A 52-year-old male, right hand dominant, sustained an injury to the right shoulder from a fall due to slipping at home and presented with pain and mild swelling and ecchymosis over the right shoulder, and associated minor abrasions over the forehead and right elbow. Both active and passive shoulder movements was painful. There was associated local tenderness and crepitus over the region of the acromion process of the right shoulder. There was no evidence of neurovascular compromise. Radiograph of the right shoulder revealed a minimally displaced fracture of the acromion process, Type II according to Kuhn classification, at the junction of the spine of the scapula and the process (Figure ).\nIt was decided to treat the fracture along conservative lines with regular follow up for at least six weeks. with conversion to surgical stabilization if so required. Conservative treatment was done with a commercially available shoulder immobilizer and arm-pouch. Since these fractures are known for their propensity to displace, serial X-rays were taken after a week and thereafter at weekly intervals up to five weeks, for evidence of healing as well as displacement, if any. At the end of five weeks, an increase in the fracture gap and inferior displacement of the acromion, compromising the sub-acromial space was noticed; a progression to Type III, and the decision to operatively stabilize the fracture was made (Figure ).\nThe patient was prepared for surgery after routine blood investigations and mandatory screening for human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B surface antigen (HBsAg). He underwent a pre-anesthesia check-up for assessment of fitness for surgery.\nUnder general anesthesia and prone position, the fracture was approached with an incision placed directly over the spine of the scapula, curving anteriorly. No deltoid or rotator cuff tear observed during the surgery. The fracture was identified and was found to be separated by a gap of more than 5 millimetres. The acromion process fragment was augmented, and the fracture was reduced under direct vision. After temporary stabilisation with two smooth Kirschner wires under image guidance, the fracture was stabilized with a 6-hole, 3.5-mm locking reconstruction plate, in compression mode, using two cortical screws and four locking bolts.\nPost-operative period was uneventful. Operative wound was examined and dressed after forty-eight hours, with drain removal at the same time, according to our departmental protocol. Gentle active movements and progressive exercises was initiated one week after the surgery within the limits of pain tolerance. Radiographs were taken 24 hours after the surgery (Figure ). They were then taken at six weeks, 12 weeks which were found to be acceptable with a clear sub-acromial space. Bony union was evident by 12 weeks (Figure ).\nThe functional outcome was assessed using the University of California Los Angeles (UCLA) Shoulder Function Scale and the Constant (Murley) Score at six weeks, 12 weeks, six months and 16 months. The score was 9 at six weeks, 15 at three months, 28 at six months and 33 at 16 months with the UCLA Shoulder Score and 33% at six weeks, 62% at three months, 82% at six months and 98% at 16 months according to the Constant Score. At the final examination, at 16 months, the patient was fully satisfied with good functional range of movement (Figures -).
Patient RF was a 42-year-old man who had a left side os acromiale with an impingement syndrome. He was first treated by a colleague orthopaedic surgeon, who performed three surgeries. The first was an arthroscopic limited decompression, followed by fixation with K-wires and tension band wiring. Because of an infection and perforation of the osteosynthesis materials, they were removed and replaced by two Acutrak screws. However, a monitoring CT showed loosening of these screws. The patient continued to suffer from a loss of strength and pain at night. As an alternative approach, an osteosynthesis using a distal clavicle osteosynthesis plate was performed. Fixation was achieved using cortical and angle-stable locking screws (4 × 10 mm and 2 × 12 mm). One compression screw was used. A bone graft was harvested from the left iliac crest and applied at the osteotomy site.