A dual injury of the shoulder: acromioclavicular joint dislocation (type IV) coupled with ipsilateral mid-shaft clavicle fracture

Abstract

A direct blow to the shoulder, as may be sustained in a road traffic accident (RTA), can result in various combinations of fracture dislocations in the shoulder joint complex. Among these, a rare variety is an acromioclavicular joint (ACJ) dislocation coupled with ipsilateral mid-shaft clavicle fracture. Diverse treatment options have been described in the literature, ranging from non-operative and operative, to hybrid management. Treatment for this complex injury is predominantly dictated by the type of dislocation and displacement of the clavicle fracture, as well as age and demand of the patient. Acute high grades of ACJ dislocation require restoration of the coracoclavicular relationship (in place of torn coracoclavicular (CC) ligament) by some form of internal fixation, thereby maintaining the ACJ reduction. An arthroscopic reinstatement of the coracoclavicular relationship using a dog bone button and fibre tape implant for this composite injury pattern has not been previously described. Furthermore, a comprehensive review of the literature associated with this injury pattern is briefly described.

Ipsilateral midshaft clavicle fracture and acromioclavicular joint dislocation: a review of literature and evidence-based diagnosis guidelines

“…23 cases were reported in the case reports. There are 20 cases with the preoperative X-ray, and one case of the X-ray 9 reported by LANCOURT in 1990 was blurry and could not be used to con rm the classi cation. Thus, a total of 19 cases X-rays were adopted.…”

Monopolar and Bipolar Combination Injuries of the Clavicle: Retrospective Incidence Analysis and Proposal of a New Classification System

“…As already published in case reports, when diagnosing a suspected mono-injury of the shoulder girdle, there is a risk of overlooking (or misinterpreting/misdiagnosing) further trauma consequences in this area [5,9,12,13,16,18]. It is often assumed that the trauma impact only develops its full force at one point and causes one single injury since the exact mechanism that is responsible for a combination of clavicle injuries is still unknown [3,39].…”

“…Type II(b) injuries are the least observed CCI but are accompanied by a clear therapy recommendation due to the presence of a maximum version of the floating(-like) clavicle [9,51]. Whether a bipolar surgical repair via TightRope should be performed or whether an alternative therapy method should be chosen for one of the clavicle poles (such as a combination of TightRope at SCJ and hook plate at ACJ) remains to be discussed [2,12,51,[57][58][59]. At minimum, a bipolar rigid restoration can have consequences in the event of renewed trauma, even if it is only slight, since this mechanical conduction causes stress due to the lack of elasticity and creates a predetermined breaking point at the clavicle [9].…”

“…It is a widespread assumption that a ligament disruption and fracture do not occur in the same case, since, either a fracture occurs, or the force disrupts the joint and ruptures ligaments [3,9,11]. While the CCI is usually detected at least at one end or occurs as a single injury, due to the rarity of the combined injury, a coincident injury at the clavicle is often not expected [3,9,[11][12][13]. Therefore, the risk of missed injuries with this entity has proven to be particularly high, and a high number of unreported cases can be assumed [12,[14][15][16][17][18][19].…”

“…While the CCI is usually detected at least at one end or occurs as a single injury, due to the rarity of the combined injury, a coincident injury at the clavicle is often not expected [3,9,[11][12][13]. Therefore, the risk of missed injuries with this entity has proven to be particularly high, and a high number of unreported cases can be assumed [12,[14][15][16][17][18][19]. A combination injury diagnosed secondarily, however, can have serious consequences in the short-term with prolonged pain and restricted mobility, and in the long-term with post-traumatic joint arthritis, which is highly likely in the event of complete instability [15][16][17]20].…”