COMPLETE
DISLOCATION
J0HN
OF
tiid
IENNE1)V
(.
I-re,,,
(‘omplete
of the
dislocation
literature
identically
treated
In
the
complete
of
to
four
coraco-clavicular
conclusions
fixation.
about
course
of our
clavicular
the
the
in
also
all
we
this
patients,
have
and
in
a common
more
end-results
uncertain.
been
series
operative
technique
considered
afresh
recalled
at
complete
twenty-five
cases
identically
been
arrived
were
A review
than
twenty-seven
treated
recently
have
injury.
numbering
encountering
have
have
study
remain
mechanism
blow
medially.
muscle,
prevents
of injury
to
\Ve
just
can
1)efore
by
for
of
the
use
clinical
preliminary
and
but
definite
of the
acromio-
dislocations.
and
the
early
exact
There
are
neglect,”
many
only
was
either
conclude
end-results.
function
In
the
inherent
protective
shoulder
a more
METHODS
OF
of
acromio-clavicular
of
on
it is
helped
medially.
the
it, with
twenty-three
right
forms
driven
fall
driving
that
joint
which,
only
So long
as
displacement.
a direct
variations
treating
acromio-clavicular
mechanism
being
gross
that
the
various
key
from
tackle,
dislocations
anatomical
render
methods
through
cases
of the
the
suffer
as in a football
any
injury
scapula
cannot
complete
discover
form
the
joint
in all
acromion
anatom
ligaments
the
intact,
on the
the
trapezoid
Of twenty-seven
unable
patient
injurzes-In
and
anterior
vulnerable.
202
conoid
serratus
The
open
of
we
1);
patients
this
inclllded
selection
ligaments
or a direct
“studied
injuries
investigations
that
been
the
varied,
fortunate
(Fig.
These
From
of acromio-claz’,cular
noted
and
been
is not
series
joint.
A natomv
these
is indeed
have
CANADA
Ontario
joint
followed
dislocation
All
by
we
examination.
lI’estern
of
a carefully
Treatment
years
acromio-clavicular
radiological
Lnizersulv
JOINT
LONDON,
CAMERON,
acromio-clavicular
disclose
cases.
past
ACROMIO-CLAVICULAR
HOWARI)
1/u’
of the
fails
THE
point
the
were
make
acromion
downwards
right-sided.
the
right
mechanisms
susceptible
of the
scapula,
We
shoulder
exhibited
have
more
by
the
target.
TREATMENT
conservative
these
dislocation;
management,
range
to
some
AND
JOINT
from
form
operation.
THE
JOURNAL
OF
BONE
SURGERY
of
COMPLETE
It must
with
be admitted
an ear, nose
acromio-clavicular
dislocation
there is not
and
throat
joint
with
An analysis
patients
pain,
crepitus
literature
of
torn
with
of
or fascia
is
by
carried
these
reconstruction
as described
as proposed
out
the
conoid
(1928),
have
wires
and
we
observed
that
shoulder
such
for
correction
across
the
have
after
they
untreated
complete
disappeared,
subluxation
mechanism
of the
particularly
experience
true in the
of Kirschner
final degrees
of abduction.
wires cutting
through
the
removal
give
capsule
as
recommended
by
end
steel
of the
results
if the
wire
clavicle
technique
with
some
end
by
stainless
outer
good
outer
or
of acromio-clavicular
display
of the
Inter-
ligaments,
experiences
men
In addition,
acromion
conservatively
movement.
joint
unfortunate
working
abducting
as
of the
can
had
treated
ligaments
excision
have
after
doctors-one
have
residual
of joint
joint,
trapezoid
for
most
of patients
limitation
unpredictable.
methods
place,
Nevertheless
We
and
or primary
their
occasionally
two
of whom
weeks
Three
20 per cent
instability
Kirschner
are
effusion
and swelling
in a good proportion
acromio-clavicular
all have
perfectly.
methods.
that
of
Bunnell
(1941),
staff
of movement.
also
of treatment
operative
of
by
Gurd
restriction
the
are discovered
University
when
However,
203
JOINT
dislocations
our
other
a psychiatrist-both
without
symptoms.
pain,
Introduction
(1940),
On
joint,
and
components
dislocation.
Murray
the
ACROMIO-CLAVICULAR
untreated
locally.
articular
disc, make
this method
There
are at least twenty-eight
joint
with
reveals
results,
THE
results.
specialist,
dislocations
of the
unsatisfactory
OF
functional
of the acromio-clavicular
likely to be much pain
is associated
position
that
good
surprisingly
have
DISLOCATION
two
weakness
of the
of
in
clavicle
the
; this
is
we have had the disappointing
with loss of position,
despite
the
anatomical
reduction
of the acromio-clavicular
dislocation
have led us to use the Bosworth
(1941) lag-screw
operation.
two weeks before.
These difficulties
We believe,
however,
after noting
the
the
severe
surgical
of the
disruption
attack
operation.
of the
acromio-clavicular
on this lesion
arthrotomy
This
ensures
healing
accurately
reduced.
Critics
of the lag-screw
important
elements
of shoulder
technique
joint
fixed
to the
point
when
the
joint
at
time
of operation,
of the acromio-clavicular
joint
of ligaments
and periarticular
that
in any
is an essential
structures
with
part
the
joint
beyond
coracoid.
shoulder
90
They
is abducted
degrees.
our patients
have
rotate
on its long
We
full
axis,
out
and
have
of coraco-clavicular
function
are removed
that
that
found
that
A standard
cases.
We
technique
has
wish to stress
been
the
of the pitfalls
of coraco-clavicular
As originally
described
by Bosworth,
the
coracoid
process,
the
operation
arthrotomy
of the acromio-clavicular
two important
steps.
The joint
OF
joint.
be
consider
that
clavicle
becomes
clavicle
occurs
occurs
are
when
invalid,
on its
the
long
arm
inasmuch
certain
firmly
axis
is carried
as
most
the clavicle
in such a patient
We will enlarge
on this later.
of
does
OPERATION
for this procedure
after
certain
errors
in our
of adherence
to this exact
technique,
whereby
fixation
may
the method
being
must
criticisms
In addition,
as one unit.
adopted
necessity
many
of the
consequently
these
painless
abduction.
but with the scapula
TECHNIQUE
earlier
rotation
pain
fixation
once the
carried
be avoided.
consisted
out
We believe
clearly
seen
under
that
and
this
the
of fixation
local
original
coracoid
of the
clavicle
anaesthesia
to
without
technique
process
neglects
must
be
sufficiently
exposed
in order to identify
its broad
base.
Arthrotomy
is necessary,
for in many
of our cases severe
disruption
of the joint
was noted,
with tearing
of the articular
disc and
interposition
of fragments
of the acromio-clavicular
ligament.
In addition,
“blind”
Screwing
of the
coracoid
is hazardous.
The
success
of the
procedure
depends
on a firm
grip
by
the
lag
screw
into the broad
base of the coracoid.
This can be secured
only under
direct
vision
or
with radiographic
control.
An axillary
view of the coracoid
is helpful.
A screw
that
looks
in perfect
position
in the antero-posterior
view may be found
to be poorly
placed
in the axial
view (Fig. 2). The screw should
be placed
vertically.
In some of our earlier
cases, introduction
VOL.
36
C
B,
NO.
2,
MAY
1954
J.
204
of the
screw
was
necessary,
W’ith
from
and
made
the
patient
acromio-clavicular
unnecessary
the
in
part
FIG.
Figure
Figure
2-Screw
3-Screw
Full
The
coracoid
tissue;
this
led
of the
position,
origin
speed
of a longer
incision
clavicle,
clavicular
the
use
screw’
than
was
difficult.
S-shaped
of the
entire
to the
coracoid
an
quarter
enhance
CAMERON
and
the
of the
of recovery
is made
to expose
coracoid
process.
It is
preservation
of
deltoid;
of the
despite
process
the
torn
and
of
plane,
directly
muscle
after
the
operation.
as the
root
is carefully
conoid
screw
towards
diameter
of the
engage
the
from
lateral
base
will
occur
screw,
of
identified,
trapezoid
base
coracoid
process
position
results
of coracoid.
over-production
and
is passed
the
3
FIG.
to
marked
ossification
the
2
has
failed
introduced
abduction
calcification
diameter
H.
4r
,;
soft
base
the
greatly
AND
lateral;
outermost
completely
will
far
of the
a semi-sitting
the
detach
medial
KENNEDY
too
engagement
joint,
to
more
a position
C.
the
along
them
the
are
later.
conoid
and
introduced
trapezoid
equal
A smaller
and
made
THE
JOURNAL
axial
rather
to
view.
than
ligaments.
is freed
preserved
quarter
process.
in
tip
of
joint
purposely
A drill
outermost
coracoid
is then
in
acromio-clavicular
ligaments
through
of the
bone
as demonstrated
in engagement
of interposing
in the
in diameter
of the
clavicle,
in
drill,
of the
same
penetrate
OF
BONE
hope
to the
the
AND
cortex
JOINT
that
thread
a vertical
diameter
of the
SURGERY
COMPLETE
process.
coraCold
the
reduCtion
of the
I)ISLOCATION
A screw
the
of
coracoid
is accurately
of suitable
joint,
process,
should
well
placed,
an
OF
axial
length
be
back
THE
is driven
vertical
at
its
If the
should
be
it should
and
least
taken
205
JOINT
home;
in position,
l)aSe.
radiograph
ACROMIO-CLAVI(’ULAR
maintain
should
doubt
arises
on
table.
the
adequately
penetrate
both
whether
cortices
the
lag
screw’
RESULTS
\Ve
have
compare
no
comparative
early
our
period
the
functional,
series
results.
following
economic,
In
our
treated
series
statistical
observations
and
cosmetic,
with
fusion
of
the
to
37;
heavy
weeks
his
36;
work.
A bricklayer
able
to lift 200
out
team
seven,
for
six
the
basketball
weeks
average
Excessive
seem
of
to
As
and
and
late
our
trapezoid
at
All
thirty-four
the
influence
deformity
being
calcification
operation.
conoid
practice
operation.
series
two
as
seen
of
the
VOL.
of the
of
these,
in
the
B,
NO.
of
which
to
a four-year
anatomical,
apl)eared
as:
marked
of
4.
full
work
Several
in
player
our
ossification
ligaments.
six
patients
weeks;
injured
a professional
age
only
when
hockey
patients
returned
a butcher
tackling
player
varied
from
ear1’
in
eight
in October
was
back
sixteen
to
with
sixty-
years.
developed
along
4);
nor
did
it
became
in a ragged
even
the
conoid
and
trapezoid
over-correction
the
of the
practice
state,
to
and
also
ligaments
deformity
did
at
if possible
preserve
purposely
not
the
time
the
torn
to over-correct
the
operation.
five
patients
mistakes
axial
2,
with
all
view;
1954
indifferent
results
were
the
over
were
young
athletic
individuals
who
In
three
of the
younger
patients
were
coracoid.
36
The
through
cosmetic,
to
December;
(Fig.
ligaments,
patients
with
good
results,
w’ith
the
least
discomfort.
In
in
w’ith
for
Using
the
ratings
rating,
our
series
trapezoid
a football
ossification
results
joint
and
37;
of meat;
method
followed
5
returned
pounds
after
conoid
economic,
functional,
‘as
turned
the
manual
standard
cases
acromio-clavicular
along
anatomical,
other
were
made.
4 as the
highest
FIG.
Extra-articular
any
by
of twenty-seven
another
made
in operative
passed
obliquely
technique:
from
one
a
very
age
of
fifty.
were
quickly
the
result
screw
lateral
missed
position
Of the
nineteen
rehabilitated
was
only
the
into
fair.
coracoid
the
tip
J.
21)6
FUNCTION
An
analysis
clavicular
along
the
of
our
joint.
A
conoid
and
acromio-clavicular
C.
OF
AND
us
to
CAMERON
this
exact
fixation,
of necessity
eliminates
JOINT
the
reconsider
coraco-clavicular
ligaments,
and
H.
ACROMIO-CLAVICULAR
led
performed
trapezoid
joint
THE
has
patients
well
KENNEDY
creates
component
an
of the
function
with
of the
subsequent
extra-articular
shoulder
acromio-
ossification
fusion
mechanism
of the
(Fig.
s).
(
‘1
1/
FIG.
6
FIG.
Left
acromio-clavicular
shoulder
on right.
Two
as
the
movements
shoulder
conform
changes
of abduction.
Inman
all joints
have
joint
with
shoulder.
joint
Excursion
Neither
and
his
They
have
of the
shoulder
has
of
been
flexes
in
been
fixed
the
Kirschner
with
described
at the
and
extends;
relationship
of these
associates
stressed
that
complex-namely,
an
between
elevation
scapula
seems
have
clavicle
rotation)
process.
same
on
joint:
a gliding
depression
humerus
two
Normal
sides.
movement
movement
during
to
various
phases
essential.
basic
abduction
the
coracoid
is the
and
and
contributed
complete
to
acromio-clavicular
and
mo’ements
(1944)
7
a screw
from
wires
(clavicular
work
is dependent
sterno-clavicular,
THE
on
the
on
function
free
acromio-clavicular,
JOURNAL
OF
BONE
AND
of
the
movement
scapuloJOINT
SURGERY
in
COMPLETE
thoracic,
the
scapulo-humeral
and
clavicle
rotates
on
by
passing
demonstrated
55
gain
60 degrees
to
rotation
DISLOCATION
occurred
its
a
THE
joints.
In addition,
longitudinal
axis
Kirschner
of elevation
wire
as
90 degrees
after
OF
the
ACROMIO-CLAVICULAR
they
to
have
arm
shown
marked
horizontally
full
From
that
degree.
into
reached
abduction.
of
a
the
during
This
strikingly
and
The
observations
abduction
was
clavicle
abduction.
these
207
JOINT
watching
greatest
it
degree
Inrnan
of
et al. warned
.1
-J
0
_______________________________
Synchronous
against
scapulo-clavicular
fusion
publication
Since
of
these
it
was
the
4),
wires
clavicular
fixation
36 B,
have
that
obvious
misgivings
NO
and
about
introduced
2,
show
rov
as
demonstrated
scapular
spine.
acromio-clavicular
joint,
Kirschner
VOL.
rotation
reflections
acromio-clavicular
(Fig.
I.
1954
in
we
most
carrying
difference
of
an’
others,
creating
patients
Kirschner
condition.
by
were
our
out
a normal
for
repeated
essence
since
into
no
joint
been
often
by
in their
and
excursion
Since
all condemning
an
extra-articular
nevertheless
coraco-clavicular
clavicle
wires
(Figs.
one
seemed
which
6 and
has
7).
clavicle
and
Inman’s
original
screw
fixation.
fusion
regained
fixation
into
in
This
full
of
the
abduction
unwarranted.
undergone
observation
coracohas
208
c.
j.
been
repeatedly
confirmed
favourably
with
transfixed
the
on
rotating
clavicle
sides
movements
of
of the
the
of depression
degree
clavicle
did
not
these
From
not
prevent
point
but
of the
on
the
scapula.
but
clavicular
by
of the
changes
coraco-clavicular
are painful.
This
rotation
the
wires
8 and
9).
(Figs.
compares
that
rotating
in the
and
spine
transfixed
synchronous
wires
Rotation
this
scapula.
scapular
normal
were
clavicular
during
corresponded
of
the
to
scapula
and
90 degrees
of abduction
or forward
flexion.
fusion
of the acromio-clavicular
joint does
creates
that
that
a synchronous
the
normal
individual
in
itself
patient
scapulo-clavicular
shoulder
rotation.
simulates
movements
older
fifty
of the
fixation
or fusion
phenomenon
was
rotation
our
patients
to synchronous
over
in tension
scapulo-clavicular
with
of the
rather
results
to adapt
joint
allowed
scapular
cadaver
be assumed
this
of rotation
can
synchronous
normally
occur
various
stages
of tension
have been observed
in the conoid
and
of these ligaments
can be altered
only by rotation
of the clavicle
Indifferent
mechanism
of the
It must
synchronously
degree
before
conclude
that
experiments
movement,
we believe
nevertheless
at both clavicle
and scapula.
shoulder
clavicle
clavicle.
of elevation
scapular
marked
we can
shoulder
Tension
transfixed
so
and
degree
rotation
In the normal
trapezoid
ligaments.
CAMERON
opposite
does
rotation
The
in our
H.
further,
Kirschner
wires
were placed
observed
; it was observed
that
on both
clavicular
occur to any
experiments
we found
The
of the
rotation
shoulder.
clavicular
Although
cadavers.
fresh
undergoes
abduction
AND
mechanism
To demonstrate
this
clavicle
and movements
and
KENNEDY
must
be
must
rely
to
allowed
extent
on
ligaments.
of the acromio-clavicular
not observed
in our younger
rapid,
full,
to
failure
rotation.
some
coraco-clavicular
invariably
attributed
scapulo-clavicular
and
slight
this
is removed
extremes
in whom
painless
of the
acromio-
the
When
joint,
the
patients,
The
play”
“
by
of abduction
synchronous
abduction.
CONCLUSIONS
1. Screw
along
the
fixation
conoid
of clavicle
to coracoid
process,
with subsequent
calcification
and trapezoid
ligaments,
creates
an extra-articular
fusion
clavicular
joint.
2. Though
the follow-up
is admittedly
healthy
adult.
It is possible
to return
to full
work
in a surprisingly
3.
The
operation
4.
A precise
5.
Screw
operative
fixation
synchronous
short
is of doubtful
in older
is most
a new
scapulo-clavicular
can be obtained
in the young
sports
and a heavy
labourer
time.
value
technique
introduces
early,
excellent
results
an athlete
to competitive
and ossification
of the acromio-
patients.
important
movement
in producing
into
the
a successful
abduction
result.
mechanism
of the
shoulder:
rotation.
REFERENCES
A.
BIRKETT,
N.
(1944):
Journal
of Surgery,
BLOOM,
F.
S.
F.
Surgery,
INMAN,
(1941):
113,
1,094.
T.,
V.
Joint.
MURRAY,
G.
Illinois:
URIST,
Surgery,
(1942):
A.
(1946):
R.
28,
C.
(1946):
C. M.,
and
Separation.
of
Dislocation.
of Bone
Gynecology
Journal
& Joint
and
of Bone
Acromioclavicular
of
The
The
26,
of
Medical
British
Surgery,
Obstetrics,
and
Joint
Joint.
27,273.
73,
17, 1,005.
Surgery,
Surgery,
866.
Gynecology,
the
of Dislocation
and
C. (1944):
Deformities
and
End
of the
Observations
on
Acromioclavicular
Joint
Journal,
of the
Joint
Outer
Clavicle.
the
Annals
Function
of
of
the
1.
Association
of Bone
Traumatic
of the
L.
ABBOTT,
Surgery,
Dislocations
Treatment
Journal
Dislocation
and
Joint
Canadian
Fixation.
Charles
M.
J. B. De
Fixation
Threaded-Wire
STEINDLER,
Journal
Surgery,
Dislocation
for
of Complete
of Bone
(1940):
D. B.
Acromio-Clavicular
Dislocation.
Separation.
Acromioclavicular
Treatment
Ligaments.
PHEMISTER,
and
The
Journal
Coracoclavicular
of Severe
563.
SAUNDERS,
Shoulder
Repair
in Acromioclavicular
Graft
Fascial
46,
B.
of Operative
Acromioclavicular
Complete
(1928):
Obstetrics,
GURD,
Fixation
(1941):
R. F. (1935):
BUNNELL,
Result
103.
Wire
B. M.
BOWERS,
and
32,
(1945):
BOSWORTH,
The
N.S.
43,
Acromio-Clavicular
Surgery,
Disabilities
24,
of
and
Rupture
of
the
270.
Joint
by
Open
Reduction
166.
the
Upper
Extremity.
Springfield,
Thomas.
Complete
Dislocations
of
the
Acromioclavicular
Journal
Joint.
of
Bone
and
Joint
813.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY