OTA 1997 Posters - Shoulder Fractures

The Functional Outcome of Acromioclavicular Joint Injury in Polytrauma Patients

Stephen H. Gallay, MD, Michael D. McKee, MD, FRCS(C), Tom Hupel, MD, Emil H. Schemitsch, MD, FRCS(S)

St. Michael's Hospital, Univ. of Toronto, Toronto, Ontario, Canada

Purpose: Using a case-control format and both disease specific and general health outcome measures, we sought to test our hypothesis that the impact of displaced acromioclavicular (AC) joint injuries in polytrauma patients has been underestimated and that shoulder function is inferior to patients with isolated AC joint injury.

Conclusion: Shoulder function in polytrauma patients with an AC joint injury was consistently worse than control patients with an isolated AC joint injury, when evaluated with disease specific shoulder instruments. The presence of an AC joint injury in a polytrauma patient had a negative effect on general health status scores, as determined by the SF-36, when compared to matched polytrauma cases without AC joint injury. A displaced AC joint injury in a polytrauma patient is often a greater problem than anticipated, and negatively affects both disease specific and general health outcomes.

Summary of Method, Results and Discussion: Currently, it is felt that most patients with isolated, displaced AC joint injuries can be managed non-operatively. However, it was our clinical impression that polytrauma patients with a displaced AC joint injury experienced more shoulder symptomatology and were less satisfied with their shoulder outcome than patients with isolated AC joint injuries. To test this hypothesis, we conducted a case-control study of polytrauma patients with displaced AC joint injuries. Seventeen polytrauma patients with a concomitant AC joint injury were identified from a prospectively collected trauma data-base between 1988 and 1996. Two patients died and 3 patients were unavailable for follow-up. The remaining 12 patients, contacted at an average of 50 months post injury, had a mean age of 42 years and a mean Injury Severity Score (ISS) of 20 (range 9-36). All patients had suffered multiple injuries at the time of their AC joint injury. There were nine grade III and three grade II AC joint injuries, and eleven were treated conservatively. Study patients were matched to 1) polytrauma patients without an AC joint injury (matched for age, sex, and ISS), and 2) patients with an isolated AC joint injury (matched for age, sex, grade of injury). The outcome evaluators used were a series of five shoulder questionnaires/disease specific measures of health status (SPADI: Shoulder Pain and Disability Index; SSRS: Subjective Shoulder Rating Scale:; SST: Simple Shoulder Test; SSI: Shoulder Severity Index; and M-ASES: Modified American Shoulder & Elbow Surgeons Form) and a general health status questionnaire, the SF-36. Shoulder function in polytrauma/AC joint injured patients was significantly worse than in control patients with an isolated AC joint injury, when evaluated with disease specific shoulder instruments (p<0.05 for SPADI, SSRS, SST, and SSI). In addition, the presence of an AC joint injury in a polytrauma patient had a negative effect on the role physical, role emotional and mental health components of the SF-36 as compared to control polytrauma patients without AC joint injury. The poor outcome of AC joint injury in polytrauma patients is likely multifactorial, and includes late recognition of the AC joint injury, high energy mechanisms of injury, poor radiographic evaluation and/or underestimation of the degree of injury, and early upper extremity weight bearing. Due to associated injuries, treatment of the AC joint disruption is often given a low priority, with inadequate physiotherapy and immobilization.