Displaced acromion fracture: A rare injury, case report

Int J Surg Case Rep. 2017; 39: 313–316.

Published online 2017 Sep 1. doi: 10.1016/j.ijscr.2017.08.051

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Introduction

Acromion fractures are extremely rare. There are no common accepted treatment schemes and fixation methods We aimed to present a case which may contribute to the diagnosis and treatment of acromion fracture in a patient with polytrauma.

Presentation of case

Acromion fracture associated with scapula and clavicle fractures was diagnosed in 40 years old patient and treated with open reduction and cannulated screw fixation. The fracture healing was completed without causing subacromial impingement.

Discussion

In patients with polytrauma, diagnosis and treatment of acromion fractures can be delayed or overlooked. In improperly treated acromion fractures; pain, movement restriction, subacromial impingement, rotator cuff injury and symptomatic nonunion can occur.

Conclusion

We recommend early surgical treatment for displaced acromion fractures, reduction of subacromial space and disruption of the superior shoulder suspensory complex.

Keywords: Acromion, Scapula, Shoulder injury, Superior shoulder suspensory complex

The acromion is a large bony projection on the superior end of the scapula. Acromion fractures are rare injuries. They constitute 8%–16% of scapula fractures ^{[1], [2]}. Recently, they are seen at the rate of 5%–6.9% as the complication of reverse shoulder arthroplasty ^[3]. Acromion fractures may occur as a result of shoulder trauma and overuse injuries. Acromion fractures may occur with glenoid process, scapula or clavicle distal fractures and disruption of superior shoulder suspensory complex ^[4]. There are no widely accepted treatment algorithm and fixation method of acromion fractures ^[5]. We aim to present a case report that contributes to diagnosis and treatment of acromion fractures. This case includes a polytrauma that involves scapula, clavicle, ulna and radius fractures accompanying acromion fracture.

The following case report is compliant with SCARE guidelines ^[6].

40 years-old male patient was evaluated in emergency room after motor vehicle accident. Patient was a motorcycle driver, an amateur swimmer, non-smoker, non-drug user. He had a normal psychosocial history. He and his family did not have a specific genetic history. He had ecchymosis, crepitation and deformity on his right arm, clavicle, scapula and forearm. He had no neurovascular deficit. On radiographic examination of the patient, right scapula nondisplaced body fracture, right acromion fracture (), right clavicle fracture and right ulna and radius shaft fracture was detected. A long arm cast and an arm sling was applied to the patient. On the CT scan applied for shoulder area (), acromion fracture was classified as Type 1 according to Ogawa, Type 3 according to Kuhn and Type A1 according to AO. Patient was informed about surgery and he agreed with early intervention and osteosynthesis.

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Preoperative shoulder x-ray.

The patient was operated after he came to emergency service. Surgery was performed by an orthopaedic surgeon. Longitudinal incision was applied between clavicle shaft and anterosuperior edge of acromion. Reduction and fixation by anatomical clavicle plate was applied to clavicle comminuted fracture. Fixation was completed by placing anatomical clavicle plate. Acromion fracture was reached over by entering between trapezius and deltoid muscles. Fracture line was transverse (). There was a reduction of subacromial space. Subacromial space and rotator cuff was observed through the fracture line. Rotator cuff was intact. Fracture reduction was applied. Compression was applied to fracture line via two 3,00 mm cannulated screw (). Fixation was evaluated after fluoroscopy application (). It was observed that the fixation was stable. Forearm fractures of the patient were also operated by applying fixation with open reduction and plate screw on the same operation.

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Akromion fracture, fixation with cannulated screw.and fluoroscopic view.

The patient was hospitalized for wound care for five days. Arm sling was used after surgery. On radiographic evaluations, reduction was observed to be successful on fracture line (). The post-operative period was uneventful. The patient tolerated surgery and physical therapy easily. The patient started passive shoulder exercise 2 weeks after surgery and active shoulder exercise 6 weeks after surgery. The patient returned to working again 8 weeks after surgery. There was no complaint of pain on the 3rd month post-operative examination of the patient. On the same examination, the patient’s right shoulder flexion was 160°, abduction was 150°, internal rotation was 45° and external rotation was 70°. And fracture union was completed (). There was no complaint of pain one year after surgery. Constant shoulder score was 94.

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Postoperative 3rd months x-ray.

Acromion fractures are rare injuries. In patients with polytrauma, diagnosis and treatment of acromion fractures can be delayed or overlooked. In improperly treated acromion fractures; pain, movement restriction, subacromial impingement, rotator cuff injury and symptomatic nonunion can occur ^{[5], [7], [8]}.

There are three classifications in acromion fractures. Ogawa and Naniwa ^[9] classified the fractures of spinoglenoid notch lateral as Type 1 and fractures of medial as Type 2. Kuhn ^[10] used a classification algorithm based on fracture displacement. He classified acromion fractures as follows; Type 1, minimally displaced, Type 2, displaced but do not reduce subacromial space and Type 3, cause a reduction in subacromial space. AO/OTA ^[11] classification is based on the level of comminution and displacement. In our case report, the acromion fracture is classified as Type 1 according to Ogawa, Type 3 according to Kuhn and Type A1 according to AO/OTA.

The patient with clavicular fracture and acromion fracture was admitted as unstable because of two injuries on superior shoulder suspensory complex ^{[4], [5]}. Acromion fracture caused reduction in subacromial space. Ogawa ^[9] determined a treatment method based on fracture type, fracture displacement and accompanying ipsilateral shoulder injuries. Kuhn ^[10] suggested surgical treatment for Type 3 fractures that cause reduction in subacromial space, symptomatic stress fractures and painful nonunions. In a recent study, according to Hill ^[5], symptomatic nonunion, subacromial impingement, displacement more than 1 cm, open fractures and disruption of superior shoulder suspensory shoulder complex require surgical treatment. In our case, we chose surgical treatment because the patient had superior shoulder suspensory complex injury and subacromial reduction.

Open reduction was applied by extending the incision to lateral, which was used to reach out clavicle fracture. We chose cannulated screw fixation because the pattern of fracture was transverse. Acromion fractures can be treated with K-wires ^{[9], [12], [13]}, tension band ^{[1], [9], [13]}, cannulated screw ^{[5], [16], [17]}, and plate screw ^{[5], [14], [15]}. Fixation with K-wires is not recommended because it may cause early implant failure and stable reconstruction may not be achieved after surgery ^[18]. Goss ^[1] suggests tension band technique and reports good results. Hill ^[5] applied plate to all acromion fractures in a study carried out with 13 patients and reported that they removed only one plate due to implant irritation. In a recent study that Zhu ^[14] evaluated an acromion pedicle fracture, he analyzed perpendicular double-plate with a locking system and reported good results. In our study, we chose cannulated screw because the fracture was on the lateral side of acromion and it was not comminuted. We showed that compression with a good reduction and screw can make the fracture healing complete successfully. It is important to avoid screw penetration into subacromial space during fixation.

In acromion fractures, implant failure can be seen after fixation with K-wire. Irritation and infection can be seen after fixation with plate screw ^[5]. Zhu ^[14] reports temporary suprascapular nerve entrapment on patients with double-plate. In our case, we didn’t encounter any intraoperative and postoperative complication.

Early surgical intervention to the patient can have a positive effect on fracture healing. Kim et al. ^[16] compared early and late treated acromion fractures and found out that while all the early surgically treated patients came back to their pre-fracture activities, the rate for late treated patients is 44%. On his study, Hill ^[5] showed that late treated patients can also get back to their work just as early treated patients do and reported that their shoulder scores are good. In our case, patient with polytrauma got back to his work 8 weeks after surgery and gained his preoperative activities 12 weeks after surgery.

Patient with shoulder trauma should be carefully examined for acromion fractures. Acromion fracture can be treated with good results with early surgical treatment and proper fixation. Surgical treatment is important to regain shoulder functions, as it enables early rehabilitation of treatment. Cannulated screw is enough and reliable for fixation. We recommend early surgical treatment for acromion fractures that reduce subacromial space and disrupt superior suspensory shoulder complex.

The authors declare that they have no conflicts of interest.

No funding source.

Not applicable.

Patient consent was obtained.

An informed consent has been obtained.

Özgür Çiçekli: contributed to surgery, data collection and writing of paper.

Abdulhalim Akar: contributed to data collection.

Hüseyin Nevzat Topçu: contributed to data collection and writing.

Özgür Çiçekli.

1. Goss T.P. The scapula: coracoid, acromial, and avulsion fractures. Am. J. Ortho. (Belle Mead N. J.) 1996;25:106–115. [PubMed] [Google Scholar]

2. Lantry J.M., Roberts C.S., Giannoudis P.V. Operative treatment of scapular fractures: a systematic review. Injury. 2008;39:271–283. [PubMed] [Google Scholar]

3. Crosby L.A., Hamilton A., Twiss T. Scapula fractures after reverse total shoulder arthroplasty: classification and treatment. Clin. Orthop. Relat. Res. 2011;469:2544–2549. [PMC free article] [PubMed] [Google Scholar]

4. Mulawka B., Jacobson A.R., Schroder L.K., Cole P.A. Triple and quadruple disruptions of the superior shoulder suspensory complex. J. Orthop. Trauma. 2015;29(June (6)):264–270. [PubMed] [Google Scholar]

5. Hill B. W., Anavian J., Jacobson A.R., Cole P.A. Surgical management of isolated acromion fractures: technical tricks and clinical experience. J. Orthop. Trauma. 2014;28(May (5)):e107–e113. [PubMed] [Google Scholar]

6. Agha R.A., Fowler A.J., Saetta A., Barai I., Rajmohan S., Orgill D.P. SCARE Steering Group. A protocol for the development of reporting criteria for surgical case reports: The SCARE statement. Int. J. Surg. 2016;27(March):187–189. [PubMed] [Google Scholar]

7. Lee C.H., Choi Y.A., Lee S.U. Ultrasonographic diagnosis of non-displaced avulsion fracture of the acromion: a case report. Ann. Rehabil. Med. 2015;39(June (3)):473–476. [PMC free article] [PubMed] [Google Scholar]

8. Dubrow S., Streit J.J., Muh S., Shishani Y., Gobezie R. Acromial stress fractures: correlation with acromioclavicular osteoarthritis and acromiohumeral distance. Orthopedics. 2014;37(December (12)):e1074–9. [PubMed] [Google Scholar]

9. Ogawa K., Naniwa T. Fractures of the acromion and the lateral scapular spine. J. Shoulder Elbow Surg. 1997;6:544–548. [PubMed] [Google Scholar]

10. Kuhn J.E., Blasier R.B., Carpenter J.E. Fractures of the acromion process: a proposed classification system. J. Orthop. Trauma. 1994;8:6–13. [PubMed] [Google Scholar]

11. Marsh J.L., Slongo T.F., Agel J. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J. Orthop. Trauma. 2007;21:S1–S133. [PubMed] [Google Scholar]

12. Mehdi Nasab S.A. Isolated displaced fracture of the acromion: a rare case report and the consequence of treatment by open reduction and pin fixation. Arch Trauma Res. 2013;1(Winter (4)):184–186. [PMC free article] [PubMed] [Google Scholar]

13. Peckett W.R., Gunther S.B., Harper G.D., Hughes J.S., Sonnabend D.H. Internal fixation of symptomatic os acromiale: a series of twenty-six cases. J. Shoulder Elbow Surg. 2004;13(4):381–385. [PubMed] [Google Scholar]

14. Zhu J., Pan Z., Zheng R., Lan S. Le Perpendicular double-plate fixation with locking system for acromion pedicle fracture. Acta Ortop Bras. 2016;24(March-April (2)):107–110. [PMC free article] [PubMed] [Google Scholar]

15. Rouleau D.M., Gaudelli C. Successful treatment of fractures of the base of the acromion after reverse shoulder arthroplasty: case report and review of the literature. Int J Shoulder Surg. 2013;7(October (4)):149–152. [PMC free article] [PubMed] [Google Scholar]

16. Kim D.S., Yoon Y.S., Kang D.H. Comparison of early fixation and delayed reconstruction after displacement in previously nondisplaced acromion fractures. Orthopedics. 2010;33:392. [PubMed] [Google Scholar]

17. Mardy A., Mechchat A., El Ghazi A., El Idrissi M., Shimi M., El Ibrahimi A., El Mrini A. Open fracture of the acromion associated with a supraspinatus tendon rupture: an exceptional case report. Pan Afr. Med. J. 2014;26(November (19)):325. [PMC free article] [PubMed] [Google Scholar]

18. Bauer G., Fleischmann W. , Dussler E. Displaced scapular fractures: indication and long-term results of open reduction and internal fixation. Arch. Orthop. Trauma Surg. 1995;114:215–219. [PubMed] [Google Scholar]

Nonoperative treatment for Body and processes, acromion

1. Phase 1: injury to the end of week 3 after injury (inflammatory phase)

Phase 1 principle: protection of the injured (operated) limb to facilitate uneventful healing.

Phase 1 aim: healing without complications while facilitating early movement.

External support – full time

Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest. Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the arm’s weight. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath that wraps around the humerus and the chest to restrict further shoulder motion and keep the arm securely in the sling.

Commercially available devices provide similar immobilization, with or without the circumferential support of a swath.

Abduction brace

In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or an abduction cushion, as shown in this diagram.

Mobilization of the upper extremity for general indications

It is essential to maintain optimal mobility of the unaffected joints to reduce arm swelling by encouraging venous return and lymphatic drainage. Active mobilization of the unaffected joints promotes the preservation of the proprioception and therefore promotes optimal joint motion.

The following exercises are recommended.

• Opening and closure of the hand
• Squeezing of a soft ball

• Bending of the wrist forward, backwards and in a circular motion.
• Movement of an open hand from side to side

• Straightening and bending of the elbow

• Squeezing the shoulder blades together while the shoulders remain relaxed
• Gentle side-to-side, forward-and-backward, and rotational movements of the neck

Mobilization of ipsilateral limb kinetic chain with no active motion of clavicle-scapula

Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not progressing satisfactorily.

Active assisted range of motion exercises are started with gravity eliminated and as comfort permits:

• External rotation at waist level
• Internal rotation at waist level
• Forward flexion without scapular protraction with the forearm supported by the table (illustrated)

• Isometric strengthening of the rotator cuff and deltoid as comfort permits

X-rays should be checked to rule out secondary fracture displacement if unexpected pain occurs.

Activities of daily living

At this stage, activities of daily living are limited to those needed to do personal care.

The patient is encouraged to use the ipsilateral hand for midline personal care activities (eg eating and toileting).

Care should be taken when motions approach extremes of range, and taking the hand behind the back may not be safe until fracture union has been confirmed (by radiographs and the absence of fracture-site pain).

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and shoulder.

Some patients may find it more comfortable to sleep in a sitting or semireclined position.

A pillow can be placed across the chest to support the injured side when sleeping on the side.

Hygiene

A non-slip mat in the shower/bathtub will improve safety. The arm can hang gently at the patient’s side while showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.

2. Phase 2: Beginning of week 4 to end of week 6 after injury (early repair phase)

Phase 2 principle: continued protection of the injured (operated) limb with the promotion of directed tissue repair.

Phase 2 aim: established healing of injured tissues with antigravity strength

External support – full time weaning to part-time or no support

Simple sling and abduction brace are used at night and for all activities when gravity is applied, both indoors and outdoors.

Pillows may support the limb while seated at rest or when performing exercises.

Mobilization for general indications

Phase 1 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with active motion of clavicle-scapula

All the exercises from Phase 1 can be continued.

Actively assisted elevation to shoulder level can be introduced.

Note: Avoid hand behind back and extreme across body adduction at this stage. This avoids adverse rotation of the clavicle and scapula.

Activities of daily living

All activities permitted in phase 1 are continued.

Activities for domestic purposes at the tabletop level are encouraged (eg short lever arm reaching and food preparation)

Radiographic control

Radiographic evidence of fracture union is expected at this time. Confirmation of union with a concurrent reduction in symptoms permits progression to phase 3.

3. Phase 3: Beginning of week 7 to end of week 12 after injury (late repair and early tissue remodeling phase)

Phase 3 principle: reestablishment of proprioception in the limb.

Phase 3 aim: encourage normal tissue structure and reinnervation through daily activities without secondary injury.

External support – weaning from full time to no support

A sling may be preferred for support at night and outdoor activities.

Mobilization for general indications

Phase 2 exercises are continued.

Mobilization of ipsilateral limb kinetic chain with motion of the clavicle-scapula

All the exercises from Phase 1 can be continued.

Actively assisted elevation above shoulder level can be introduced.

Note: Hand behind the back and across body adduction is permitted at this stage. This facilitates rotation of the clavicle and scapula.

Isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles are permitted.

A “shoulder therapy set” might be helpful. Typically included devices are:

An exercise bar lets the patient use the uninjured left shoulder to passively move the affected right side.

Rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to provide full passive forward flexion of the injured right shoulder.

As passive motion improves and active assisted exercises progress satisfactorily and the fracture becomes fully consolidated, one can begin strengthening. The first one strengthens by active motion against gravity. To increase muscle strength, one must increase the resistance against which the muscles work. Endurance training follows.

Elastic devices (therabands) are helpful in providing varying degrees of resistance. Ultimately the athletic patient can progress to resistance machines and free weights.

Activities of daily living

All activities permitted in phase 2 are continued with the addition of social activities, active elevation, and abduction of the injured limb as comfort permits.

Radiographic control

Radiographic evidence of fracture consolidation is expected at this time. Confirmation of consolidation without adverse features (eg displacement, fixation failure, or heterotopic bone) in the absence of symptoms permits progression to phase 4.

4. Phase 4: Beginning of week 13 after injury (remodeling and reintegration phase)

Phase 4 principle: normalization of the proprioceptive function with optimal biomechanics

Phase 4 aim: to establish normal tissue structure and reinnervation through training and practice for optimal endurance.

Mobilization of ipsilateral limb kinetic chain with no limits of movement

Sport or occupational work hardening exercises are introduced under supervision.

Activities of daily living

All activities, including sport and occupational activities requiring resisted elevation and abduction, is encouraged.

Rehabilitation after injuries of the acromioclavicular joint company blog

More about rehabilitation. Methods and terms of recovery.

Acromioclavicular joint joint is a flat joint with meniscoid tissue in its cavity, which serves as a biological shock absorber from loads transmitted from the upper limb. Often, due to the performance of its biomechanical functions, this joint is subjected to various injuries.

The main symptoms of rupture of the acromioclavicular joint are:

• pain in the shoulder area, without irradiation;
• limitation of mobility in the shoulder joint, its abduction is difficult;
• a sharp decrease in tone in the damaged upper limb;
• when pressing on the collarbone, the “piano key symptom” is positive;
• visual deformities in the area of ​​the shoulder joint.

Degrees of pain in case of damage to the acromioclavicular joint:

I degree – pain is insignificant, tolerable, swelling and hematoma are not visually determined. Movements persist, but cause pain. Such symptoms are characteristic of a partial rupture of the ligaments of the joint.

II degree – severe pain, tissue swelling and hematoma are noticeable. Movement is severely limited. In this case, most of the ligamentous apparatus is damaged.

III degree – severe pain in the shoulder, impossibility of movement, swelling, hematoma. Not only ligaments are involved in the process, but also neighboring tissues: joint capsule, muscles.

Make an appointment with a traumatologist-orthopedist Ondar Temir Evgenievich and get an effective rehabilitation program :

Rehabilitation: Description

It should be noted that since this injury often occurs as a result of social and domestic injuries, the rehabilitation of a rupture of the acromioclavicular joint is relevant for young patients of working age. Diagnosis of damage to the acromioclavicular joint is made by an orthopedic traumatologist during the collection of anamnesis, subjective and objective examination data. In case of disputed cases, in addition to radiography, a tomographic examination is performed.

Terms of rehabilitation

The rehabilitation period is on average 1–2 months, depending on the technique of the operation performed. If a plate was installed, then it takes 1-1.5 months to restore the range of motion from the joint, and up to 1 month of rehabilitation after removing the plate.

Why is rehabilitation needed?

If the acromioclavicular joint is not restored, then a number of undesirable consequences arise, such as shoulder displacement downward, a cosmetic defect in the form of the clavicle protruding upward under the skin, a decrease in muscle strength, a crunch when moving, and, worst of all, the development of arthrosis of this joint with the formation of osteophyte spikes leading to impingement syndrome and degenerative rupture of the rotator cuff.

Taking into account the anatomical features of the acromioclavicular joint, some difficulties in rehabilitation, and possible associated injuries of neighboring anatomical structures, the doctor’s task should always include additional instrumental research, especially when being in a specialized hospital. Rehabilitation takes a short period of time, and even in elderly patients, but such short-term courses make it possible to avoid many consequences that often require repeated hospitalization in a hospital.

Sports and rehabilitation center “New Step” offers modern and effective methods of recovery after damage to the acromioclavicular joint. Reception is conducted by experienced specialists who develop an individual rehabilitation program and accompany patients at each stage of the study.

You can sign up for a consultation by phone +7 (495) 477-55-40 or through online feedback form .

Sports and rehabilitation center “New Step”:

Our main goal is to bring back the joy of an active life to you!

Dislocations of the acromial, sternal ends of the clavicle – symptoms of trauma, first aid and treatment, rehabilitation – Department of Traumatology NCC No. 2 (CCH RAS)

Clavicle is a curved S-shaped bone, consisting of the body and having two ends with articular surfaces – acromial (external) and sternum (internal). Together with the scapula, it forms the girdle of the upper limbs. The clavicle is the only bone that connects the trunk (axial skeleton) to the upper limb. Due to the fact that the clavicle is involved in the formation of two joints (sternoclavicular and acromioclavicular), there are two types of dislocations: the sternal end of the clavicle and the acromial end of the clavicle. Most often, dislocations of the acromial end occur, dislocations of the sternal end of the clavicle are much less common. Dislocation of the scapular (acromial) end can be complete or incomplete (depending on which ligament is torn). Dislocation of the sternal end is subdivided into suprasternal, presternal and retrosternal (depending on the trajectory of the clavicle displacement).

Causes of injury.

Most often, a dislocation occurs as a result of an injury – a fall on a straight abducted arm, on the shoulder and elbow joints (indirect mechanism of injury) or a direct blow to the clavicle area with a heavy object (direct mechanism). And also dislocations can occur as a result of various injuries received in an accident.

Signs of dislocation.

• Moderate limited pain at the site of injury
• Deformity at the site of injury (due to protrusion of the outer end of the bone)
• Puffiness
• Painful palpation
• Restriction and pain when moving the arm
• “Symptom of the key” – a sure sign of a rupture of the acromioclavicular junction.

Diagnostics.

Specialists to contact for advice:

• Trauma Consultation
• Surgeon’s consultation

Treatment.

For the treatment of dislocations of the clavicle, two methods are used: conservative and surgical intervention. A conservative treatment method is used to reduce dislocations of the acromial end of the clavicle in a closed way using anesthesia. Then the specialist fixes the reduced clavicle with a plaster cast, special splints with constant pressure and support (orthopedic pads). With a complete dislocation and rupture of the ligaments, urgent surgical treatment is required.