Sam Dyer, PA-C, MHS, is a NCCPA-certified physician assistant with more than 20 years of practice experience in orthopedics. He also holds a Certificate of Added Qualifications in Orthopaedic Surgery from the NCCPA. He practices at Emerge Orthopedics in Chapel Hill, North Carolina, and Durham, North Carolina. He is the current president of the PAOS, and writes an orthopedic blog on the PAOS website titled the OrthoPA-C. He has also authored an onboarding manual for PAs new to orthopedics, which can currently be read by PAOS members on the PAOS website, and plans to publish the work in the future. He has written numerous forum posts for the PAOS website and PAOS newsletter. He enjoys seeing a variety of patients and conditions in his practice. He also has developed a charity advocacy program for the PAOS titled PAOS CARES, where he teaches primary care providers at community health centers and rural health clinics MSK injection techniques.


BLOG: Case study 52-year-old right hand-dominant woman

by Sam Dyer, PA-C, MHS

A 52-year-old right hand-dominant woman was seen in the orthopedic clinic after sustaining a fall from a horse. She had increased shoulder pain and loss of motion. She reported pain primarily along the superior aspect of her shoulder with no numbness or tingling in the arm or hand. She had no loss of grip and was distal neurovascular intact. She did notice a “hard knot” over the posterior/superior shoulder that was painful.

The initial radiographs are shown here:

Source: Sam Dyer, PA-C, MHS


The diagnosis was discussed with the patient and the decision was made for surgery. What is the diagnosis?


This patient has an uncommon acromioclavicular (AC) separation that is actually best determined by the trauma axillary view (see arrows). Notice the posterior position of the distal clavicle with relation to the AC joint? It is a grade IV separation where the clavicle has penetrated the trapezius posteriorly. She had open reduction with internal fixation with repair of the AC ligament and reconstruction of the coracoclavicular ligaments with a hamstring allograft.