ACROMIOCLAVICULAR JOINT INJURY

This is a radiograph of a patient brought to the emergency department after being knocked off his bicycle in a low-velocity road traffic accident. He complained of pain and deformity around the shoulder.

1. Describe the appearances in this radiograph.

This is a plain radiograph of the left shoulder and the obvious abnormality is an increase in the acromioclavicular joint space and malalignment of the distal clavicle with the acromion representing a dislocation of the acromioclavicular joint.

2. In your clinical assessment of this patient, what associated injuries might you specifically look for?

Having completed an assessment of the patient along ATLS guidelines and estab- lished that this is truly an isolated injury I would pay close attention to the condi- tion of the soft tissues, looking for signs of any open wound and any suggestion that the overlying skin may be degloved, puckered or under tension. I would conduct a careful neurovascular assessment to identify any deficit. These injuries can be asso- ciated with brachial plexus injuries, although these are not common. I would look carefully for clinical or radiographic signs of associated fractures of the clavicle, acromion, coracoid or scapula.

3. Assuming that this is an isolated injury, how would you manage this patient definitively?

There is demonstrable widening of the acromioclavicular joint space with the distal clavicle shown to lie superior to the superior border of the acromion and a marked increase in the coraco-clavicular distance. In the Rockwood system of classification this is a type V injury and I would offer surgery. Options include surgical coraco- clavicular ligament repair, LARS reconstruction, clavicle hook plate fixation or a modified Weaver–Dunn procedure. My preference would be to perform a modi- fied Weaver–Dunn procedure through a bra-strap incision. The distal end of the clavicle is excised before reducing the clavicle into position and transferring the