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== | ||
=== | ===Workup=== | ||
[[File: | [[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 | ||
=== | ===Diagnosis=== | ||
==== | [[File:AC_Joint_Separation.jpg|thumb|AC joint separation]] | ||
*AC ligament sprain | {| {{table}} | ||
| align="center" style="background:#f0f0f0;"|'''Classification''' | |||
| align="center" style="background:#f0f0f0;"|'''Anatomic Injury''' | |||
| align="center" style="background:#f0f0f0;"|'''Exam''' | |||
| align="center" style="background:#f0f0f0;"|'''X-ray''' | |||
| align="center" style="background:#f0f0f0;"|'''Image''' | |||
|- | |||
| '''Type I'''|| | |||
*AC ligament sprain | |||
*AC joint intact | |||
*AC ligament torn | || | ||
*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 | |||
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*AC and CC ligaments torn | [[File:Classification type 1 of AC separation.png|120px]] | ||
|- | |||
| '''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 | |||
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*Partial elevation of the distal clavicle with no or minimal widening of CC distance | |||
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[[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 | |||
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[[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 | ||
|| | |||
*SC dislocation may be appreciated | |||
|| | |||
*Axillary view required to visualize the posterior dislocation | |||
|| | |||
[[File:Classification type 4 of AC separation.png|120px]] | |||
|- | |||
*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 | ||
*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 | |||
|| | |||
*Complete dislocation with clavicle displaced inferiorly | [[File:Classification type 5 of AC separation.png|120px]] | ||
|- | |||
| '''Type VI''' | |||
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*Complete dislocation with clavicle displaced inferiorly | |||
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*Complete disruption of the AC and CC ligaments | |||
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[[File:Classification type 6 of AC separation.png|120px]] | |||
|} | |||
==Management== | ==Management== | ||
===Type | ===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 | ===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 | ===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 | ===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== | ||
* | *'''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
- 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
- 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
- Passively flex arm so It is parallel with ground; then passively adduct across body
- Ability to touch contralateral shoulder with injured arm suggests lack of shoulder dislocation
Differential Diagnosis
Shoulder and Upper Arm Diagnoses
Traumatic/Acute:
- Shoulder Dislocation
- Clavicle fracture
- Humerus fracture
- Scapula fracture
- Acromioclavicular joint injury
- Glenohumeral instability
- Rotator cuff tear
- Biceps tendon rupture
- Triceps tendon rupture
- Septic joint
Nontraumatic/Chronic:
- Rotator cuff tear
- Impingement syndrome
- Calcific tendinitis
- Adhesive capsulitis
- Biceps tendinitis
- Subacromial bursitis
- Cervical radiculopathy
Refered pain & non-orthopedic causes:
- Referred pain from
- Neck
- Diaphragm (e.g. gallbladder disease)
- Brachial plexus injury
- Axillary artery thrombosis
- Thoracic outlet syndrome
- Subclavian steal syndrome
- Pancoast tumor
- Myocardial infarction
- Pneumonia
- Pulmonary embolism
Evaluation
Workup
- 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
- AC joint
Diagnosis
Classification | Anatomic Injury | Exam | X-ray | Image |
Type I |
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Type II |
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Type III |
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Type IV |
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Type V |
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Type VI |
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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
- ↑ 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