CASE REPORT

Conservatively treated acromioclavicular jointdislocation: a 45-years follow-up

R.K. Soni

Bedford Hospital, Kempston Road, Bedford MK42 90J, UK

Accepted 1 September 2003

Introduction

Surgery for acromioclavicular joint (AC) dislocationhas been advocated since the pre-antiseptic era,4

however the best primary treatment of acromiocla-vicular dislocation is still unclear. Recently variousauthors have questioned the value of an operation.The need for early reduction and fixation of ACdislocation is cosmetic.11 Furthermore, ‘‘it mustbe remembered that a patient with a poor anato-mical result may have no symptoms, whereas ana-tomical restoration of the joint does not alwaysrelieve symptoms’’.1 More recently, a systemicanalysis of the literature has shown that conserva-tive treatment appears to be the method of choicefor third degree AC dislocation.3 The only indicationfor acute reconstruction is when the lateral end ofthe clavicle is so displaced that it tents the skin andmay compromise skin viability. The longest follow-up results after conservative treatment for acutedislocation is 14 years.12 This report describes acase with a complete dislocation of the AC joint45 years after the injury.

Case report

A 76-year-old right hand dominant man sustaineddislocation of the right acromioclavicular joint inAugust 1955 following a road traffic accident (RTA).He had no other associated injuries. The dislocatedright AC joint was treated with Elastoplast strapping

to support the arm and depress the clavicle for 6weeks. This was removed after 6 weeks, and aprogramme of physiotherapy was recommended.He returned to work as a telecommunication engi-neer 3 weeks after the removal of the shoulderstrapping and worked as normal until retirementin 1982, which was not related to his right shoulderinjury in any way. The patient returned to fullactivities including the resumption of his usualsports including rugby, tennis and golf 5 monthsafter the accident. His shoulder remained entirelyasymptomatic for the next 43 years.

He then developed some pain and stiffness in theright shoulder. The pain was localized over thedeltoid region and was diffuse and aching in char-acter but it did not preclude him from pursuing hisusual leisure activities such as golf, nor did it inter-fere with daily activities such as dressing, undres-sing, combing hair, shaving and feeding. Herequired no analgesics, and rated the intensity ofhis pain as 3 out of 10. He had some stiffness andexertional weakness in the shoulder, but this did notgive rise to any functional disability except forlimitation in overhead use of his right arm.

There was prominence of the distal end of theclavicle but no other abnormality on examination.Active and passive glenohumeral motion was lim-ited to 908 of elevation in the plane of the scapula,208 of external rotation with arm at the side andinternal rotation to posterior superior iliac spine.Muscle strength was normal. Forced crossed armadduction in the 908 forward flexed position did notproduce pain in the AC joint. There was no evidenceof associated instability or rotator cuff insufficiencybased on history and physical examination. Neuro-

Injury, Int. J. Care Injured (2004) 35, 548—550

E-mail address: r121253@hotmail.com (R.K. Soni).

0020–1383/$ — see front matter � 2003 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2003.09.007

vascular examination of the right upper extremitywas normal.

Radiographs revealed ossification of the coraco-clavicular ligament (CC ligament) with completebridging between the coracoid process and theclavicle. There is also bridging in the line ofthe trapezoid and conoid ligament. There isexpansion of the lateral end of the clavicle withnew bone formation on the inferior aspect and itlies high (Fig. 1). The coracoclavicular distance

was not altered in the stress view of the AC joint(Fig. 2).

Discussion

Treatment of the dislocated A C joint is controver-sial. Both surgical and non-surgical methods havebeen found to yield comparable results, regardlessof the technique employed. Maintenance of an

Figure 1 Follow-up radiograph (zanca view of right AC joint) showing ossification of the coraco-clavicular ligamentwith complete bridging between the coracoid process and the clavicle. There is bridging in the line of the trapezoid andconoid ligament. There is expansion of the lateral end of the clavicle with new bone formation on the inferior aspectand it lies high.

Figure 2 Stress view of the AC joint. The coraco-clavicular distance is not altered.

Conservatively treated acromioclavicular joint dislocation: a 45-years follow-up 549

anatomical reduction is not necessary for adequatefunction of the shoulder.6,15 The anatomical gainsof surgery are small; as some loss of reductionvarying from 20 to 40% follows all operations.8,14

Furthermore, surgery not only fails to improve onthe results of conservative treatment but alsoexposes the patient to possible complications.6

The results of conservative treatment in 30 patientsover an average of 12.5 years follow-up revealedthat all but one had a good outcome.12

Approximately half of the patients managed con-servatively experience spontaneous improvementin joint position,5 and if conservative treatmentresults in persistent dislocation, this is consideredcompatible with perfect function.11

Ossification in the region of the torn CC ligamenthas been reported following AC joint dislocationtreated surgically or non surgically and may appearas early as the third week.10,17,18 The incidence ofossification of the coracoclavicular interval rangesfrom 50 to 80%.7 It is higher following operativemanagement.2 The major CC ligament ossificationfollowing conservative treatment with follow-upbetween 4 and 5 years is reported to be 23%.5 Thisincreased to 31% with follow-up at greater than 12years in the same group of patients.12 Therefore itappears that the incidence of CC ligament ossifica-tion increases with longer duration of follow-up.

The relevance of the ossification of the CC liga-ment is controversial. Some consider it to be part ofthe normal repair process,13 whilst others regard itas undesirable.2 Some even consider it to be irre-levant to clinical outcome.16 The radiologicalappearance of this particular case however, showsthat major ossification in the region of CC ligamentmust create an extra-articular acromioclaviculararthrodesis. This provides the same effect as cor-acoclavicular screw fixation in stabilising the lateralend of the clavicle.

Ossification of the coracoclavicular interval is notonly a consummation devoutly to be wished, butalso one positively to be contrived. Some, in fact,sprinkle of bone dust in the coracoclavicular regionduring the operation to encourage ossification.9

This case demonstrates the normal healing pro-cess and probably the natural history of the injuryfollowing conservative treatment.

References

1. Allman Jr FL. Fractures and ligamentous injuries of theclavicle and its articulation. J Bone Joint Surg (Am) 1967;49A:774—84.

2. Banister G. The management of complete acromioclaviculardislocation, M.Ch. Orth. thesis, University of Liverpool;1983. p. 48.

3. Bathes H, Tingart M, Bouillon B, Tiling T. Conservativeor surgical therapy of acromioclavicular joint injury–—whatis reliable? A systematic analysis of the literature using‘‘evidence-based medicine’’ criteria. Chirurg 2000;71(9):1082—9 (in German).

4. Cooper ES. New method of treating longstanding dislocationof the scapuloclavicular articulation. Am J Med Sci 1861;41:389.

5. Dias JJ, Steingold RF, Richardson RA, Tesfayohannes B,Gregg PJ. The conservative treatment of acromioclaviculardislocation: review after five years. J Bone Joint Surg (Br)1987;69:719—22.

6. Ejeskar A. Coracoclavicular wiring for acromioclavicularjoint dislocation: a ten-year follow-up study. Acta OrthopScand 1974;45:652—61.

7. Glick JM, Milburn LJ, Haggerty JF, Nishimoto D. Dislocatedacromioclavicular joint: follow-up study of 35 unreducedacromioclavicular dislocation. Am J Sports Med 1977;5:264—70.

8. Guttmann D, Paksima NE, Zuckerman JD. Complications oftreatment of complete acromioclavicular joint dislocations.AAOS Instructional Course Lectures 2000;49:407—13.

9. Kato F, Hayashi H, Miyazaki T, et al. Treatment of acutecomplete dislocation of the acromioclavicular joint. In:Bateman JE, Welsh RP, editors. Surgery of the shoulder.Philadelphia: BC Decker Inc.; 1984. p. 679.

10. Kennedy JC, Cameron H. Complete dislocation of theacromioclavicular joint. J Bone Joint Surg 1954;36B(2):202—8.

11. Milbourn E. On injuries to the acromioclavicular joint,treatment and results. Acta Orthop Scand 1950;19:349—82.

12. Nicol EA. Miners and mannequins. J Bone Joint Surg1954;36B:171.

13. Pekka P, Jan-Magnus B, Pertti P, Par S. Surgical treatmentof acromioclavicular dislocation: a review of 39 patients.Injury 1983;14:415—20.

14. Rawes ML, Dias JJ. Long term results of conservativetreatment for acromioclavicular dislocation. J Bone JointSurg 1996;78B(3):410—2.

15. Smith MJ, Stewart MJ. Acute acromio-clavicular separa-tions. A 20 years study. Am J Sports Med 1979;7(1):62—71.

16. Taft TN, Wilson FC, Oglesby JW. Dislocation of theacromioclavicular joint. J Bone Joint Surg 1987;69A:1045.

17. Warren-Smith CD, Ward MW. Operation for acromioclavi-cular dislocation. J Bone Joint Surg 1987;69B:715—8.

18. Weitzman G. Treatment of acute acromioclavicular jointdislocation by a modified Bosworth method Report ontwenty-four cases. J Bone Joint Surg 1967;49A:1167—78.

550 R.K. Soni