Acromioclavicular Joint Injury


Article Author:
John Kiel


Article Editor:
Kimberly Kaiser


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
12/2/2018 12:55:19 PM

Introduction

Injury to the acromioclavicular (AC) joint is a common injury among athletes and young individuals.

Etiology

The AC joint is a diarthrodial joint defined by the lateral process of the clavicle articulating with the acromion process as it projects anteriorly off the scapula. The joint is primarily stabilized by the acromioclavicular ligament providing horizontal stability across the joint. Supporting structures include two coracoclavicular ligaments (trapezoid and conoid ligaments), which provide vertical stability, as well as the coracoacromial ligament. These ligaments can be injured, and if the injury is severe, one or more of these ligaments can be torn. The acromioclavicular joint can also be disrupted clinically and radiographically. Mild injuries are not associated with any significant morbidity, but severe injuries can lead to significant loss of strength and function of the shoulder. Acromioclavicular injuries may be associated with a fractured clavicle, impingement syndromes, and more rarely neurovascular insults.[1][2]

Epidemiology

AC injuries are frequently seen after sporting events, car accidents, falls from a bicycle, and other sports-related activities (e.g., skiing). AC joint injuries account for more than 40% of all shoulder injuries and nearly 10% of all injuries in collision sports such as football, lacrosse, and ice hockey.[3][4]

Pathophysiology

The most common mechanism of injury is direct trauma to the lateral shoulder or acromion process with the arm in adduction. Falling on an outstretched hand or elbow may also lead to AC joint separation.

History and Physical

Patients with an AC joint injury typically present with shoulder pain, usually superior-anterior in location, and will describe a mechanism of injury suggesting this type of injury. They may describe pain radiating to the neck or shoulder which is often worse with movement or when they try to sleep on the affected shoulder. On examination, the clinician may observe swelling, bruising, or a deformity of the AC joint depending on the degree of injury. The patient will be tender at that location. They may have a restriction in active and passive range of motion secondary to pain. The examiner can assess the stability of the AC joint with anterior-posterior mobility (acromioclavicular ligament) and vertical mobility (coracoclavicular ligaments). It is important to evaluate the entire clavicle for possible fracture or sternoclavicular injury as well as perform a full neurovascular exam on the affected extremity.

Evaluation

Standard x-rays are adequate to make a diagnosis of acromioclavicular joint injury and should be used to evaluate for other causes of traumatic shoulder pain. AC joint injuries may not always be evident on regular radiographic views (anteroposterior [AP], lateral). Additional views include the zanca view, an AP view performed by tilting the beam 10 to 15 degrees cranial, as well as bilateral AP views to compare displacement to the contralateral shoulder. Weighted stress views may be used to evaluate the displacement of the joint when the diagnosis is uncertain on standard AP views. If there is continued uncertainty in diagnosis, the provider may also consider ultrasound or MRI for further diagnostic evaluation.

Treatment / Management

Acromioclavicular joint injuries follow a Rockwood classification system of type I to type VI. Type I is referred to as a sprain and demonstrates no radiographic displacement. Type II involves tearing of the acromioclavicular ligament and sprain of the coracoclavicular ligament with less than 25% increase in the coracoclavicular interspace or with the clavicle elevated but not superior to the border of the acromion. Type I and II sprains are managed non-operatively with a sling, analgesia, ice, and physical therapy. Type III AC joint separation involves tearing of both the acromioclavicular ligament and coracoclavicular ligaments resulting in clavicle elevation above the border of the acromion but less than a 25 mm increased coracoclavicular distance on x-ray compared to the contralateral side. Type III injuries are frequently managed non-operatively similar to type I and II; however, if the displacement is greater than 20 mm; the patient is a laborer, elite athlete, or concerned about cosmesis; or is not improving with conservative management, then surgical intervention should be considered. Posterior displacement of the distal clavicle into the trapezius defines type IV injuries. Superior displacement of the distal clavicle by more than 25 mm defines type V injuries. Type VI is rare and is an inferolateral displacement in a subacromial or subcoracoid displacement behind the coracobrachialis or biceps tendon. Type IV through VI injuries are typically managed surgically, and the case should be discussed with an orthopedic surgeon.[1][3][5]

Staging

Rockwood Classification of AC Joint Injuries (acromioclavicular [AC], coracoclavicular [CC]).[6]

  • I: AC ligament sprain; CC ligament intact; no radiographic abnormalities
  • II: AC ligament is torn; CC ligament sprain; clavicle elevated but not superior to the border of the acromion or there is a less than 25% increase in the CC interspace
  • III: AC and CC ligaments are torn; clavicle is elevated above the border of the acromion or there is a 25% to 100% increase in the CC interspace
  • IV: AC and CC ligaments are torn; posterior displacement of the distal clavicle into the trapezius
  • V: AC and CC ligaments are torn; superior displacement of the distal clavicle by more than 25 mm
  • VI: AC and CC ligaments are torn; inferolateral displacement in a subacromial or subcoracoid displacement behind the coracobrachialis or biceps tendon

Prognosis

The prognosis for AC joint injuries is generally favorable. Most injuries are non-operative, and individuals typically regain functional motion by 6 weeks and return to normal activity by 12 weeks. Surgically managed injuries have a longer recovery time including immobilization for 6 weeks and a gradual return to full activity around 6 months.[7][8][9]

Complications

The most common complication of AC joint separation is residual joint pain affecting anywhere from 30% to 50% of individuals. AC joint arthritis is also a known complication and is more common with surgical management.

Postoperative and Rehabilitation Care

Rehabilitation of AC joint separation primarily includes rest, a brief period of immobilization in a sling (typically 3 to 7 days), ice, NSAIDs, and physical therapy. Return to physical activity and sport is guided by both the physician and physical therapist.

Consultations

Type I and II AC joint separations do not necessarily require an evaluation by a specialist; however, type III through VI should be evaluated by an orthopedic surgeon or sports medicine physician.

Deterrence and Patient Education

  • A separated shoulder or AC joint injury is an injury to the joint formed by the collarbone and a bone of the shoulder blade that sits on top of the shoulder.
  • This injury is most commonly caused by falling directly on or taking direct blow to that shoulder.
  • Symptoms typically include pain and swelling.
  • Most shoulder separations can be managed without surgery but can take weeks to months to heal.
  • Management includes a sling, ice, rest, analgesics, and physical therapy.
  • Although uncommon, more severe shoulder separations can require surgery.
  • Most individuals can return to their usual activities after being cleared by their physician.

Pearls and Other Issues

  • The position of the AC joint makes it vulnerable to direct trauma to the superior or lateral aspect of the shoulder.
  • In an isolated injury, patients typically have pain and swelling over the joint with or without a deformity depending on the degree of injury.
  • All patients should receive a radiographic evaluation of the affected shoulder, and if the diagnosis is in question, obtain radiographs of the contralateral AC joint as well.
  • Type I and II injuries occur twice as frequently as type III to VI injuries.
  • Most injuries can be managed non-operatively. If uncertainty exists or it is a Rockwell grade III or greater, an orthopedic physician should be urgently consulted.
  • Non-operative management includes rest, protection with a sling, ice, NSAIDs, and physical therapy.

Enhancing Healthcare Team Outcomes

AC joint injuries commonly present to the emergency department. The mild injuries are usually managed conservatively but the severe injuries may require surgery; hence it is important to consult the orthopedic surgeon when the diagnosis is made to grade the injury. For mild injuries, the nurse practitioner, emergency department physician and primary caregiver should recommend physical therapy, once the acute pain has resolved. Pharmacist and nurses should work with the team to educate the patient and family and assist in pain control.  Those wishing to return to sports should first consult with the orthopedic surgeon. [10]


  • Image 40 Not availableImage 40 Not available
    Contributed by S. Dulebohn, M.D.
Attributed To: Contributed by S. Dulebohn, M.D.

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Acromioclavicular Joint Injury - Questions

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A 17-year-old male was hiking when he tripped and fell on his side, landing on the lateral aspect of his left shoulder where you observe a minor abrasion. He is able to abduct, extend, and flex at the shoulder, but is limited by pain. He reports a painful lump on the top of the shoulder at the lateral aspect of the clavicle. His radial pulse is 2+ and sensation to light touch is intact. Which of the following is the most likely diagnosis?



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What is the appropriate treatment for a type II acromioclavicular joint injury?



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A football player who sustained a direct blow to the shoulder has tenderness over the acromioclavicular joint but no step-off or deformity. X-rays show no fracture, dislocation, or subluxation. Which of the following is the best management?



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Which type of acromioclavicular joint injuries do not require surgical intervention and can be managed non-operatively?



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Which radiographs are useful in the evaluation of a suspected acromioclavicular joint injury?



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A 49-year-old male presents to the clinic complaining of shoulder pain after tripping and falling onto his outstretched hand. Which of the following physical exam maneuvers has the greatest sensitivity for identifying acromioclavicular joint pathology?



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A 58-year-old female presents to the emergency department after a motor vehicle accident, in which she was ejected from the vehicle. She complains of severe shoulder pain located diffusely along the superior aspect of her shoulder. On physical examination of the shoulder, there is scattered ecchymoses with notable superior displacement of the distal clavicle by 3 cm. There is pain to palpation along the clavicle, which does not articulate with the acromion. According to the Rockwood classification of acromioclavicular dislocations, what type is this dislocation?



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A 25-year-old male football player presents for evaluation of shoulder pain after another player tackled him and fell on his shoulder. He did not feel a "pop" and was able to play the rest of the day. However, the pain has progressively worsened. On general inspection, there is no acute abnormality, deformity, or dislocation. There is pain to palpation at the acromioclavicular joint. Adduction of the arm across the body elicits pain. Radiographs of the shoulder show no fractures or dislocation. According to the Rockwood classification, what type of acromioclavicular injury does this patient have?



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A 17-year-old male football player presents for evaluation of shoulder pain after another player tackled him and fell on his shoulder. He did not feel a "pop" and was able to play the rest of the day. However, the pain has progressively worsened. On general inspection, there is no acute abnormality, deformity, or dislocation. There is pain to palpation at the acromioclavicular joint. Adduction of the arm across the body elicits pain. Radiographs of the shoulder show no fractures or dislocation. According to the Rockwood classification, what type of acromioclavicular injury does this patient have?



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A 17-year-old male comes into the clinic with complaints of significant right shoulder pain. He fell directly onto his shoulder after diving for a tackle in a football game. On physical exam, there is tenting laterally and significant tenderness to palpation. X-rays reveal no fractures of the clavicular shaft or proximal humerus; however, the lateral aspect of the clavicle seems to be riding superiorly in relation to the acromion. What is the most likely diagnosis?



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Acromioclavicular Joint Injury - References

References

Gowd AK,Liu JN,Cabarcas BC,Cvetanovich GL,Garcia GH,Manderle BJ,Verma NN, Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques. The American journal of sports medicine. 2018 Oct 1     [PubMed]
Hyland S,Varacallo M, Anatomy, Shoulder and Upper Limb, Clavicle null. 2018 Jan     [PubMed]
Sirin E,Aydin N,Mert Topkar O, Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures. EFORT open reviews. 2018 Jul     [PubMed]
Ruiz Ibán MA,Sarasquete J,Gil de Rozas M,Costa P,Tovío JD,Carpinteiro E,Hachem AI,Perez España M,Asenjo Gismero C,Diaz Heredia J,García Navlet M, Low prevalence of relevant associated articular lesions in patients with acute III-VI acromioclavicular joint injuries. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2018 Aug 10     [PubMed]
Hashiguchi H,Iwashita S,Abe K,Sonoki K,Yoneda M,Takai S, Arthroscopic Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Dislocation. Journal of Nippon Medical School = Nippon Ika Daigaku zasshi. 2018     [PubMed]
Granville-Chapman J,Torrance E,Rashid A,Funk L, The Rockwood classification in acute acromioclavicular joint injury does not correlate with symptoms. Journal of orthopaedic surgery (Hong Kong). 2018 May-Aug     [PubMed]
Stein T,Müller D,Blank M,Reinig Y,Saier T,Hoffmann R,Welsch F,Schweigkofler U, Stabilization of Acute High-Grade Acromioclavicular Joint Separation: A Prospective Assessment of the Clavicular Hook Plate Versus the Double Double-Button Suture Procedure. The American journal of sports medicine. 2018 Sep     [PubMed]
Byrne PA,Hopper GP,Wilson WT,Mackay GM, Acromioclavicular Joint Stabilisation Using the Internal Brace Principle. Surgical technology international. 2018 Nov 11     [PubMed]
López-Alameda S,Fernández-Santás T,García-Villanueva A,Varillas-Delgado D,Garcia de Lucas F, Results of surgical treatment of acromioclavicular dislocations type III using modified Weaver Dunn technique. Revista espanola de cirugia ortopedica y traumatologia. 2018 Mar - Apr     [PubMed]
Müller D,Reinig Y,Hoffmann R,Blank M,Welsch F,Schweigkofler U,Stein T, Return to sport after acute acromioclavicular stabilization: a randomized control of double-suture-button system versus clavicular hook plate compared to uninjured shoulder sport athletes. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2018 Dec     [PubMed]

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