Acromioclavicular joint injury: Difference between revisions

 
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==Background==
==Background==
[[File:Right shoulder with AC Ligaments.jpg|thumb|Right shoulder anatomy with AC Ligaments.]]
*Occurs via direct trauma to the adducted shoulder
*Occurs via direct trauma to the adducted shoulder
*Acromioclavicular and coracoclavicular ligaments may be affected
*Accounts for 40% of all shoulder injuries and 10% of all injuries in collision sports (football, hockey, etc.)<ref>Sirin E, Aydin N, Mert Topkar O. Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures. EFORT Open Rev. 2018;3(7):426-433. Published 2018 Jul 17. doi:10.1302/2058-5241.3.170027</ref>
*Acromioclavicular (AC) and coracoclavicular (CC) ligaments may be affected
*Routine use of stress radiographs is controversial (low yield)
*Routine use of stress radiographs is controversial (low yield)


==Clinical Features==
==Clinical Features==
[[File:Luxation acromioclaviculaire.jpeg|thumb|Acromion-clavicle injury. Note that the left shoulder is lower and the "piano key"; Screws on the radiography are a former trauma repair and unrelated to present trauma.]]
*Tenderness directly over AC joint (with possible deformity)
*Tenderness directly over AC joint (with possible deformity)
*AC compression test
*AC compression test
**Passively flex arm so It is parallel with ground; then passively adduct across body
**Passively flex arm so It is parallel with ground; then passively adduct across body
***Pain suggests AC joint injury
***Pain suggests AC joint injury
*Ability to touch contralateral shoulder with injured arm suggests lack of [[shoulder dislocation]]


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
===Imaging===
===Workup===
[[File:AC_Joint_Separation.jpg|thumb|AC joint separation]]
[[File:AC Separation XRAY (enhanced).png|thumb|]]
[[File:AC Type III.JPG|thumb]]
*AP shoulder (highly consider comparison view)
*AP shoulder (highly consider comparison view)
**AC joint
**AC joint
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***Helps to confirm ant-post position of clavicle in injury types III-IV
***Helps to confirm ant-post position of clavicle in injury types III-IV


===Classification===
===Diagnosis===
====Type 1====
[[File:AC_Joint_Separation.jpg|thumb|AC joint separation]]
*AC ligament sprain; AC joint intact
{| {{table}}
*Exam
| align="center" style="background:#f0f0f0;"|'''Classification'''
**Mild swelling, no deformity
| align="center" style="background:#f0f0f0;"|'''Anatomic Injury'''
**CC ligaments are nontender
| align="center" style="background:#f0f0f0;"|'''Exam'''
**Only distal-most 1-2cm of clavicle is tender
| align="center" style="background:#f0f0f0;"|'''X-ray'''
**Active overhead and cross-body ROM are limited by pain  
| align="center" style="background:#f0f0f0;"|'''Image'''
*X-ray
|-
**Often no abnormality is seen on xray; slight widening of the AC joint may occur  
| '''Type I'''||
 
*AC ligament sprain
====Type 2====
*AC joint intact
*AC ligament torn; coracoclavicular (CC) ligament may be partially torn but is intact
||
*Exam
*Mild swelling, no deformity  
**Prominent and tender AC joint with significant swelling    
*CC ligaments are nontender  
**Minimal tenderness of CC ligaments reflecting lack of significant injury
*Only distal-most 1-2cm of clavicle is tender  
**May be instability of the distal clavicle in the horizontal plane  
*Active overhead and cross-body ROM are limited by pain
*X-ray
||
**Partial elevation of the distal clavicle with no or minimal widening of CC distance  
*Often no abnormality is seen on xray
 
*Slight widening of the AC joint may occur
====Type 3====
||
*AC and CC ligaments torn; complete dislocation of the joint
[[File:Classification type 1 of AC separation.png|120px]]
*Exam
|-
**Deformity of the AC joint is clearly visible
| '''Type II'''
**Marked tenderness of CC ligaments (helps distinguish Type 3 from type 2)
||
*X-ray
*AC ligament torn
**Elevated distal clavicle and increased CC distance
*Coracoclavicular (CC) ligament may be partially torn but is intact
**Distal clavicle is positioned above the plane of the top of the acromion  
||
 
*Prominent and tender AC joint with significant swelling  
====Type 4====
*Minimal tenderness of CC ligaments reflecting lack of significant injury  
*May be instability of the distal clavicle in the horizontal plane
||
*Partial elevation of the distal clavicle with no or minimal widening of CC distance
||
[[File:Classification type 2 of AC separation.png|120px]]
|-
| '''Type III'''||
*AC and CC ligaments torn
*Complete dislocation of the joint
||
*Deformity of the AC joint is clearly visible  
*Marked tenderness of CC ligaments (helps distinguish Type 3 from type 2)  
*Palpable posterior fullness or deformity despite significant swelling
||
*Elevated distal clavicle and increased CC distance  
*Distal clavicle is positioned above the plane of the top of the acromion
||
[[File:Classification type 2 of AC separation.png|120px]]
|-
| '''Type IV'''||
*Complete dislocation with posterior displacement of distal clavicle in/through trapezius
*Complete dislocation with posterior displacement of distal clavicle in/through trapezius
*Exam
||
**Palpable posterior fullness or deformity despite significant swelling
*SC dislocation may be appreciated
**SC dislocation may be appreciated  
||
*X-ray
*Axillary view required to visualize the posterior dislocation
**Axillary view required to visualize the posterior dislocation
||
 
[[File:Classification type 4 of AC separation.png|120px]]
====Type 5====
|-
*More severe form of type III injury
| '''Type V'''
*Superior dislocation of the joint of 1-3x the normal spacing
||
*CC ligament distance is increased 2-3x normal
*More severe form of type III injury  
*Disruption of the deltotrapezial fascia
*Superior dislocation of the joint of 1-3x the normal spacing  
*Exam
*CC ligament distance is increased 2-3x normal *Disruption of the deltotrapezial fascia
**Shoulder appears to droop
||
**Severe superior displacement of clavicle (may cause tenting, ischemia of skin)
*Shoulder appears to droop  
**Clavicle is perhced above the muscle and does not reduce when patient shrugs shoulder
*Severe superior displacement of clavicle (may cause tenting, ischemia of skin)  
*X-ray
*Clavicle is perhced above the muscle and does not reduce when patient shrugs shoulder
**Clavicle is elevated above acromion approximately 1-3x width of the clavicle  
||
**CC distance is increased 2-3x normal range  
*Clavicle is elevated above acromion approximately 1-3x width of the clavicle  
 
*CC distance is increased 2-3x normal range
====Type 6====
||
*Complete dislocation with clavicle displaced inferiorly  
[[File:Classification type 5 of AC separation.png|120px]]
*X-ray
|-
**Complete disruption of the AC and CC ligaments
| '''Type VI'''
||
*Complete dislocation with clavicle displaced inferiorly
||
||
*Complete disruption of the AC and CC ligaments
||
[[File:Classification type 6 of AC separation.png|120px]]
|}


==Management==
==Management==
===Type 1===
===Type I===
*Rest, ice, sling
*Rest, ice, [[sling]]
*ROM and strengthening exercises as soon as tolerated
*ROM and strengthening exercises as soon as tolerated
*Return to sport or work is limited only by pain  
*Return to sport or work is limited only by pain  


===Type 2===
===Type II===
*Rest, ice, sling x 3-7 days
*Rest, ice, [[sling]] x 3-7 days
*ROM and strenghtnening exercises as soon as tolerated
*ROM and strenghtnening exercises as soon as tolerated
*Return to sport or work once full ROM and strength are regained
*Return to sport or work once full ROM and strength are regained


===Type 3===
===Type III===
*Rest, ice, sling x2-3 weeks
*Rest, ice, [[sling]] x2-3 weeks
*ROM and strengthening exercises as soon as tolerated
*ROM and strengthening exercises as soon as tolerated
*Return to sport or work 6-12 weeks following injury
*Return to sport or work 6-12 weeks following injury
*Ortho consultation within 1 week
*Ortho consultation within 1 week


===Types 4-6===
===Types IV-VI===
*Require orthopedic evaluation; emergent if neurovascular compromise exists
*Require orthopedic evaluation; emergent if neurovascular compromise exists
*Generally operative
*Generally operative


==Disposition==
==Disposition==
*Generally outpatient, unless neurovascular compromise
*'''Admission Criteria'''
**Neurovascular compromise
**Open or unstable fractures
**Admission for operative repair may be needed for Types IV, V, and VI
*'''Discharge Criteria'''
**Type I/Type II may be discharged with orthopedic follow-up
**Type III may be discharged with urgent orthopedic follow-up


==See Also==
==See Also==

Latest revision as of 19:58, 28 July 2021

Background

Right shoulder anatomy with AC Ligaments.
  • Occurs via direct trauma to the adducted shoulder
  • Accounts for 40% of all shoulder injuries and 10% of all injuries in collision sports (football, hockey, etc.)[1]
  • Acromioclavicular (AC) and coracoclavicular (CC) ligaments may be affected
  • Routine use of stress radiographs is controversial (low yield)

Clinical Features

Acromion-clavicle injury. Note that the left shoulder is lower and the "piano key"; Screws on the radiography are a former trauma repair and unrelated to present trauma.
  • Tenderness directly over AC joint (with possible deformity)
  • AC compression test
    • Passively flex arm so It is parallel with ground; then passively adduct across body
      • Pain suggests AC joint injury
  • Ability to touch contralateral shoulder with injured arm suggests lack of shoulder dislocation

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Workup

AC Separation XRAY (enhanced).png
AC Type III.JPG
  • AP shoulder (highly consider comparison view)
    • AC joint
      • Normal width of AC joint in adults is 1-3mm
      • By age 60 width is often less than 1mm
      • Children and adolescents have a slightly wider joint space
    • CC joint
      • Normal distance is 11-13mm
      • Comparison to opposite CC joint space is more important
        • Increase in CC distance of 25-50% indicates complete CC ligament disruption
    • Zanca view (AP with 10-15 degree cephalic tilt)
      • Consider if AP view is ambiguous, concern for type II injury or distal clavicle injury
    • Axillary view
      • Obtain if coracoid tenderness is present to rule-out associated coracoid fracture
      • Helps to confirm ant-post position of clavicle in injury types III-IV

Diagnosis

AC joint separation
Classification Anatomic Injury Exam X-ray Image
Type I
  • AC ligament sprain
  • AC joint intact
  • Mild swelling, no deformity
  • CC ligaments are nontender
  • Only distal-most 1-2cm of clavicle is tender
  • Active overhead and cross-body ROM are limited by pain
  • Often no abnormality is seen on xray
  • Slight widening of the AC joint may occur

Classification type 1 of AC separation.png

Type II
  • AC ligament torn
  • Coracoclavicular (CC) ligament may be partially torn but is intact
  • Prominent and tender AC joint with significant swelling
  • Minimal tenderness of CC ligaments reflecting lack of significant injury
  • May be instability of the distal clavicle in the horizontal plane
  • Partial elevation of the distal clavicle with no or minimal widening of CC distance

Classification type 2 of AC separation.png

Type III
  • AC and CC ligaments torn
  • Complete dislocation of the joint
  • Deformity of the AC joint is clearly visible
  • Marked tenderness of CC ligaments (helps distinguish Type 3 from type 2)
  • Palpable posterior fullness or deformity despite significant swelling
  • Elevated distal clavicle and increased CC distance
  • Distal clavicle is positioned above the plane of the top of the acromion

Classification type 2 of AC separation.png

Type IV
  • Complete dislocation with posterior displacement of distal clavicle in/through trapezius
  • SC dislocation may be appreciated
  • Axillary view required to visualize the posterior dislocation

Classification type 4 of AC separation.png

Type V
  • More severe form of type III injury
  • Superior dislocation of the joint of 1-3x the normal spacing
  • CC ligament distance is increased 2-3x normal *Disruption of the deltotrapezial fascia
  • Shoulder appears to droop
  • Severe superior displacement of clavicle (may cause tenting, ischemia of skin)
  • Clavicle is perhced above the muscle and does not reduce when patient shrugs shoulder
  • Clavicle is elevated above acromion approximately 1-3x width of the clavicle
  • CC distance is increased 2-3x normal range

Classification type 5 of AC separation.png

Type VI
  • Complete dislocation with clavicle displaced inferiorly
  • Complete disruption of the AC and CC ligaments

Classification type 6 of AC separation.png

Management

Type I

  • Rest, ice, sling
  • ROM and strengthening exercises as soon as tolerated
  • Return to sport or work is limited only by pain

Type II

  • Rest, ice, sling x 3-7 days
  • ROM and strenghtnening exercises as soon as tolerated
  • Return to sport or work once full ROM and strength are regained

Type III

  • Rest, ice, sling x2-3 weeks
  • ROM and strengthening exercises as soon as tolerated
  • Return to sport or work 6-12 weeks following injury
  • Ortho consultation within 1 week

Types IV-VI

  • Require orthopedic evaluation; emergent if neurovascular compromise exists
  • Generally operative

Disposition

  • Admission Criteria
    • Neurovascular compromise
    • Open or unstable fractures
    • Admission for operative repair may be needed for Types IV, V, and VI
  • Discharge Criteria
    • Type I/Type II may be discharged with orthopedic follow-up
    • Type III may be discharged with urgent orthopedic follow-up

See Also

References

  1. Sirin E, Aydin N, Mert Topkar O. Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures. EFORT Open Rev. 2018;3(7):426-433. Published 2018 Jul 17. doi:10.1302/2058-5241.3.170027