AC
Joint Injuries
Brian R. Wolf, MD
Univ. of Iowa Sports Medicine
12/1/05
Acromio-clavicular Sprain/Dislocation
]
Also referred to “shoulder
separation”
]
Likely the most common sports
related shoulder injury, especially contact sports
]
More common in males (5:1)
]
More often incomplete injury than
complete (2:1)
Anatomy
]
Connects axial skeleton to upper
extremity
]
Diarthrodial joint with articular
cartilage, fibrocartilage disk
]
AC ligaments
]
Superior, inferior, anterior,
posterior
]
Coracoclavicular ligaments
]
Conoid, trapezoid
Biomechanics of AC Joint
]
5-20 degrees of rotation
]
AC ligaments
]
AP stability
]
Axial distraction
]
CC ligaments
]
Vertical stability
]
Both ligaments must be disrupted
for a complete dislocation
Mechanism of injury
]
Direct force from fall onto
shoulder, or blow to shoulder (most common)
]
Indirect-fall on outstretched hand
]
AC ligaments tear first, then
trapezoid, then conoid
Presentation and PE
]
Acute injury
]
Pain swelling at AC joint region
]
+/- deformity
]
Pain with FF and with cross body
adduction
]
Tenderness at AC
Presentation and PE
]
Chronic AC injury
]
Same signs and symptoms
]
May c/o of crepitus and popping
with shoulder motion
]
Deformity may have increased with
time.
Radiographs
]
AP shoulder
]
Axillary lateral
]
Zanca view
]
15 degree cephalad AP view
Classification
Classification
]
Type I: strain of AC ligs, CC
ligaments intact
]
Tenderness, swelling
]
No deformity
]
Type II: rupture of AC ligs, CC
ligaments intact
]
Tenderness, swelling
]
Mild deformity
Classification
]
Type III: rupture of AC and CC
ligs.
]
sig. tenderness and swelling
]
Obvious deformity (25-100%
increase in CC inter space)
]
Type IV: Same as III except
clavicle displaced posteriorly into trapezius muscle (from more anterior force)
]
Rare
]
Signif. Deformity, clavicle can
button hole into trapezius making reduction difficult
Classification
]
Type V: all ligaments torn,
delto-trapezial fascia often disrupted
]
Severe deformity (>100% increase
in CC interspace)
]
Pain, swelling
]
Type VI: displaced beneath
coracoid and conjoined tendon
]
Rare
]
Secondary to severe trauma
Treatment
]
Type I and II: non-operative,
immobilization in supportive sling)
]
Figure eight brace, Kenny Howard
brace: must monitor for skin pressure
]
Type I: 1-2 weeks, gradually
resume activities as tolerated
]
Type II: likely minimum of 3-6
weeks before return to activities
]
Not all Type I and II injuries do
well:
]
Damage to meniscus or cartilage
]
Cox AJSM ‘81:
]
42% clicking, pain
]
23% limited participation
]
Mouhsine JSES ’03
]
26% AC pain, adduction pain
]
25% residual AP instability
]
22% activity related pain
]
27% surgery at 2.2 yrs
Treatment
]
Type III: controversial
]
Non-operative-return at 8-12 weeks
]
Operative
]
Acute: reduction and screw
fixation
]
Chronic: distal clavicle excision
and reduction / reconstruction of CC ligaments
]
Return in 4-6 months
Optimal Treatment???
]
Any series that has compared
outcomes has not shown true difference in results
]
Recent survey of NFL team
physicians—most would try non-operative first
]
Things to consider
]
What bridges do you burn with
non-op trial? With surgery?
]
Contact athlete—potential to fail
again
]
Thrower?
Treatment
]
Type V: Operative fixation
]
Reduce AC joint
]
DCE if >4 wks.
]
Repair/reconstruct CC ligaments
]
2 months sling, PT at 4 weeks,
strengthening at 8 weeks, return to sports 6 months.
Acromioclavicular joint arthrosis
]
More common than glenohumeral
arthritis
]
Often can occur in conjunction
with rotator cuff disorders
]
Etiology
]
Injury in past
]
idiopathic
Common scenarios
]
Weight lifters
]
Can get osteolysis of distal
clavicle
]
Heavy laborers
]
Often comes bilaterally
AC joint pain
]
History
]
Pain with overhead activities
]
Reaching across chest
]
Point tenderness
AC joint
]
Exam: point tender over AC joint
]
Pain with adduction of shoulder across chest
]
Radiographs: spurs, OA at AC joint.
Treatment
]
Activity modification
]
Medication
]
Injection: steroid
]
Surgery: distal clavicle resection
]
Indications: failure of non-operative means, focal pain at ac
joint, relief from injection
Arthroscopic distal clavicle resection
Distal clavicle resection
Thank you