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Am Fam Physician. 1998;58(6):1298-1303

to the editor: I am writing in response to the article “Pitfalls in the Radiologic Evaluation of Extremity Trauma: Part I. The Upper Extremity,” written by Drs. Shearman and El-Khoury.1
The authors discussed the diagnosis of acromioclavicular joint dislocations and stated, “Stress views taken with weights suspended from each wrist will provide the diagnosis.”1 They offered no reference for their statement. The best evidence and current treatment preference for type III (complete) acromioclavicular joint dislocations support the abandonment of stress view radiographs.
While the comparison of weighted (stress) and unweighted (plain) radiographs is commonly mentioned in textbooks and articles, the results of the first and only prospective, randomized, blinded, controlled study comparing plain radiographs with stress views indicate that only a plain radiograph comparing injured and uninjured acromioclavicular joints is needed to grade a dislocation.2 Stress views may mask the diagnosis of a type III injury.2 Support for the use of stress views is lacking.
The importance of differentiating between a type I dislocation or a type II (partial) dislocation and a type III dislocation has changed because the preferred treatment of type III injuries is now conservative treatment rather than surgery. In 1974, 92 percent of the chairs of orthopedic residency programs recommended surgery for the treatment of type III dislocations.3 Results of two long-term, prospective, randomized, comparative studies4,5 in the late 1980s showed that conservative treatment is as good as or better than surgery. In 1992, 72 percent of the chairs of orthopedic residency programs preferred conservative treatment of type III joint dislocations over surgery.6 Sixty-nine percent of Major League Baseball team orthopedists prefer conservative treatment, even for a type III dislocation of the throwing shoulder in their starting pitchers.7 If types I, II and III joint dislocations receive the same conservative treatment, radiographs for grading are unnecessary. Plain radiographs may be helpful, however, in ruling out other injuries that may need a different treatment approach.
Interestingly, an informal, nonscientific, unpublished survey among physicians at one hospital revealed that most orthopedists did not order any type of radiograph for the diagnosis of acromioclavicular joint dislocations and none ordered stress views. All of the radiologists surveyed recommended the comparison of plain radiographs and stress views. Family physicians were divided on the question, with the majority choosing to obtain stress views. Medical practice should not be changed on the basis of anecdotes or expert opinion. However, the fact that the majority of orthopedists have stopped ordering stress views should at least compel consideration of the existing evidence.
In summary, the preferred management of type III acromioclavicular joint dislocations has changed from surgery to conservative treatment. If the grading of an acromioclavicular joint dislocation is desired, plain radiographs that compare the injured and uninjured joint are adequate. Based on the best medical evidence, as well as the cost, the time involved and the exposure to radiation that patients receive, stress view radiographs should no longer be the standard method of evaluation of acromioclavicular joint dislocations.

editor's note: This letter was sent to the authors of “Pitfalls in the Radiologic Evaluation of Extremity Trauma: Part I. The Upper Extremity,” who declined to reply.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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