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Aspects of Current Management: J. A. Fraser-Moodie, N. L. Shortt, and C. M. Robinson Injuries to the acromioclavicular joint J Bone Joint Surg Br 2008; 90-B: 697-707 [Abstract] [Full text] [PDF]

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Authors' reply:

James A Fraser-Moodie, C M Robinson   (7 August 2008)

Missed Grade IV AC Joint Dislocation

Ziad Harb, Koushik Ghosh and Quamar Bismil   (30 July 2008)

Authors' reply: 7 August 2008
James A Fraser-Moodie, Orthopaedic Registrar Edinburgh Shoulder Clinic, Royal Infirmary of Edinburgh, C M Robinson Send letter to journal: Re: Authors' reply: jamesfrasermoodie{at}hotmail.com James A Fraser-Moodie, et al.	Sir, We thank Messers Harb et al for their letter highlighting the potential for a missed type IV acromioclavicular joint injury, supported by the cited case report. We would agree that a better understanding of these injuries should help ensure a timely diagnosis and appropriate management. The case report describes how difficulties in making a diagnosis may arise if soft tissue swelling prevents posterior distal clavicle displacement being apparent initially. Difficulties may also arise if poor familiarity with, or failure to closely scrutinise, the standard AP radiograph causes a more subtle abnormality to be missed, and if stress radiographs are relied upon to reveal significant instability at the joint. We described a systematic approach to the assessment and management of these injuries, and in particular we stated that an orthogonal view (in addition to the plain AP radiograph) is required to assess anteroposterior translation. In the case concerned a second view would almost certainly have clearly demonstrated the abnormality, and only in the event that adequate plain radiographs could not be obtained would further imaging be appropriate. We also addressed the application of stress radiographs, concluding that a selective use is appropriate. This case confirms again the potential failings of stress radiographs used in the initial assessment process, as they clearly added nothing to the diagnosis or management, despite a significantly displaced dislocation, presumably as the distal clavicle was trapped in the trapezius muscle and not able to displace. J. Fraser-Moodie, Orthopaedic Registrar, C.M. Robinson, Edinburgh Shoulder Clinic, Royal Infirmary of Edinburgh, Edinburgh, UK.
Missed Grade IV AC Joint Dislocation 30 July 2008
Ziad Harb, Senior House Officer in Trauma & Orthopaedics St George's Hospital, London, Koushik Ghosh and Quamar Bismil Send letter to journal: Re: Missed Grade IV AC Joint Dislocation ziadharb{at}doctors.net.uk Ziad Harb, et al.	Sir, We read with interest the article by Fraser-Moodie et al. We would like to commend the authors on a very well-written and useful overview of acromioclavicular joint dislocation. The authors allude to, but do not specifically emphasise, the potential pitfalls of grade IV dislocation. In such injuries the displacement may be purely in the sagittal plane, and hence missed on the AP and stress radiographs. Clinical reassessment at an interval and additional radiology (oblique radiograph, MRI scan) should be considered for such cases.1 Z. Harb, MBBS, MRCS Eng, Senior House Officer in Trauma & Orthopaedics, K. Ghosh, Q. Bismil, St George's Hospital, London, UK. 1. Lee A, Bismil Q, Allom R, Pike J. Missed type IV AC joint dislocation: A case report. Injury Extra 2006;37:283-5. http://www.sciencedirect.com (accessed 30/07/08).