Acromio-Clavicular Injuries in athlete-1

ACROMIOCLAVICULAR
INJURIES
IN ATHLETE
VIRGINIA A NUGROHO (188071700011003)
PPDS IKFR FKUB MALANG
PEMBIMBING: DR. SAMIAH RACHMAWATI, SPKFR
04 AGUSTUS 2019
Definition
injury to the acromioclavicular (AC) joint with disruption of the
AC ligaments with or without coracoclavicular (CC) ligament
disruption
Epidemiology
• Incidence
common injury making up 9% of shoulder girdle injuries
• demographics
more common in males and athletes
Mechanism
• direct trauma from a fall or
• blow to the acromion
• chronic injuries from overuse stress.
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
ANATOMY
ACROMIOCLAVICULAR
JOINT
• diarthrodial joint:
the articulation between
the lateral end of the
clavicle and the medial
acromion of the scapula
• covered by
fibrocartilage
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicularinjuries-ac-separation
• acromioclavicular (AC) ligaments
• controls horizontal motion and anterior- ANATOMY OF
posterior stability
LIGAMENTS AC
• has superior, inferior, anterior and posterior
components
• posterior and superior AC ligaments are most
important for stability
• coracoclavicular (CC) ligaments
• controls vertical motion and superiorinferior stability
• two ligaments
• conoid
• medial
• inserts on clavicle 4.5cm medial to lateral edge
• most important for vertical stability
• trapezoid
• lateral
• inserts on clavicle 3cm medial to lateral edge
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
MOTION
a) primarily gliding motion
b) rotational motion is minimal
• clavicle rotates 40-50° posteriorly with shoulder elevation
• only 5~8° rotation through the AC joint, due to synchronous
scapuloclavicular motion
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
CLASSIFICATION OF
ACROMIOCLAVICULAR
JOINT INJURIES
Ellenbecker, T.S., 2011. Shoulder
rehabilitation: Non-operative
SIGN & SYMPTOMS
• Type 1 : Minimal tenderness and swelling  pain is generally
self-limiting  discomfort with full-arm abduction and flexion
• Type 2 : minimal to moderate strength and ROM deficiencies.
• Type 3 : pain and an easily identifiable deformity (step-off
deformity)  holding the arm in the adducted position to
counteract the pain produced by the weight of the arm.
• Type 4 : bump in the posterior skin of the shoulder.
• Type 5 : severe shoulder droop, marked pain, and a CC
distance increase up to three times
• Type 6 : acromion will be prominent on palpation with an
obvious step down to the clavicle. It has been reported that
occasional transient paresthesia accompanies this
dislocation; however, it subsides with reduction
Ellenbecker, T.S., 2011. Shoulder rehabilitation: Non-operative treatment. Thieme.
EXAMINATION
• observation of the
static position of the
shoulder girdle,
• palpation of the AC
joint and surrounding
structures,
• provocative testing,
which may include
radiographs.
Cuccurullo, S.J., 2014. Physical medicine and rehabilitation board review. Demos Medical Publishing.
Brotzman, S.B. and Manske, R.C., 2011. Clinical orthopaedic rehabilitation e-book:
An evidence-based approach-expert consult. Elsevier Health Sciences.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Stanley, H., 1976. Physical examination of the spine and extremities. New York.
IMAGING
• Radiographs required views
•
bilateral anteroposterior (AP) view of AC joints
•
compare displacement to contralateral side
•
•
•
measured as distance from top of coracoid to bottom of clavicle
axillary lateral view
•
required to diagnose Type IV (posterior)
•
performed by tilting the x-ray beam 10-15° cephalad and using only 50% of the standard shoulder AP
penetrance
zanca view
• additional veiws
•
•
cross-body adduction view (Basmania)
•
scapular Y performed with cross-body adduction stress
•
•
usually no longer used
may help differentiate Type II from Type III
weighted stress views
• findings
•
fractures can mimic AC separations
•
•
base of coracoid fracture
Neer type 2A distal clavicle fracture
•
ligaments remain attached to distal fragment as proximal (medial) fragment displaces
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
axillary lateral view
zanca view
DIFFERENTIAL DIAGNOSA
• Coracoid fracture
• base of coracoid fracture can mimic a CC ligament
disruption
• has superiorly displaced distal clavicle, but normal CC
distance (normal is 11-13mm)
• Distal clavicle fracture (Neer 2A)
- can mimic AC separations as well, as ligaments
remain attached to distal component
• Rotator cuff tear (most tenderness over the greater
tuberosity, not the AC joint; no visible deformity or
radiographic findings)
• Fracture of the acromion
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
TREATMENT
Treatment
• depending on the degree of separation and acuity of injury.
ACUTE AC JOINT INJURIES:
• Types I and II
– Rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs).
– Sling for comfort for the first 1 to 2 weeks.
– Avoid heavy lifting and contact sports.
– Shoulder–girdle complex stabilization and strengthening.
– Return to play: When the patient is asymptomatic with full ROM.
■ ■ Type I: 2 weeks
■ ■ Type II: 6 weeks
• Type III: Controversial
– Conservative or surgical route depends on the patient’s need (occupation or sport) for
particular shoulder stability.
– Surgical for those indicated (heavy laborers, athletes).
• Types IV, V, and VI
– Surgery is recommended: Open reduction internal fixation (ORIF) or distal clavicular
resection with reconstruction of the CC ligament.
CHRONIC AC JOINT INJURIES/PAIN
• Corticosteroid injection.
• May require a clavicular resection and CC reconstruction
Cuccurullo, S.J., 2014. Physical medicine and rehabilitation board review. Demos Medical Publishing.
TREATMENT NON-OPERATIVE
• Type 1 : often not be medically treated , patients
typically ignore the injury.
• If treated, the Goals  (1) regulate the pain
response, (2) promote a healing environment
as well as protect the damaged tissue, and
(3) deter ROM loss.
• icing the injured area incrementally and positioning
the arm in an arm sling up to 1 week. Passive or
active assisted ROM exercises
Ellenbecker, T.S., 2011. Shoulder rehabilitation: Non-operative treatment. Thieme.
• Type 2 : wear a Kenny Howard sling or an AirCast
AC Joint Sports Sling (Aircast Corp., Summit, NJ) up
to 3 weeks
Ellenbecker, T.S., 2011. Shoulder
rehabilitation: Non-operative
treatment. Thieme.
• return to activities and sports within 2 to 4 weeks,
once full ROM and strength are normal.
Ellenbecker, T.S., 2011. Shoulder
rehabilitation: Non-operative treatment.
Thieme.
COMPLICATION
• Residual pain at AC joint
• 30-50%
• AC arthritis
• more common with surgical management than with
nonoperative treatment
• Hardware failure
• CC screw breakage/pullout
• Coracoid fracture
• can occur with coracoid tunnel drilling
- Deformity, weakness on lifting the arm, chronic shoulder
pain, and numbness in the arm are possible.
https://www.orthobullets.com/shoulder-and-elbow/3047/acromio-clavicular-injuries-ac-separation
HOME EXERCISE PROGRAM FOR
ACROMIOCLAVICULAR INJURIES
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5, p.585588.
Brotzman, S.B. and Manske, R.C., 2011. Clinical orthopaedic rehabilitation e-book:
An evidence-based approach-expert consult. Elsevier Health Sciences.
REFERENCE
• Brotzman, S.B. and Manske, R.C., 2011. Clinical orthopaedic
rehabilitation e-book: An evidence-based approach-expert consult.
Elsevier Health Sciences.
• Cuccurullo, S.J., 2014. Physical medicine and rehabilitation board
review. Demos Medical Publishing.
• Cifu, D.X., 2015. Braddom's physical medicine and rehabilitation Ebook. Elsevier Health Sciences.
• Ellenbecker, T.S., 2011. Shoulder rehabilitation: Non-operative
treatment. Thieme.
• Essentials, A.A.O.S., Essentials of Musculoskeletal Care. Section, 5,
p.585588.
• https://www.orthobullets.com/shoulder-and-elbow/3047/acromioclavicular-injuries-ac-separation
• Stanley, H., 1976. Physical examination of the spine and extremities.
New York.