Diagnostic Assessment — Right Shoulder - Acromioclavicular Joint Dislocation
Example 1 of 1 · fictitious patient (Veteran AV)
Diagnostic Assessment
Right Shoulder - Acromioclavicular Joint Dislocation
BOP Code: 56 of 2019 (Dislocation of a Joint and Subluxation of a Joint)
RH Code: 55 of 2019 (Dislocation of a Joint and Subluxation of a Joint)
ADF History
Veteran AV, date of birth 08 April 1980, Australian Army, Driver (Royal Australian Corps of Transport), enlisted 19 January 1998, medically discharged 20 November 2013. Operational service: East Timor, 25 September 1999 to 20 February 2000 (warlike); Afghanistan, 02 March 2008 to 15 July 2008 (warlike; aeromedically evacuated).
Occupational History
Army drivers operate and maintain heavy trucks, load and unload cargo, change tyres and secure loads, climbing on and off high vehicle decks many times a day. The work involves lifting, pulling straps and chains, and repeated stepping and jumping down from cab and tray height onto hard ground.
On operations drivers move in convoys on routes threatened by improvised explosive devices, with a high risk of blast injury, traumatic brain injury and lower limb fractures, and in training they are exposed to vehicle rollovers and crush injuries. Shoulder injuries from falls and from loading are common in the trade.
History
Veteran AV, a driver in the Australian Army, dislocated her right acromioclavicular joint on 03 March 2019 when she fell onto the shoulder during a generalised tonic-clonic seizure caused by post-traumatic epilepsy from a traumatic brain injury sustained in an improvised explosive device blast in Afghanistan in 2008. In the same seizure several other joints dislocated, and she was morbidly obese and five weeks pregnant at the time. Surgical reconstruction was delayed for almost a year.
Timeline
- 14 Jun 2005 — The veteran's truck rolled during a night driving exercise in Australia. CT showed a fracture of the right posterior acetabular wall, managed with open reduction and internal fixation, and an L4/5 disc prolapse with right L5 radiculopathy. She returned to restricted duties after five months. "acetabular fracture, L4/5 prolapse"
- 22 Aug 2007 — Fell from a truck tray onto her right shoulder while securing a load during peacetime service. Examination showed tenderness and a step at the right acromioclavicular joint. X-ray showed a grade II acromioclavicular joint sprain with mild widening and no coracoclavicular disruption. She was managed in a sling for two weeks and had residual laxity on cross-body adduction at review in October 2007. "grade II AC sprain, R"
- 12 Jul 2008 — During warlike service in Afghanistan her truck struck an improvised explosive device. She lost consciousness for about 25 minutes with a Glasgow Coma Scale score of 11 and post-traumatic amnesia of three days, and CT showed a left frontoparietal contusion. She sustained a left tibial plateau fracture requiring fixation. She was aeromedically evacuated and was left with mild right-sided spasticity. "moderate TBI, tibial plateau fracture"
- 02 Feb 2010 — First generalised tonic-clonic seizure, 19 months after the brain injury. EEG showed left frontal epileptiform discharges. A neurologist diagnosed post-traumatic epilepsy and commenced sodium valproate. Her weight rose from 74 kg to 96 kg over the next two years. She had further breakthrough seizures in 2011 and 2012 and was medically discharged in 2013. "post-traumatic epilepsy, valproate commenced"
- 17 Aug 2016 — Right total hip replacement for osteonecrosis of the femoral head following the 2005 acetabular fracture. MRI of the lumbar spine before surgery showed L4/5 and L5/S1 spondylosis with a residual L4/5 disc protrusion. Weight 118 kg, height 1.67 m, BMI 42.3. "R THR, lumbar spondylosis"
- 09 May 2017 — Left total knee replacement for post-traumatic osteoarthritis following the 2008 tibial plateau fracture. Pre-operative X-rays recorded right patellar maltracking with lateral tilt and medial tibiofemoral narrowing in the right knee. Right shoulder X-ray for pain recorded acromioclavicular joint osteoarthritis. Valproate was changed to levetiracetam in 2018 in preparation for pregnancy. "L TKR, R AC joint OA"
- 03 Mar 2019 — Brought to the emergency department after a witnessed generalised tonic-clonic seizure at home, during which she fell heavily onto her right shoulder from standing and vomited with her jaw wide open. She had a visible step deformity at the right acromioclavicular joint, a shortened internally rotated right leg, a deformed left knee, a laterally displaced right patella and an open locked jaw. Serum beta-hCG was positive, consistent with a five-week pregnancy. BMI 42.6. "seizure, multiple dislocations, pregnant"
- 11 Mar 2019 — Orthopaedic review confirmed a Rockwood type V right acromioclavicular joint dislocation with rupture of the coracoclavicular ligaments and an avulsion fracture of the distal clavicle articular margin. The hip, knee, patellofemoral and temporomandibular dislocations had been reduced in the emergency department. Reconstruction of the acromioclavicular joint was deferred because of her pregnancy and anaesthetic risk, and the funding approval for surgery after delivery took a further four months. "Rockwood type V, surgery deferred"
- 24 Feb 2020 — Anatomical coracoclavicular ligament reconstruction of the right acromioclavicular joint. The operation note recorded a chronic, fixed superior dislocation with scarred and retracted deltotrapezial fascia, making reduction more difficult than in an acute repair. She was left with persisting shoulder pain and reduced overhead strength. "CC reconstruction, chronic dislocation"
Symptoms
At onset the veteran had severe right shoulder pain, a prominent bump at the top of the shoulder where the clavicle had displaced upwards, and inability to lift the arm. After onset the deformity persisted, with pain lying on the right side, weakness lifting and carrying, and clicking and aching at the top of the shoulder.
Since the reconstruction she reports persisting pain at the acromioclavicular joint with overhead activity, reduced strength, difficulty carrying her child and shopping, and night pain lying on the right side.
Imaging
- 22 Aug 2007 — X-ray right acromioclavicular joint: "Mild widening of the acromioclavicular joint consistent with a grade II sprain. Coracoclavicular distance normal."
- 09 May 2017 — X-ray right shoulder: "Acromioclavicular joint osteoarthritis with joint space narrowing, subchondral sclerosis and inferior osteophytes."
- 03 Mar 2019 — X-ray right shoulder and Zanca view: "Complete superior dislocation of the acromioclavicular joint with the coracoclavicular distance increased to 210 per cent of the left side. Small avulsion fragment from the inferior articular margin of the distal clavicle."
- 03 Mar 2019 — X-ray right hip, left knee and right knee: "Posterior dislocation of the right total hip prosthesis. Dislocation of the left total knee prosthesis. Lateral dislocation of the right patella with tibiofemoral subluxation of the right knee."
- 07 Mar 2019 — MRI right shoulder: "Complete rupture of the acromioclavicular and coracoclavicular ligaments with detachment of the deltoid and trapezius from the distal clavicle, consistent with a Rockwood type V injury. Pre-existing acromioclavicular joint osteoarthritis."
Onset Date
The most likely date of onset of this condition is 03 Mar 2019.
At that date the veteran had been discharged from the Army for five years and was living at home. She had post-traumatic epilepsy from a moderate traumatic brain injury sustained on warlike service in Afghanistan in 2008, a right total hip prosthesis, a left total knee prosthesis, lumbar spondylosis, a BMI of 42.6 and right acromioclavicular joint osteoarthritis following a service sprain in 2007. She was five weeks pregnant. During a generalised tonic-clonic seizure she fell from standing directly onto her right shoulder.
This date is appropriate because the dislocation is an acute traumatic event: her neurology review of 18 January 2019 recorded a normal right shoulder contour with no deformity, and she presented to the emergency department on the day of the seizure with a step deformity, confirmed on X-ray that day.
For the pregnancy factor, the six weeks before onset run from 20 Jan 2019 to 03 Mar 2019; she was pregnant throughout that period, with a positive beta-hCG on 03 Mar 2019 consistent with conception in late January 2019. The obesity, lumbar spondylosis, joint prostheses, soft tissue and bony damage and the neurological disease process were each established before 03 Mar 2019 and present on that date.
There are no separate worsening factors in these Statements of Principles other than the inability to obtain appropriate clinical management. After onset the dislocation remained unreduced from 03 Mar 2019 until reconstruction on 24 Feb 2020, and became a chronic fixed dislocation with scarring and retraction of the soft tissues, as recorded in the operation note.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Shoulder - Acromioclavicular Joint Dislocation (ICD-10 S43.1), a Rockwood type V injury, under the Statements of Principles concerning dislocation of a joint and subluxation of a joint, Balance of Probabilities No. 56 of 2019 and Reasonable Hypothesis No. 55 of 2019.
The acromioclavicular joint links the outer end of the clavicle to the acromion of the scapula and is stabilised by the acromioclavicular ligaments, the coracoclavicular ligaments and the deltotrapezial fascia. A dislocation is a complete loss of contact between the articulating surfaces. It usually follows a fall onto the point of the shoulder, which drives the acromion downwards. In a type V injury all the stabilising ligaments and the muscle attachments are torn and the clavicle is displaced markedly upwards. Without timely surgical reconstruction the joint remains unstable and painful, with weakness of overhead activity.
The dislocation occurred during a seizure caused by post-traumatic epilepsy from a brain injury sustained on warlike service in Afghanistan, in a shoulder already weakened by a service sprain and osteoarthritis. It began on 03 March 2019, was confirmed on X-ray and MRI, and was reconstructed in February 2020.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
03 March 2019.
When did the veteran first present to a health / medical provider for this condition?
03 March 2019.
When was the condition confirmed / formally diagnosed?
03 March 2019.
When did the veteran first present to you (or your practice) for this condition?
14 August 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on X-ray on 03 March 2019, which showed complete superior displacement of the clavicle relative to the acromion with loss of contact between the articulating surfaces, and a coracoclavicular distance of 210 per cent of the uninjured side. MRI on 07 March 2019 confirmed complete rupture of the acromioclavicular and coracoclavicular ligaments with detachment of the deltoid and trapezius from the distal clavicle.
These findings meet the Statement of Principles definition of dislocation of a joint, an episode of displacement with complete loss of contact between the articulating surfaces of the bones, and the Rockwood classification of a type V injury. The diagnosis was confirmed by an orthopaedic surgeon on 11 March 2019 and at operation on 24 February 2020.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 03 March 2019, after 1 July 2004. The injuries and diseases on which the factors rely arose from the veteran's service after 1 July 2004, including warlike service in Afghanistan in 2008. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service, including the 2005 vehicle rollover and the 2007 shoulder sprain. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan, where the brain injury that caused her epilepsy and the tibial plateau fracture were sustained.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint, No. 56 of 2019
Causative factors
Factor 9(1): having physical trauma to the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- On 03 March 2019, during a generalised tonic-clonic seizure, the veteran fell from standing directly onto the point of her right shoulder, driving the acromion downwards, as witnessed by her partner and recorded in the emergency department. The seizure was caused by post-traumatic epilepsy from her service brain injury, and her falls risk was increased by the right hip and lumbar injuries from the 2005 peacetime vehicle rollover.
Factor 9(2): having damage to a soft tissue structure as specified at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The veteran sustained a grade II sprain of the right acromioclavicular ligaments in a fall from a truck tray on peacetime service on 22 August 2007, with residual laxity documented in October 2007. This ligament damage was present at onset, and MRI on 07 March 2019 showed complete rupture of the acromioclavicular and coracoclavicular ligaments, which contribute to stability of the joint.
Factor 9(3): having a fracture, avulsion or bony abnormality involving the articulating surfaces of the affected joint, at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- X-ray on 03 March 2019 showed an avulsion fragment from the inferior articular margin of the distal clavicle, and the joint had pre-existing osteoarthritic osteophytes and sclerosis of the articulating surfaces, shown on X-ray on 09 May 2017, which followed the 2007 service sprain.
Factor 9(4): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- Two disease processes as specified were present at onset. Acromioclavicular joint osteoarthritis, a degenerative condition of the affected joint, was shown on X-ray on 09 May 2017 after the 2007 service sprain. The veteran also had mild right-sided spasticity from her traumatic brain injury, a brain injury with spasticity, which altered the muscular control of the right shoulder girdle.
Factor 9(5): for dislocation of a temporomandibular joint or subluxation of a temporomandibular joint only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- In the same seizure on 03 March 2019 the veteran vomited with her jaw forced wide open and dislocated her left temporomandibular joint, which was found open and locked in the emergency department and reduced manually. The seizure arose from post-traumatic epilepsy related to service.
Factor 9(6): for dislocation of a tibiofemoral joint or subluxation of a tibiofemoral joint only, having morbid obesity at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- In the same seizure the veteran's right knee subluxed at the tibiofemoral joint, shown on X-ray on 03 March 2019. Her BMI was 42.6 on that date, which is morbid obesity. The weight gain followed inactivity from her service hip and lumbar injuries and sodium valproate prescribed for post-traumatic epilepsy.
Factor 9(7)(a): for dislocation of a total hip joint prosthesis only: being obese at the time of the clinical onset of dislocation of a joint; — MET
- In the same seizure the veteran's right total hip prosthesis, inserted on 17 August 2016 for osteonecrosis following the 2005 peacetime acetabular fracture, dislocated posteriorly. Her BMI was 42.6 at the time, well above the definition of being obese.
Factor 9(7)(b): for dislocation of a total hip joint prosthesis only: having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of dislocation of a joint; — MET
- The veteran had an L4/5 disc prolapse from the 2005 peacetime vehicle rollover and L4/5 and L5/S1 spondylosis with a residual L4/5 disc protrusion on MRI in August 2016. Both were present when her right hip prosthesis dislocated on 03 March 2019. Lumbar stiffness increases the demand on hip flexion and the risk of prosthetic dislocation.
Worsening factors
Factor 9(8): inability to obtain appropriate clinical management for dislocation of a joint or subluxation of a joint. — MET
- A type V acromioclavicular dislocation is best reconstructed within about three weeks. The veteran's reconstruction was deferred because of pregnancy and anaesthetic risk, and the funding approval after delivery took a further four months, so the joint was not reconstructed until 24 February 2020, almost a year after injury. The operation note recorded a chronic fixed dislocation with retracted, scarred soft tissues and she has a poorer outcome. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint, No. 55 of 2019
Causative factors
Factor 9(1): having physical trauma to the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The veteran fell onto the point of her right shoulder during a generalised tonic-clonic seizure on 03 March 2019. The seizure was caused by post-traumatic epilepsy resulting from the moderate traumatic brain injury she sustained in an improvised explosive device blast on warlike service in Afghanistan on 12 July 2008. Seizure is listed as an example of trauma to a joint.
Factor 9(2): having damage to a soft tissue structure as specified at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The acromioclavicular and coracoclavicular ligaments, which stabilise the joint, were completely ruptured in the seizure-related fall on 03 March 2019, as shown on MRI on 07 March 2019. The fall was caused by epilepsy arising from her warlike service brain injury.
Factor 9(3): having a fracture, avulsion or bony abnormality involving the articulating surfaces of the affected joint, at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The seizure-related fall caused an avulsion fracture of the inferior articular margin of the distal clavicle, shown on X-ray on 03 March 2019. The epilepsy that caused the fall arose from her brain injury on warlike service in Afghanistan.
Factor 9(4): having a disease process as specified affecting the normal structural or functional relationship between the articulating surfaces of the affected joint at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- The veteran had mild right-sided spasticity from the frontoparietal brain injury sustained on warlike service in Afghanistan on 12 July 2008, a brain injury with spasticity that impaired muscular control and protective reflexes of the right shoulder girdle. It was present at onset on 03 March 2019.
Factor 9(5): being pregnant within the six weeks before the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- Serum beta-hCG on 03 March 2019 was positive, consistent with a five-week pregnancy, and the pregnancy was confirmed on ultrasound at the antenatal clinic on 19 March 2019. She was pregnant throughout the six weeks before onset, from 20 January 2019. Sleep deprivation and nausea in early pregnancy contributed to the breakthrough seizure from her service-related epilepsy, and pregnancy hormones increase ligamentous laxity.
Factor 9(6): for dislocation of a temporomandibular joint or subluxation of a temporomandibular joint only, undertaking an activity or undergoing a medical procedure that involves wide opening of the mouth at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- During the seizure on 03 March 2019, caused by epilepsy from her warlike service brain injury, the veteran vomited with her mouth forced wide open and dislocated her left temporomandibular joint, which was reduced in the emergency department.
Factor 9(7): for dislocation of a patellofemoral joint only, being obese at the time of the clinical onset of dislocation of a joint; — MET
- In the same seizure her right patella dislocated laterally, shown on X-ray on 03 March 2019, when her BMI was 42.6. Her weight rose from 74 kg after the warlike service brain injury, through inactivity and sodium valproate prescribed for the resulting epilepsy.
Factor 9(8): for dislocation of a tibiofemoral joint or subluxation of a tibiofemoral joint only, being severely obese at the time of the clinical onset of dislocation of a joint or subluxation of a joint; — MET
- In the same seizure her right knee subluxed at the tibiofemoral joint, shown on X-ray on 03 March 2019, when her BMI was 42.6, above the threshold of 35 for being severely obese. The obesity followed the brain injury and epilepsy treatment arising from warlike service.
Factor 9(9)(a): for dislocation of a total hip joint prosthesis only: being obese at the time of the clinical onset of dislocation of a joint; — MET
- Her right total hip prosthesis dislocated posteriorly in the same seizure on 03 March 2019, when her BMI was 42.6. The obesity followed inactivity and valproate treatment after her warlike service brain injury.
Factor 9(9)(b): for dislocation of a total hip joint prosthesis only: having lumbar spondylosis, lumbar intervertebral disc prolapse, lumbar spondylolisthesis, lumbar spinal stenosis or lumbar spinal fusion at the time of the clinical onset of dislocation of a joint; — MET
- L4/5 and L5/S1 lumbar spondylosis with a residual L4/5 disc protrusion was shown on MRI in August 2016, aggravated by heavy lifting and vehicle-mounted driving on warlike service in East Timor and Afghanistan. It was present when her hip prosthesis dislocated on 03 March 2019.
Factor 9(10): for dislocation of a total knee joint prosthesis only, having morbid obesity at the time of the clinical onset of dislocation of a joint; — MET
- Her left total knee prosthesis, inserted on 09 May 2017 for post-traumatic osteoarthritis following the tibial plateau fracture sustained in the blast on warlike service in Afghanistan, dislocated in the same seizure on 03 March 2019. Her BMI was 42.6, which is morbid obesity.
Worsening factors
Factor 9(11): inability to obtain appropriate clinical management for dislocation of a joint or subluxation of a joint. — MET
- Reconstruction of the type V dislocation was deferred because of pregnancy and the anaesthetic risk from her warlike service-related epilepsy and obesity, and funding approval took a further four months after delivery. The joint was not reconstructed until 24 February 2020, almost a year after injury, by which time it was a chronic fixed dislocation with retracted soft tissues.
The % contribution of the causes is 100% and significant.
Sequelae
The acromioclavicular joint dislocation is a sequela of the veteran's accepted post-traumatic epilepsy and traumatic brain injury, of the obesity that followed her service injuries and their treatment, and of the 2007 acromioclavicular sprain and resulting osteoarthritis. It has in turn caused chronic right shoulder pain and weakness that limit her lifting, carrying and overhead activity, and required reconstruction.
Unintended Consequence
Met. The obesity that contributed to the dislocations in the seizure, and the reduced protective control of her limbs, followed long-term sodium valproate prescribed by Defence-arranged neurology for post-traumatic epilepsy from 2010 to 2018, which caused weight gain of more than 20 kilograms. This is an unintended consequence of treatment provided by the Commonwealth while she was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. A Rockwood type V acromioclavicular dislocation is best reconstructed within about three weeks of injury. The veteran's surgery was deferred because of pregnancy and the anaesthetic risk from her service-related epilepsy and obesity, and the funding approval after delivery took a further four months. The joint was reconstructed on 24 February 2020, almost a year after injury, when it had become a chronic fixed dislocation with scarred and retracted soft tissues. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this delay amounts to an inability to obtain appropriate clinical management, and it contributed to her poorer surgical outcome.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 14 Jun 2005, Trauma admission, CT and operation report, Orthopaedic surgeon
- 22 Aug 2007, Outpatient health record and X-ray right acromioclavicular joint, Medical Officer, Garrison health centre
- 12 Jul 2008, Trauma admission and CT report, Role 3 hospital, Afghanistan
- 02 Feb 2010, Neurology consultation and EEG, Neurologist
- 17 Aug 2016, Operation report and MRI lumbar spine, Orthopaedic surgeon
- 09 May 2017, Operation report and X-rays right shoulder and right knee, Orthopaedic surgeon
- 18 Jan 2019, Neurology review, Neurologist
- 03 Mar 2019, Emergency department record, X-rays and pathology, Emergency physician
- 07 Mar 2019, MRI right shoulder, Radiologist
- 11 Mar 2019, Orthopaedic consultation, Orthopaedic shoulder surgeon
- 19 Mar 2019, Antenatal ultrasound, Obstetrician
- 24 Feb 2020, Operation report, Orthopaedic shoulder surgeon
- Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint (Balance of Probabilities) No. 56 of 2019, Repatriation Medical Authority
- Statement of Principles concerning Dislocation of a Joint and Subluxation of a Joint (Reasonable Hypothesis) No. 55 of 2019, Repatriation Medical Authority
