Alt Tag for Image Spinner

Acromioclavicular Separation & Treatment

Acromioclavicular Separation & Treatment post thumbnail

AC Joint separation Direct force by far most common mechanism of Acromioclavicular Separation Treatment ■ Fall onto point of shoulder AC Joint separation ( acromioclavicular joint) traumatic injury
■ Acromion gets driven downward and clavicle is stabilized by sternoclavicular (SC) ligaments
■ Sequence of ligamentous injuries: acromioclavicular (AC) ligaments, coracoclavicular (CC) ligaments, deltoid and trapezial muscle attachments, skin
■ Inferior dislocation (type VI separation) likely caused by downward force on clavicle
■ Injury may also be caused by indirect force with humeral head being driven into acromion
➣ Will cause no damage to CC ligaments

A common athletic injury

➣ Football
➣ Hockey
➣ Lacrosse
➣ Bicycling (esp. mountain biking)
➣ Snowboarding


Motorcycle accidents

➣ Tend to be complex with associated injuries
■ Patients report pain, swelling at AC
■ Chronically may have deformity, clicking, pain

Physical exam of Acromioclavicular Separation

■ Inspection of deformity
➣ Rule out posterior buttonholing of clavicle through deltotrapezial fascia
■ Neurovascular and rotator cuff strength exam
6 Acromioclavicular Separation
■ Palpation of AC and CC regions
■ Cross-body adduction
■ Injuries to rule out acutely
➣ Clavicular shaft fracture
➣ Acromion and coracoid fractures
➣ Brachial plexus injuries
➣ SC joint injuries
➣ Pneumothorax
➣ Scapulothoracic dissociation

physiotherapy management in Fractures


Chronically must rule out other sources of pain


➣ SLAP tear
➣ Cervical radiculopathy
➣ Rotator cuff tear

Studies of Acromioclavicular Separation & Treatment

■ Preferably done standing
■ AP (Zanca view)
➣ 15◦ cephalic tilt to avoid superimposition of AC joint on scapula
➣ Reduced exposure needed as in AP view of glenohumeral joint
■ Axillary view
➣ Rule out posterior displacement of clavicle
➣ Rule out coracoid and acromion fractures
➣ Film other side if questionable
■ Standing AP view of both shoulders
➣ Measure CC distances and calculate % increase on affected side
➣ CC distance normally 1.0–1.3 cm
■ Weighted views
➣ Help distinguish type II from type III
➣ Not needed, as they seldom change treatment plan or decision
to perform surgery
■ MRI
➣ Can delineate ligamentous injury and arthritis, useful for surgical planning

Differential diagnosis

■ Lateral clavicle fracture
■ Periosteal sleeve fracture
■ Bipolar AC separation + SC joint injury
■ Combined AC separation + coracoid process fracture
■ Glenohumeral joint dislocation

Type and grades of Acromioclavicular Separation & Treatment

Acromioclavicular Joint separation and shoulder separation grades

■ Classification system based on injury to AC and CC ligaments and severity and direction of displacement of clavicle
➣ Grade I Acromioclavicular Joint separation: Sprain of AC ligaments; CC ligaments intact; no increase in CC distance
➣ Grade II Acromioclavicular Joint separation: Disruption of AC ligaments and sprain of CC ligaments; increase in CC distance <25%; weighted views would show equal CC distances

➣ Grade III Acromioclavicular Joint separation : Disruption of AC and CC ligaments; CC distance 25–100%; deltotrapezial fascia is intact

➣Grade IV Acromioclavicular Joint separation : Disruption of AC and CC ligaments; clavicle is posteriorly displaced into deltotrapezial fascia; may not have significant superior displacement

➣ Grade V Acromioclavicular Joint separation: Disruption of AC and CC ligaments; marked superior displacement of clavicle with CC distance of 100–300%; torn deltotrapezial fascia

➣Grade VI Acromioclavicular Joint separation: Disruption of AC ligaments +/− CC ligaments; inferior displacement of clavicle in either subacromial (CC ligaments intact) or sub coracoid (CC ligaments disrupted) location; subcoracoid dislocation associated with severe injury, rib fractures, and clavicle fracture

Acromioclavicular Joint separation
Type and Grade Acromioclavicular Joint separation

■ Treatment AC Joint separation

➣ Types I and II

✅ Ice and sling for comfort for 1–2 weeks

✅ Return to activity when full pain-free range of motion present

✅ May take longer in type II injuries

✅ Kenny Howard brace – presses down on clavicle and pushes arm upwards

✅ Must be worn 24 hours a day

✅ Can cause skin breakdown over clavicle and anterior interosseous nerve palsy

✅ Pts w/ type II may develop persistent symptoms in future secondary to posttraumatic degeneration, osteolysis of distal clavicle, loose cartilage fragments, or unstable meniscus

✅ Treat with distal clavicle excision +/− CC stabilization

✅ Distal clavicle excisions fare poorly if grade II injury present

➣ Type III

✅ Operative vs. nonoperative treatment remains controversial

✅ Literature unclear on the matter, but careful review reveals that recent trend is to opt for nonoperative treatment 8 Acromioclavicular Separation

✅ Patients treated nonoperatively recover sooner, with no difference in strength or pain

✅ Exceptions to this are in overhead laborers and perhaps throwing athletes

✅ Nonoperative treatment  Sling for 2–4 weeks

✅ Early pendulum and ROM exercises

✅ Begin strengthening at 4–6 weeks

✅ Avoid contact sports for 4–8 weeks

➣ Types IV and V

✅ Operative treatment recommended

✅ Early (first 2 weeks) surgery results are better than late surgery

✅ Type IV tends to be more painful

✅Type V symptomatology generally relative to degree of displacement

➣ Type VI

✅ Operative treatment recommended

✅ Excision of distal clavicle facilitates reduction

Acromioclavicular Joint separation
Acromioclavicular Joint separation

✅ Operative treatment

✅ Acute indications are grades IV, V, and VI separations

➣ Relative indications include grade III separations in overhead laborers

➣ >30 operative techniques described
➣ Transfer of coracoacromial ligament with or without CC fixation
(Weaver-Dunn)
✅ Distal clavicle may or may not be resected
✅ Late AC joint degeneration avoided with resection
✅ CC fixation achieved with suture or synthetic material through a drill hole in the clavicle
✅ Placing cerclage around clavicle causes abnormal anteriorization of clavicle and potential for material to cut through clavicle
✅ Avoid use of permanent synthetic tapes (Dacron or Mersilene) due to foreign body reaction and late infection


➣ CC fixation


✅ Screw placed through clavicle into coracoid
✅ Biomechanically strong
✅ Perform in conjunction with repair of ligaments when done acutely
✅ Requires removal at 8 weeks
✅ Technically difficult
✅ Easy to drill into coracoid but often screw can “blow out” the coracoid
✅ May abnormally anteriorize the clavicle


➣ AC fixation


✅ Kirschner wires across AC joint
✅ Can be done percutaneously without repair of CC ligaments or open with repair
✅ Violates joint and can lead to arthritis
✅ Requires second procedure for hardware removal
✅ Pins can migrate!
✅ Never use smooth pins


➣ Dynamic muscle transfer
✅ Transfer of coracoid with short head of biceps to clavicle
✅ Exchange of a dynamic constraint for a static one
✅ Half have continued aching
✅ Risk of injury to musculocutaneous nerve


■ Rehabilitation
➣ Sling for 6 weeks
➣ Daily pendulum exercises started at week 1
➣ No active forward flexion or abduction for 6 weeks
➣ No lifting of any kind for 6 weeks
➣ Start progressive active range of motion and strengthening at 6 weeks


Disposition
N/A

Prognosis

■ Nonoperative treatment of grade III injuries appears to be equivalent to surgery
➣ Earlier return with nonoperative treatment
■ Non operated athletes may return to play when range of motion full and strength normal
■ Operatively treated athletes should avoid contact for 6 months
■ Complications of surgery
➣ Loss of reduction
➣ Infection
➣ Deltoid dehiscence
➣ Calcification of CC ligaments (not a problem; seen also in non operative treatment)

➣ Erosion of fixation through clavicle
➣ Foreign body reaction to synthetic tapes

Caveats and Pearls

■ Results of surgery done within a few weeks of injury are superior to those done chronically
■ Grade IV separations don’t always have superior displacement
■ No need for aggressive rehabilitation
■ A small amount of superior displacement can be expected after reconstruction
■ Conoid ligament (medial) controls vertical stability
■ Trapezoid ligament (lateral) controls axial load of joint
■ Superior and posterior AC ligaments control anterior-posterior
■ Only 5–8◦ of motion at AC joint
➣ Clavicle does rotate 40–50◦ with full elevation of shoulder
➣ Upward rotation of clavicle is combined with downward rotation of the scapula, controlled by CC\ ligaments (synchronous scapulo clavicular rotation)
➣ AC or CC fixation has little effect on shoulder motion

Categories:
Dr .Lalit Choudhary
Hii everyone, I'm Dr Lalit Choudhary PT. Born and brought up in delhi. Practicing as a professional PHYSIOTHERAPIST. As a therapist I love to interact with others and and get myself updated regarding all the social issues which are leading my countrymen to distress themselves. Yes, I agree that Iam a workaholic but my work gives me immense pleasure but there are sometimes when I feel stressed up so to relax myself I travel to new places, meet new people and try to adopt their culture. Most of the time I like to travel hills as it helps me to relax and enjoy our nature beauty. For being a good therapist and to deal with all the difficulties I always prefer to be good listener and have good patience that is what my strength is. I also work as a social worker and the Founder of thesocialphysiofitnessclub and PHYSIO FIT INDIA. In last I just want to say that " I believe that physical therapy is not just a therapy but actually a remedy which not only make you physically fit but also adds happiness, joy and more days to your life." So don't just sit and thought now it's time to stand and work on yourself.

Leave a Reply

Your email address will not be published.