Acromioclavicular injuries

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Background

  • Occurs via direct trauma to the adducted shoulder
  • Acromioclavicular and coracoclavicular 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

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Imaging

AC joint separation
  • 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

Classification

Type 1

  • AC ligament sprain; AC joint intact
  • Exam
    • 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
  • X-ray
    • Often no abnormality is seen on xray; slight widening of the AC joint may occur

Type 2

  • AC ligament torn; coracoclavicular (CC) ligament may be partially torn but is intact
  • Exam
    • 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
  • X-ray
    • Partial elevation of the distal clavicle with no or minimal widening of CC distance

Type 3

  • AC and CC ligaments torn; complete dislocation of the joint
  • Exam
    • Deformity of the AC joint is clearly visible
    • Marked tenderness of CC ligaments (helps distinguish Type 3 from type 2)
  • X-ray
    • Elevated distal clavicle and increased CC distance
    • Distal clavicle is positioned above the plane of the top of the acromion

Type 4

  • 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
  • X-ray
    • Axillary view required to visualize the posterior dislocation

Type 5

  • 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
  • Exam
    • 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
  • X-ray
    • 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
  • X-ray
    • Complete disruption of the AC and CC ligaments

Management

Type 1

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

Type 2

  • Rest, ice, sling x3-7 days
  • ROM and strenghtnening exercises as soon as tolerated
  • Return to sport or work once full ROM and strength are regained

Type 3

  • 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 4-6

  • Require orthopedic evaluation; emergent if neurovascular compromise exists

See Also

References