ACJ Separation FINAL

8/3/2019 ACJ Separation FINAL

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A CASE PRESENTATION BY

TRAUMA TEAM 04.02.10



TRAUMA TEAM © – Slide 2 From 39

REVIEW OF

THE CASE




CASE PRESENTATION

34/M/ Right hand dominant Military Man - N251480Electively admitted for Hook plate Right ACJ

Hx of trauma- MVA (MB vs Car)- in May 2008

Acromio-Clavicular Joint separation

Conservative mx

Right frontal contusion w IVH bleeding (Lt lat. Ventricles) Conservative Mx

Multiple orbital fractures and Glaucoma

Conservative Mx

Contracture of Rt Elbow (2 to cerebral injury) Tardieu Angle < 20 degrees

Otherwise no significant medical illnesses




CASE PRESENTATION

Chief complaint(s)Bone prominence

Pain

Impaired function due to decreased ROM and pain

Cosmetic




CASE PRESENTATION

ExaminationProminence distal clavicle

Skin indentation

Reduced ROM




CASE PRESENTATION

Imaging (Classification Rockwood type IV)






http://slidepdf.com/reader/full/acj-separation-final 9/65TRAUMA TEAM © – Slide 9From 39

head

RtShoulder


http://slidepdf.com/reader/full/acj-separation-final 10/65TRAUMA TEAM © – Slide 10 From 39

Coracoid

Anchor band





CASE PRESENTATION

Pt discharged day 4 post operativelyF/U Rehabilitation, Neurosurgery, Ophthalmology



CASE PRESENTATION

Post operative imaging


http://slidepdf.com/reader/full/acj-separation-final 14/65TRAUMA TEAM © – Slide 14From 39 DISCUSSION



AC joint injuries range from a mild sprain of

supporting ligaments to a complete separation ofthe AC joint

Peak incidence is in the second decade of life

The injury is rare in skeletally immaturepatients

Males 5 times more than females

The AC joint is at risk for traumatic injurybecause of its subcutaneous position on the topof the shoulder

KEY CONCEPTS

Wilkie W. et al, Distal Clavicle Fractures and Acute Acromioclavicular Joint Injuries; Hong Kong Medical Journal,VOL.11 NO.5 MAY 2006 Medical Bulletin, VOL.15 No.1 JAN 2010, 20-24

Micheal S. et al, Acromioclavicular and Sternoclavicular Injuries and Clavicular, Glenoid, and Scapular Fractures, JBone Joint Surg Am. 2009;91:2492-510

Leesa L et al, Acromioclavicular Joint Injuries, In Rockwood C, Wilkins K, King R (eds).Fractures in Adults , 6th ed. Philadelphia: JB Lipincott 2006; 1330-1348



The coracoclavicular ligaments (the trapezoid

and conoid) are key stabilizing structures of theacromioclavicular joint,

AC ligaments (superior, inferior, posterior andanterior ligaments) provide horizontal jointstability to the AC joint.

The superior AC ligament is the most importantof these 4 ligaments

AC joint injuries represent approximately 40%of shoulder injuries in athletes

KEY CONCEPTS

Wilkie W. et al, Distal Clavicle Fractures and Acute Acromioclavicular Joint Injuries; Hong Kong Medical Journal,VOL.11 NO.5 MAY 2006 Medical Bulletin, VOL.15 No.1 JAN 2010, 20-24

Micheal S. et al, Acromioclavicular and Sternoclavicular Injuries and Clavicular, Glenoid, and Scapular Fractures, JBone Joint Surg Am. 2009;91:2492-510

Leesa L et al, Acromioclavicular Joint Injuries, In Rockwood C, Wilkins K, King R (eds).Fractures in Adults , 6th ed. Philadelphia: JB Lipincott 2006; 1330-1348



MECHANISM OF INJURY

Direct trauma (sport inuryies)classically, landing on the point of the shoulder



MECHANISM OF INJURY

Direct trauma (sport inuryies) classically, landing on the point of the shoulder



C



CLASSIFICATION(MODIFIED ROCKWOOD)

Type I: mild forceno AC no CC disrupted

Type II: moderate toheavy force AC disruptedCC intact

Type III: severe forceboth AC and CCdisrupted

Rockwood CA, Williams GR, Young DC.Disorders of the acromioclavicular joint. In:Rockwood CA, Matsen FA, Wirth MA, LippittSB, editors. The shoulder. 3rd ed.Philadelphia: Saunders; 2004.

D Tossy, Acromioclavicular separations: useful and practical classification forTreatment, Clin Orthop. 1963. Vol. 28; 111-19

C



CLASSIFICATION(MODIFIED ROCKWOOD)

Type IV: distal clavicledisplaced posteriorly intotrapezius

Type V: Exaggeratedform of type III- scapula-

coracoclavicularinterspace 100-300%greater than the normalside

Type VI: rare, inferior

dislocation of the clavicle

Rockwood CA, Williams GR, Young DC.Disorders of the acromioclavicular joint. In:Rockwood CA, Matsen FA, Wirth MA, LippittSB, editors. The shoulder. 3rd ed.Philadelphia: Saunders; 2004.

D Tossy, Acromioclavicular separations: useful and practical classification forTreatment, Clin Orthop. 1963. Vol. 28; 111-19




DIAGNOSISHISTORY AND PHYSICAL EXAM

Injury to the AC joint should be suspected inanyone with pain after a traumatic injury to theshoulder region

Prominence of the outer end of the clavicle,

abrasion, or swelling in the area of the AC joint

step-off may be felt in type III to VI separations

Local tenderness and swelling AC joint injuries

Pain is associated with arm movements

In type VI shoulder looks flat

Farber et al, Acromioclavicular Joint Separation, 5-Minute Orthopaedic Consult, 2nd

Edition, 2007 Lippincott Williams & Wilkins, 12-16



TRAUMA TEAM © – Slide 23From 39 Typ

AP view

Axillary view

Zanca View (AC Joint View)

Stryker view (if acromion fracture issuspected)

DIAGNOSISIMAGING

Zanca View (AC Joint View)

10-15 cephalic tilt

Low penetration






DIAGNOSIS

Type I Type II

Type III

Type IV

Type V

Type VI

Equal to sprain of AC joint AC tender

No displacement

Radiological finding are normal

Diagnosis are based on history andphysical

Micheal S. et al, Acromioclavicular and Sternoclavicular Injuries and Clavicular, Glenoid, and ScapularFractures, J Bone Joint Surg Am. 2009;91:2492-510

Leesa L et al, Acromioclavicular Joint Injuries, In Rockwood C, Wilkins K, King R (eds). Fractures inAdults , 6th ed. Philadelphia: JB Lipincott 2006; 1330-1348




DIAGNOSIS

Type I

Type II

Type III

Type IV

Type V

Type VI

AC tender Slightly tender

Acromion slightly depressed but stillin contact with clavicle

Joint unstable in AP plan Distance between clavicle andacromion is preserved








DIAGNOSIS

Type I

Type II

Type III

Type IV

Type V

Type VI

The clavicle is dislocated in a posteriordirection

A distinct visible deformity withextreme prominence of the clavicle overthe scapular spine

Although the AC is unstable, does notmove due to because it is impaled overthe scapula

Posterior displacement of the clavicle

is seen on the axillary radiograph,






DIAGNOSIS

Type I

Type II

Type III

Type IV

Type V

Type VI

Obvious visible deformity of the distalpart of the clavicle associated withdownward and slightly anteriordisplacement

Not completely reducible because the

distal part of the clavicle is herniatedthrough the deltotrapezial fascia

increase in the coracoclaviculardistance (of up to 300%) and superiordisplacement of the distal part of theclavicle are seen on the AP radiograph.








TREATMENT

Type I

Type II

Type III

Type IV

Type V

Type VI

Sling immobilization and symptomatictreatment of pain are usually all that arenecessary for these injuries.

Activities are resumed as tolerated.


Leesa L et al, Acromioclavicular Joint Injuries, In Rockwood C, Wilkins K, King R (eds). Fractures in

Adults , 6th ed. Philadelphia: JB Lipincott 2006; 1330-1348










Surgical treatment is recommended for Open injury

Closed type IV, V and VI

Some Type III (as mentioned before)

Over head athletes and heavy manual workers

Brachial plexopathy

SURGICAL TREATMENT




There is currently no "gold standard" surgery to repairacromioclavicular separations, and many surgeries havebeen created.

More commonly attempting to fix with suture between theclavicle and the coracoid process

SURGICAL TREATMENT

Weaver –Dunnreconstruction

Steinmann pins or Kwire across the AC joint

Lag screw between theclavicle and the coracoidprocess






SURGICAL TREATMENT

Modified Weaver-Dunn: tens of modifications have beenemerged and still emerging… augmentation

Steven J et al, Current treatment ofacromioclavicular separations, 2008CurrOpin Orthop 18:373 –379

http://www.wheelessonline.com/ortho/ac_joint_separation Date recieved 03.02.10

Even with thesemodifications, themodern surgeries do

not match intactcoracoclavicularligament strength incadaveric testing




SURGICAL TREATMENT

http://www.biomedcentral.com/1471-2474/10/6/figure/F3

Modified Weaver-Dunn: tens of modifications have beenemerged and still emerging… augmentation




SURGICAL TREATMENT

Anatomical reconstruction using autografts or allografts

Steven J et al, Current treatment of

acromioclavicular separations, 2008CurrOpin Orthop 18:373 –379




SURGICAL TREATMENT

Arthroscopic reconstruction

Steven J et al, Current treatment ofacromioclavicular separations, 2008CurrOpin Orthop 18:373 –379

An endobutton isplaced through atunnel created in the

coracoid followed byfixation over a washerat the distal clavicle.

No ligament or

tendon is transferred.




SURGICAL TREATMENT

Hook Plates

Thierry M et al, The treatment of acromioclavicular joint dislocationTossy grade III, with a clavicle hook plateActa Orthopædica Belgica,Vol. 70 - 6 - 2004

Tierry et al conducted a retrospectively study in 2004

12 Patient with Tossy III

Mean Follow up 20 months

Mean constant score Operated side 91.3

uninvolved 93.9

7 pts as same or better constant score

2 pts with 5 scores or less

2 pts more than 5 scores

3 wound infection, 3 humps






SURGICAL TREATMENT

Hook Plates

Leesa L et al, Acromioclavicular Joint Injuries, InRockwood C, Wilkins K, King R (eds). Fracturesin Adults , 6th ed. Philadelphia: JB Lipincott 2006;1330-1348

During 1990s, a technique involvingthe use of a hook plate has beendescribed. This technique has a highcomplication rate, and a secondprocedure is always required to

remove the plate. This plate does notoffer any benefit over morecommonly used procedures




REHABILITATION

Operated shoulder should be supported with an arm slingfor 4-6 weeks

Passive and active assisted mobilization could be startedafterwards

Any rigid fixations such as screws and plate should be

removed once the biological healing of ACJ hasconsolidated as implant failures may result

Too early removal of the implant will result inredisplacement of the ACJ

Average timing of removal is around 12 weeks aftersurgery

Wilkie W. et al, Distal Clavicle Fractures and Acute Acromioclavicular JointInjuries; Hong Kong Medical Journal, VOL.11 NO.5 MAY 2006 Medical Bulletin,VOL.15 No.1 JAN 2010, 20-24






Complications related to surgical treatment include: Injury to the great vessels

Possible mortality related to pin migration

Continued pain if resection of the distal clavicle is inadequate,

particularly if the joint remains unstable Compromised stability if clavicle resection is excessive

Erosion into the clavicle by synthetic augmentation devices

Wound infection

Osteomyelitis

AC arthritis

Late fracture

Recurrent deformity

COMPLICATION



TRAUMA TEAM © – Slide 48 From 39 THANK YOU










Coracoid

Anchor bandMersilene Type Sling




Coracoid

Anchor band








REFFERENCES

1) Micheal S. et al, Acromioclavicular and Sternoclavicular Injuries and Clavicular,Glenoid, and Scapular Fractures, J Bone Joint Surg Am. 2009;91:2492-510

2) Leesa L et al, Acromioclavicular Joint Injuries, In Rockwood C, Wilkins K, King R(eds). Fractures in Adults , 6th ed. Philadelphia: JB Lipincott 2006; 1330-1348

3) Kingsley et al, Orthopaedic Key Review Concepts, 1st Edition, 2008 LippincottWilliams & Wilkins, 545-553

4) Andrew C. et al, What’s New in Sports Medicine, J Bone Joint Surg Am.

2009;91:241-56

5) Farber et al, Acromioclavicular Joint Separation, 5-Minute Orthopaedic Consult,2nd Edition, 2007 Lippincott Williams & Wilkins, 12-16

6) Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especiallycomplete acromioclavicular separation. J Bone Joint Surg [Am] 1972;54:1187-1194

7) Steven J et al, Current treatment of acromioclavicular separations, 2008Curr Opin

Orthop 18:373 –3798) James K. Weaver, Harold K. Dunn (September 1, 1972). "Treatment of

Acromioclavicular Injuries, Especially Complete Acromioclavicular Separation"Journal of Bone and Joint Surgery 54 (6): 1187 –1194

9) Mehta s. et al, Orthopaedic Key Review Concepts, 1st Edition, 2008 LippincottWilliams & Wilkins, 549-552












CASE PRESENTATION

Post operative photoes




Epidemiology

NO KNOWN MEDICAL ILLNESSH/O MVA ON 28/5/2009SUSTAINED1. RT FRONTAL CONTUSION WITH IVH BLEED LT LATERAL

VENTRICLES (CT BRAIN 28/5/2010) TX CONSERVATIVELY2. RT ACROMIO –CLAVICULAR JOINT DISRUPTIONCURRENTLY ON CONSERVATIVE MX3. H.O MULTIPLE ORBITAL #- CONSERVATIVE MX

E/A FOR HOOK PLATE RIGHT ACJ ON 19/1/2010CURRENTLY PT WELL, NO ACUTE COMPLAINT, ABLE TO WALK

WITHOUT HELP.




Epidemiology

O/E:

IN WARD:REVIEWED BY NEUROSERGERY: TCA NEURO CLINIC 3/12- TO

GET NEW APPOINTMENTSUGGEST TO REFER OPTHALMOLOGY

HOOK PLATING+ MARSALINE TAPE SLING WAS DONE ON19/1/2010

àPOST OP, PT WELL NOT IN PAINO/E: R1/R2 - <20 (TARDIEU ANGLE)

Rt ELBOW COTRACTURE: END RANGE BICEPS CONTRACTURE45 DEGREE

ASSESSMENT BY OCCUPATIONAL THERAPY:ADL: FULLY IDEPENDANT EXCEPT HAVING DIFFICULTIES IN

DRESSING FOR ZIPPING AND BUTTONING




Epidemiology

REFERRED TO REHAB FOR BOTOX INJECTIONÀ NOT FOR BOTOX INJECTING: PLAN FOR TCA 1/12 AT REHAB

CLINIC . TO CONSIDER CASTING

CHECK X RAY POST OP: ACCEPTABLE

C/O REDUCE VISUAL OF RIGHT EYE SINCE POST TRAUMA.REFERRED TO EYE FOR ASSESMENT AND FURTHER

MANAGEMENTSEEN BY OPTHAL DAY BEFORE DISCHARGE. PLAN AS BELOW.

DISCHARGE PLAN:TCA NEXT FRIDAY 29/1/2010 WITH TRAUMA TEAMTCA REHAB CLINIC 1/12. TO CONSIDER CASTINGTCA NEUROSURGERY 3/12TCA 1/12 TO R/V WITH RPT HVF- PLAN KIV TO START

ANTIGLAUCOMA. ( TX AS NTG) IF HVF STILL UNCONCLUSIVE

AS PLANED BY OPTHAL



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