ACROMIOCLAVICULAR INJURYHerry S. NatawijayaOrthopaedic and TraumatologyBandung

AnatomyDiarthrodial jointArticular surface: hyaline cartilage fibrocartilageAC ligament and deltoid-trapezius muscle horizontal stabilityCC ligament : conoid and trapezoid vertical stability

IncidenceRowe - Marble (1962): 52 AC joint injury among 1603 shoulder-girdle injuryThorndike - Quigley (1956): 223 of 578 athletes Rockwood : 300 of 520 third decadesMale : female = 5:1 to 10 : 1

ClassificationGraded by the amount of injury to the AC and CC ligamentCadenat (1917), complete and incompleteAllman-tossy, recognized 3 typeRockwood dan Salvatore, mencadi 6

Classification

DiagnosisMechanism of InjuryPhysical ExaminationRadiographic findings

Mechanism of Injury

DIRECT FORCEFalling onto the point of the shoulderThe arm in an adducted position

Mechanism of Injury

INDIRECT FORCEFall on the outstretched handA force transmitted to the arm, humeral head, acromion process AC injury

Physical ExaminationType I: minimal pain with arm movement, no tenderness over CC interspacesType II: subluxation of the AC joint, moderate to severe pain, clavicle may superior to the acromion, AC joint pain when shoulder move, clavicle unstable

Physical ExaminationType IIIcomplete dislocation of AC joint upper extremity adductedclavicle prominent to tent the skinany motion of the arm increases the pain

Physical ExaminationType IVsame to type IIclavicle displaced posteriorlymotion of the shoulder is more painful

Physical ExaminationType Vsame with type IIIclavicle grossly superior displaced toward the base of the neckextensive muscle and soft-tissue disruption

Physical ExaminationType VIsuperior aspect of the shoulder flat acromion is prominentinferior stepdown of coracoid processthere may be associated fracture of clavicula and rib

Radiographic findingsAP viewZanka viewAxillary lateral viewStryker notch viewAP Stress viewLateral Stress view

Radiographic findingsStryker Notch viewZanka view

Radiographic findingsAP stress view

Radiographic findingsType INormalMild soft-tissue swelling No widening, no separation, no deformityType IILateral clavicle slightly elevatedAC joint widened

Radiographic findingsType IIIComplete AC dislocationClavicle displacedIncrease CC interspace

Radiographic findingsType IVPosterior displacement of the distal clavicleIncrease CC interspace

Radiographic findingsType VMarked increase CC interspaceClavicle grossly displaced superiorly from acromion

Radiographic findingsType VITwo types of inferior AC diclocation: subacromial and subcoracoidSubacromial type: decrease CC distance, clavicle is in a subacromialSubcoracoid type: reversed CC distance, clavicle displaced inferior to the coracoid process

Treatment Type ISymptoms subside after 7 10 daysIce bag Shoulder protected until painless

TreatmentType IIArm sling : 10 -14 daysEarly and gradual rehabilitationAvoid heavy lifting and contact sport : 8 -12 (6) weeksPersistent pain operative

Treatment Type IIIControversial non-operative is majorityNon-operative: short-term (1-2 weeks) sling support, NSAID, early mobilizationOperative: Possible indication: polytraumaVarious operative procedure

Treatment

TreatmentType IV and VReduction of the deformity and stabilization of the clavicleORIF followed conservative treatmentRepair of the deltotrapezial fascia

TreatmentType VIOpen reduction by lateral retraction of the scapulaClavicle stabilizing:Deltoid and trapezius muscle repair AC joint capsule repair

Prognosis Type I,excellentType II,recover fully, but small percentage required debridement or excision of clavicle because of arthritisType III,IV,V,VI, excellent result with both operative and non-operative

Complication Operative Wound infection, osteomyelitis, AC arthritis, soft-tissue ossification, erosions of bone by metal, late fracture through the implant holes in the bone, procedure to remove, migrations of metal, metal failure, unsightly scar, inadequate purchase of the fixation, recurrent deformity.

ComplicationNon-operativeTissue interposed, joint stiffness, close supervision, immobilization device restrictive and uncomfortable, skin irritation, lose the reduction, everyday activities restricted, pressure sores, deformity, soft-tissue ossification, AC arthritis.

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