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Acute Rockwood type III acromioclavicular joint dislocation — MSRA MCQ

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HardShoulder InjuriesAcute Rockwood type III acromioclavicular joint dislocationMSRA

A 29-year-old police officer attends general practice 2 days after falling directly onto the point of his right shoulder during a rugby match. In the emergency department, radiographs excluded fracture and showed widening of the acromioclavicular joint with superior displacement of the distal clavicle, consistent with a Rockwood type III acromioclavicular joint dislocation. He was discharged in a sling. He is concerned that the visible prominence means that the shoulder must be put back into place urgently, particularly because of his manual occupation. He has focal tenderness over the acromioclavicular joint and pain on cross-body adduction. Glenohumeral passive movement is near full, although painful at the end range. There is no skin tenting, dysphagia, chest pain, paraesthesia, weakness, vascular compromise, or fever. What is the most appropriate management now?

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Correct answer: D — Continue non-operative management with analgesia, a sling for comfort only, early gentle shoulder movement, and orthopaedic virtual-fracture-clinic review of the radiographs

Explanation lettering: D = shown as A · C = shown as B · E = shown as C · B = shown as D · A = shown as E

This is an isolated Rockwood type III acromioclavicular (AC) joint dislocation: the mechanism is a direct impact onto the shoulder, there is focal AC-joint tenderness and clavicular prominence, and glenohumeral passive movement is largely preserved. There are no features requiring emergency reassessment, such as skin compromise, neurovascular deficit, suspected posterior sternoclavicular injury, fracture, or unreduced glenohumeral dislocation. Initial treatment is non-operative. The sling is for comfort rather than rigid immobilisation, and gentle movement should begin as pain permits. The residual clavicular prominence commonly persists but does not itself imply failed treatment or mandate reduction. Orthopaedic review of the imaging is appropriate, with surgery reserved for selected patients with persistent symptoms or functional limitation after specialist assessment. Current systematic-review evidence shows no meaningful functional advantage of routine surgery over conservative care for acute Rockwood III injuries, while surgery introduces procedure-related complications. A is incorrect because AC-joint dislocations are not managed by closed reduction in the emergency department. C is tempting because of his occupation and deformity, but these are considerations for later specialist shared decision-making, not automatic indications for immediate surgery. D risks stiffness and is inconsistent with early safe mobilisation. E is unnecessary because the examination and radiographs already identify the injury and do not suggest an acute rotator-cuff tear.

Reference: AC Joint Injury (Approved July 2025) — https://rightdecisions.scot.nhs.uk/media/jgcaidpl/10b-ac-joint-injury.pdf Surgical vs conservative: what is the best treatment of acute Rockwood III acromioclavicular joint dislocation? A systematic review and meta-analysis (2025) — https://pubmed.ncbi.nlm.nih.gov/40071962/