the
sternoclavicular joint and the clavicle are
transmitted from the distal clavicle to the
scapula through the coracoclavicular ligament and acromioclavicular joint, functioning similarly to a crankshaft. Shoulder elevation occurs when the glenoid is
rotated upward with the scapula.10
In the current case, the anatomic relationship between the clavicle and the
scapula was disturbed by malunions of
the distal clavicle and coracoid. Therefore, scapular movement was limited
and the forward shoulder elevation angle
decreased. Intensive physiotherapy to expand forward shoulder elevation required
excessive movement at the claviclescapula junction, causing pain in the coracoclavicular interval.
This example is very rare and would
not be expected to be seen commonly,
but it shows that deformities resulting
from fresh double disruption injuries
must be corrected precisely in young, active patients. The remarkable malunions
that develop can cause serious shoulder
mobility disorders. It is difficult, if not
impossible, to correct malunion with
double disruption by performing an osteotomy at only 1 site. Adequate correction requires osteotomy at all sites of
malunion.
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