Acromioclavicular joint injury: Difference between revisions

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==Clinical Features==
==Clinical Features==
*Tenderness directly over AC joint (w/ possible deformity)
*Tenderness directly over AC joint (with possible deformity)
*AC compression test
*AC compression test
**Passively flex arm so it's 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==
{{Shoulder DDX}}
{{Shoulder DDX}}


==Diagnosis==
==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 w/ 10-15 degree cephalic tilt)
**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 fx
***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===
====Type 1====
{| {{table}}
*AC ligament sprain; AC joint intact
| align="center" style="background:#f0f0f0;"|'''Classification'''
*Exam
| align="center" style="background:#f0f0f0;"|'''Anatomic Injury'''
**Mild swelling, no deformity
| align="center" style="background:#f0f0f0;"|'''Exam'''
**CC ligaments are nontender
| align="center" style="background:#f0f0f0;"|'''X-ray'''
**Only distal-most 1-2cm of clavicle is tender
|-
**Active overhead and cross-body ROM are limited by pain  
| '''Type 1'''||
*X-ray
*AC ligament sprain
**Often no abnormality is seen on xray; slight widening of the AC joint may occur  
*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 2====
==Management==
*AC ligament torn; coracoclavicular (CC) ligament may be partially torn but is intact
===Type 1===
*Exam
*Rest, ice, sling
**Prominent and tender AC joint w/ significant swelling     
*ROM and strengthening exercises as soon as tolerated
**Minimal tenderness of CC ligaments reflecting lack of significant injury
*Return to sport or work is limited only by pain
**May be instability of the distal clavicle in the horizontal plane
*X-ray
**Partial elevation of the distal clavicle w/ no or minimal widening of CC distance


====Type 3====
===Type 2===
*AC and CC ligaments torn; complete dislocation of the joint
*Rest, ice, sling x 3-7 days
*Exam
*ROM and strenghtnening exercises as soon as tolerated
**Deformity of the AC joint is clearly visible
*Return to sport or work once full ROM and strength are regained
**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====
===Type 3===
*Complete dislocation w/ posterior displacement of distal clavicle in/through trapezius
*Rest, ice, sling x2-3 weeks
*Exam
*ROM and strengthening exercises as soon as tolerated
**Palpable posterior fullness or deformity despite significant swelling
*Return to sport or work 6-12 weeks following injury
**SC dislocation may be appreciated
*Ortho consultation within 1 week
*X-ray
**Axillary view required to visualize the posterior dislocation


====Type 5====
===Types 4-6===
*More severe form of type III injury
*Require orthopedic evaluation; emergent if neurovascular compromise exists
*Superior dislocation of the joint of 1-3x the normal spacing
*Generally operative
*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====
==Disposition==
*Complete dislocation w/ clavicle displaced inferiorly
*Generally outpatient, unless neurovascular compromise
*X-ray
**Complete disruption of the AC and CC ligaments
 
==Treatment==
*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==
==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
  • 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

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

Classification Anatomic Injury Exam 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

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

References