Journal of Orthopaedic Surgery 2012;20(1):121-5
Recurrent shoulder dislocations secondary to
coracoid process fracture: a case report
Hitesh Lal,1 Pankaj Bansal,2 Vinod Kumar Sabharwal,1 Lalrin Mawia,1 Deepak Mittal1
Department of orthopaedics, Postgraduate Institute of Medical Education & Research, Dr. Ram Manohar Lohia Hospital,
New Delhi, India
2
BL Kapur Hospital, New Delhi, India
1
INTRODUCTION
ABSTRACT
Coracoid process fracture is easily missed in recurrent
anterior shoulder dislocation. We report one such case
in a 48-year-old man. Radiology revealed the Bankart
lesion and the Hill-Sachs lesion only; the coracoid
process fracture was discovered intra-operatively.
The anatomy of the shoulder was restored by fixing
the fragment to its scapular remnant with a 4-mm
cannulated cancellous screw. The tip and the proximal
fragment were reamed before inserting the screw.
This fragment was routed with attached short head
of biceps and coracobrachialis through the lower one
third of the subscapularis, before homing it and fixing
it to the proximal coracoid fragment. This extraarticular repair resulted in less stiffness than any
intra-articular procedure. At the 2-year follow-up, the
patient had had no further shoulder dislocation.
Key words: bone screws; fracture fixation; shoulder
dislocation
Coracoid process fracture is uncommon. It can be
due to direct trauma or associated with dislocations
of acromioclavicular and shoulder joints.1,2 It can
also occur during treatment for acromioclavicular
dislocations,3 as avulsion-fractures by muscle pull
of the biceps and coracobracobrachialis4 and as
stress fractures in trapshooter shoulders.5 Coracoid
process fractures and non-unions are easily missed
on radiographs,6 as they rarely cause disturbing
symptoms. Only 9 cases of coracoid process fracture
with shoulder instability have been reported.1,6–11
CASE REPORT
In January 2009, a 48-year-old right-handed man
presented with recurrent right shoulder dislocation.
Eight years earlier, he had sustained injury to
his shoulder when a heavy load slipped and fell
behind his back. The shoulder was hyper-abducted
and -extended, as he was throwing the load in an
overhead position. The load slipped behind his back
Address correspondence and reprint requests to: Dr Pankaj Bansal, C-11 (first floor), Vikram Nagar, Kotla, Delhi, 02, India. E-mail:
bansalpankajj@gmail.com
Journal of Orthopaedic Surgery
122 H Lal et al.
and added an element of external rotation, which
led to anterior dislocation of the shoulder. He felt
pain immediately and could not move his shoulder.
He underwent closed reduction and immobilisation
elsewhere and had an uneventful recovery. Two years
later, he sustained another dislocation while holding
an overhead bar in a bus when the bus suddenly
braked. The arm was hyper-abducted, -extended,
and externally rotated. He again underwent closed
reduction and immobilisation. Since then, more
episodes of dislocation occurred in the past 6 years
(about 3 per year); the last one was 1.5 months earlier.
On examination, there was slight wasting of the
anterior deltoid muscles, as the smooth rounded
contour of the shoulder was lost. Bony contours of
the coracoid, clavicle, acromion, scapular spine,
and lateral humeral head prominence were normal.
The Dugas and Hamilton ruler tests for shoulder
dislocation were negative, but apprehension, anterior
draw, relocation, and fulcrum tests for anterior
shoulder instability were positive. Abduction and
external rotation of the shoulder were restricted
owing to the patient’s apprehension. There was no
neurovascular deficit; axillary and suprascapular
motor and sensory nerve tests were normal. The
patient had no ligamentous laxity or other signs
suggestive of collagen disorders. Radiographs
revealed no obvious bony lesion on the scapular
side, but a Hill-Sachs lesion of the humeral head was
evident in full internal rotation (Fig. 1). Magnetic
resonance imaging revealed anterior capsule-labral
tear (Bankart lesion) with a wedge-shaped impaction
along the posterolateral aspect of the humeral head
(Hill-Sachs depression), but no tear was noted in the
rotator cuff (Fig. 2).
The patient was prepared for open Bankart repair
for the Hill-Sachs lesion. The deltopectoral approach
was used. After the clavipectoral fascia was incised,
a small bony fragment was noted at the lower border
of the subscapularis. Based on its tendon and muscle
fibre direction, the fragment appeared to be a fractured
coracoid process. The subscapularis underneath the
retracted coracoid process was normally attached
to the lesser tuberosity of the humerus. So it was
decided to restore the anatomy of the shoulder by
fixing the fragment to its scapular remnant with a
4-mm cannulated cancellous screw. The tip and the
proximal fragment were reamed before inserting the
screw. This fragment was routed with the attached
short head of biceps and coracobrachialis through the
lower one third of the subscapularis, before homing
it and fixing it to the proximal coracoid fragment (Fig.
3). This extra-articular repair resulted in less stiffness
than any intra-articular procedure.
Figure 1 Preoperative radiographs showing no obvious
bony lesion on the scapular side, but there is a Hill-Sachs
lesion of the humeral head (arrow) in full internal rotation.
At the 2-year follow-up, the patient had had no
further shoulder dislocation.
DISCUSSION
There are 2 types of coracoid process fractures
according to their relationship with the
coracoclavicular ligaments.6,14,15 Type-I fractures occur
behind the site of attachment of coracoclavicular
ligaments (between the scapular body and the
coracoclavicular ligaments) and may destroy the
scapuloclavicular connection. These fractures are
typically associated with additional shoulder injuries
(such as acromioclavicular dislocation, fractures of
the scapular spine, acromion, and/or lateral clavicle),
which further destabilise both the coracoid process
fracture and the scapuloclavicular connection, and
disrupt the superior shoulder suspensory complex.
Type-II fractures occur anteriorly/distally to the
attachment of these ligaments. They are usually
caused by impaction by the humeral head or avulsion
by the conjoined tendon, and do not disturb the
scapuloclavicular connection. Our patient probably
had the type-II fracture, as it was related to avulsion
but not acromioclavicular joint injury. When lifting
a load, the elbow was flexed and the biceps and its
concomitant short head contracted. When the weight
fell over his head, the biceps stretched and the
coracoid process and short biceps head avulsed and
fractured.
The mechanism of fracture during shoulder
dislocation involves 2 aspects: (1) strong traction
exerted by the attached muscles leading to avulsion
and fracture, and (2) direct impact of the dislocated
humeral head leading to fracture.1,16
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Recurrent shoulder dislocations secondary to coracoid process fracture 123
Figure 2 Magnetic resonance images showing an anterior capsule-labral tear (Bankart lesion) with a wedge-shaped impaction
(arrow) along the posterolateral aspect of the humeral head (Hill-Sachs depression), but no tear in the rotator cuff.
Figure 3 Postoperative scapular Y and Stryker notch radiographs and a computed tomographic transverse section showing
fixation of the coracoid process with a screw.
Coracoid process fractures are easily missed,
as the symptoms are non-specific and shoulder
dislocation tends to dominate the picture.13
Diagnosing such a fracture requires good
clinicoradiological acumen and the use of a scapular
Y view, a Stryker notch view, or an anterior oblique or
axillary view of the shoulder. We missed it because:
(1) The patient presented late with no previous
records and radiographs. (2) Radiographs were
unremarkable except for the Hill-Sachs lesion. In
retrospect, a narrow tip coracoid probably indicated
an associated chip fracture of the coracoid tip. The
124 H Lal et al.
axillary radiograph was a lateral and not oblique
view, which shows up the coracoid process fracture
better.1 (3) Magnetic resonance imaging showed the
Bankart and Hill-Sachs lesions only, likely owing to
inadequate sections perpendicular to the fracture
plane. Thus, magnetic resonance imaging appears
inferior to computed tomography in diagnosing
these fractures.
Recurrent anterior shoulder instability was
likely due to both the coracoid process non-union
and the Bankart and Hill-Sachs lesions. The avulsed
coracoid process fragment with its conjoined tendon
was widely displaced inferiorly to the lower border
of the subscapularis. This led to deficiency of the
dynamic protective anterior apron (against anterior
instability of the shoulder). From deep to superficial,
the anterior apron of the shoulder is formed by the
anterior capsule, subscapularis, and the conjoined
tendons of short head of biceps and coracobrachialis.17
The conjoined tendons of short head of the biceps and
coracobrachialis form the superficial and foremost
layer. During hyperabduction, they also exert a
dynamic protective horizontal adduction, which is
a stabilising force on the shoulder. As the fragment
was widely displaced, the subscapularis may have
jumped/subluxated over the coracoid in an overhead
abduction position. The Latarjet procedure and
modified Boytchev procedures keep the subscapularis
inferior to the equator of the humeral head in
overhead abduction, as they are routed through it,
and thus protect the shoulder from dislocation.18,19
Fixation of the coracoid process with its attached
tendons (after routing through the subscapularis to
reinforce the anterior wall) was effective in stabilising
the shoulder. Restoration of corocoid anatomy should
be sufficient to stabilise the shoulder, because of
the stabilising role of the coracoid-conjoint tendon
complex.
Open Bankart repair for recurrent avulsed anterior
inferior glenohumeral ligaments and the labrum
complex is the treatment of choice. We adopted the
Journal of Orthopaedic Surgery
middle path of the Boytchev procedure to restore
the anatomy of the coracoid process. The coracoid
process was transferred through the subscapularis to
its parent fragment. This extra-articular repair results
in less stiffness than any intra-articular procedure
like the Bankart repair. The Bankart lesion may be the
primary cause or may have developed secondarily to
recurrent dislocation.
Open approaches achieve a low recurrent
instability rate (5%),20 although the complication of
subscapularis rupture may ensue.21,22 Arthroscopic
repair has a lower risk of subscapularis failure and
enables smaller incisions, better range of movement,
and earlier return to work. Compared to the open
operations, patients treated arthroscopically achieve
higher functional scores postoperatively, but have
a significantly increased risk of recurrent instability
and dislocation (12–16%).20,23 Other studies report
comparable outcomes following the extra-articular,
non-anatomic Bristow-Latarjet procedure with open
techniques.19 Thus, the modified extra-articular
Boytchev procedure was used to fix the fractured
coracoid tip to its parent by rerouting it through
the subscapularis. This kept the subscapularis and
conjoint tendon approximated to the anteroinferior
aspect of glenohumeral joint, and thus acted as a
static anterior shoulder stabilising apron. Moreover,
it avoided the disadvantage of the original Boytchev
procedure, wherein the coracoid is routed behind
the subscapularis, thus lifting it away from the
glenohumeral joint and increasing the risk of
recurrent dislocation.24,25 As the coracoid fragment
with its attached conjoint tendon was passed through
the lower third of the subscapularis, which was
kept inferior to the equator of the humeral head in
overhead abduction.18,19 The pressure between the
humeral head and the subscapularis tendon was
increased. This enhanced proprioceptive stimuli
in the subscapularis tendon and thus accelerated
the protective reflex needed to prevent shoulder
dislocation.26
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