Acromioclavicular joint injury: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
*Tenderness directly over AC joint ( | *Tenderness directly over AC joint (with possible deformity) | ||
*AC compression test | *AC compression test | ||
**Passively flex arm so | **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== | ||
{{Shoulder DDX}} | {{Shoulder DDX}} | ||
== | ==Evaluation== | ||
===Imaging=== | ===Imaging=== | ||
[[File:AC_Joint_Separation.jpg|thumb|AC joint separation]] | [[File:AC_Joint_Separation.jpg|thumb|AC joint separation]] | ||
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***Comparison to opposite CC joint space is more important | ***Comparison to opposite CC joint space is more important | ||
****Increase in CC distance of 25-50% indicates complete CC ligament disruption | ****Increase in CC distance of 25-50% indicates complete CC ligament disruption | ||
**Zanca view (AP | **Zanca view (AP with 10-15 degree cephalic tilt) | ||
***Consider if AP view is ambiguous, concern for type II injury or distal clavicle injury | ***Consider if AP view is ambiguous, concern for type II injury or distal clavicle injury | ||
**Axillary view | **Axillary view | ||
***Obtain if coracoid tenderness is present to rule-out associated coracoid | ***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 | ***Helps to confirm ant-post position of clavicle in injury types III-IV | ||
===Classification=== | ===Classification=== | ||
==== | {| {{table}} | ||
*AC ligament sprain | | 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''' | |||
|- | |||
| '''Type 1'''|| | |||
*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 | |||
|- | |||
| '''Type 2''' | |||
|| | |||
*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 | |||
|- | |||
| '''Type 3'''|| | |||
*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 | |||
|- | |||
| '''Type 4'''|| | |||
*Complete dislocation with posterior displacement of distal clavicle in/through trapezius | |||
|| | |||
*SC dislocation may be appreciated | |||
|| | |||
*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 | |||
|| | |||
*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 | |||
|- | |||
| '''Type 6''' | |||
|| | |||
*Complete dislocation with clavicle displaced inferiorly | |||
|| | |||
|| | |||
*Complete disruption of the AC and CC ligaments | |||
|} | |||
====Type | ==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 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 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 | ||
*Generally operative | |||
* | |||
==== | ==Disposition== | ||
*Generally outpatient, unless neurovascular compromise | |||
* | |||
==See Also== | ==See Also== | ||
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==References== | ==References== | ||
<references/> | |||
[[Category:Orthopedics]] | [[Category:Orthopedics]] |
Revision as of 18:12, 28 September 2019
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
- 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
Imaging
- 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
Classification
Classification | Anatomic Injury | Exam | X-ray |
Type 1 |
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Type 2 |
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Type 3 |
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Type 4 |
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Type 5 |
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Type 6 |
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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 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 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
- Generally operative
Disposition
- Generally outpatient, unless neurovascular compromise