A 12-year-old male patient was admitted to the clinic due to mild pain on anterior aspect of his right shoulder with mild limitation in active motion. Medical history of the patient was uneventful except falling to right side while playing football three days before admission. He recalled hitting the lateral aspect of his right shoulder to the ground and crepitation which occurred for once while self- examining shoulder motion in the direction of forward flexion. The patient had been admitted to the emergency department of a hospital on the same day of injury and informed to have soft tissue injury. Analgesic medication without any external support was given. A written informed consent was obtained from the legal guardian of the patient.
No unusual finding could be identified on inspection. Mild-to-moderate pain could be elicited with palpation on the coracoid process. Crepitus was not identified upon palpation as well as during active and passive shoulder motion. The range of forward flexion, extension, abduction, adduction, external rotation and internal rotation were 0-170, 0-20, 0-160, 0-40, 0-20 and 0-90 degrees on the right shoulder, respectively, while the range of forward flexion, extension, abduction, adduction, external and internal rotations were 0-180, 0-50, 0-170, 0-60, 0-40 and 0-90 degrees on the left shoulder, respectively. The patient mentioned mild aggravation of pain during active motion of the right shoulder. Active elbow flexion- extension was within the range of 0-150 degrees for both sides. Neurological evaluation was normal. Bilateral shoulder radiographs did not demonstrate any apparent finding of pathology. With respect to history of previous trauma, computed tomography (CT) images were obtained and revealed isolated coracoid mid-process fracture (Eyres type 2) with considerable anteroinferior displacement of the distal fragment (Figure 1). Conservative management including Velpeau sling use and analgesic medication were opted for the patient.
Physical and radiologic examinations were performed on each outpatient follow-up visit. The patient reported significant relief with Velpeau sling use two weeks after admission. At the end of fourth week, he was almost pain-free during rest as well as active and passive shoulder motion. The follow-up CT examination, obtained at the end of fourth week, confirmed significant callus formation (Figure 2). With respect to callus formation and vanished symptoms, Velpeau sling was discontinued and active shoulder motions were allowed with restrictions from weightlifting for four weeks. Physical examinations and plain radiographs could not identify any remarkable finding during follow-up. Until he fell to his right side from a couch at 11th month of follow-up, the patient was symptom-free in daily activities including weightlifting and sport activities. Upon this incident, he reported pain and limitation in the right shoulder motion. No additional finding could be detected on examination. Radiologic examination including CT, which proved complete osseous union with disappearance of coracoid fracture line, did not reveal any pathologic finding (Figure 3). The patient was completely symptom-free on the last visit which was 14 months after the diagnosis of fracture and the Disabilities of the Arm, Shoulder and Hand score was 0.