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Acromioclavicular Separations: Etiology & Treatment By Jennifer R. Farrell A Senior Project April 11, 2001.

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Presentation on theme: "Acromioclavicular Separations: Etiology & Treatment By Jennifer R. Farrell A Senior Project April 11, 2001."— Presentation transcript:

1 Acromioclavicular Separations: Etiology & Treatment By Jennifer R. Farrell A Senior Project April 11, 2001

2 Introduction Acromioclavicular (AC) separation:Acromioclavicular (AC) separation: –Acromion pulls apart from clavicle –Scapula falls away –Common in athletics –Classification varies

3 Anatomy of the AC Joint Diarthrodial joint.Diarthrodial joint. –Freely moveable. Formed by the distal clavicle and acromion.Formed by the distal clavicle and acromion. Coracoclavicular (CC), Acromioclavicular (AC) and Coracoacromial (CA) ligaments maintain joint reduction and stability.Coracoclavicular (CC), Acromioclavicular (AC) and Coracoacromial (CA) ligaments maintain joint reduction and stability. (Rockwood et al., 1998)

4 Function of the AC Joint Suspend upper extremitySuspend upper extremity Transmit forces to the axial skeleton.Transmit forces to the axial skeleton. Responsible for allowing arm to swing clear of the trunk (Hauser, 1996).Responsible for allowing arm to swing clear of the trunk (Hauser, 1996). AC joint must have a strong ligament complex for support.AC joint must have a strong ligament complex for support.

5 Ligaments Involved Acromioclavicular capsuleAcromioclavicular capsule –Four AC ligaments Coracoclavicular ligamentCoracoclavicular ligament –Trapezoid and Conoid. Coracoacromial ligamentCoracoacromial ligament (Klassen, Morey & An, 1997)

6 Motion of the AC joint Elevate and abduct the arm.Elevate and abduct the arm. The clavicle is capable of 30° to 40° of upward rotation (Field & Warren, 1996 and Hauser, 1996).The clavicle is capable of 30° to 40° of upward rotation (Field & Warren, 1996 and Hauser, 1996). Motion occurs in a triaxial pattern (Klassen et al., 1997).Motion occurs in a triaxial pattern (Klassen et al., 1997). 90% of restraint to posterior displacement and resistance to horizontal translation by AC ligament (Field & Warren, 1996).90% of restraint to posterior displacement and resistance to horizontal translation by AC ligament (Field & Warren, 1996). Coracoclavicular ligaments are the prime stabilizers and prevent superior dislocation (Klassen et al., 1997).Coracoclavicular ligaments are the prime stabilizers and prevent superior dislocation (Klassen et al., 1997).

7 Classification of Injury AC joint injuries are classified based on the severity of injury sustained to the ligaments and supporting musculature (Rockwood, Williams & Young, 1998).AC joint injuries are classified based on the severity of injury sustained to the ligaments and supporting musculature (Rockwood, Williams & Young, 1998). Traditionally only three types.Traditionally only three types. The most widely used 3-grade classification system is the Tossy system.The most widely used 3-grade classification system is the Tossy system.

8 Tossy System Type I injury:Type I injury: –Basic sprain or contusion of the AC ligaments. –No tear or visible deformity, except slight swelling. Type II injury:Type II injury: –Partial tear of the CC ligaments. –Superior clavicle, obvious swelling and difficulty lifting objects. Type III injury:Type III injury: –Completely ruptured CC ligaments. –Severe pain, disability, swelling and marked deformity (Tossy, Mead & Sigmond, 1963).

9 Classification of Injury Since Tossy et al’s (1963) study, many studies have proposed expanding the classification system.Since Tossy et al’s (1963) study, many studies have proposed expanding the classification system. In addition, the Tossy system has been modified.In addition, the Tossy system has been modified.

10 Modifications to the Original Tossy System Types I, II and III injuries modified in a study by Zlotsky, 1976.Types I, II and III injuries modified in a study by Zlotsky, Field and Warren (1996) divided types II and III into IIA & IIB, and IIIA & IIIB.Field and Warren (1996) divided types II and III into IIA & IIB, and IIIA & IIIB.

11 Additions to the Tossy System In a study by Gazielly (1995) types IV and V were proposed, while keeping the original Tossy classifications the same.In a study by Gazielly (1995) types IV and V were proposed, while keeping the original Tossy classifications the same. Hauser (1996) argued for six classes of AC separations while using the modified Tossy system proposed by Zlotsky (1976).Hauser (1996) argued for six classes of AC separations while using the modified Tossy system proposed by Zlotsky (1976).

12 Classification Overview Most commonly used classification system presently (Rockwood et al., 1998).Most commonly used classification system presently (Rockwood et al., 1998). Types I, II and III depict the modified Tossy system proposed by Zlotsky (1976).Types I, II and III depict the modified Tossy system proposed by Zlotsky (1976). Types IV, V and VI illustrate the classes proposed by Hauser (1996) and Gazielly (1995).Types IV, V and VI illustrate the classes proposed by Hauser (1996) and Gazielly (1995). (Rockwood et al., 1998)

13 Mechanism of Injury  Direct Mechanism*  Indirect Mechanism* * (Rockwood et al., 1998)* (Rockwood et al., 1998)

14 Mechanics of Injury With both direct and indirect trauma, the clavicle usually detaches from the acromion process superiorly.With both direct and indirect trauma, the clavicle usually detaches from the acromion process superiorly. The clavicle will appear as a prominent protrusion on the superior aspect of the shoulder.*The clavicle will appear as a prominent protrusion on the superior aspect of the shoulder.* –*(Irvin et al., 1998). There have been cases reported in which the clavicle is lodged under the acromion, displaced anterior, posterior or simply resting on top of the acromion.*There have been cases reported in which the clavicle is lodged under the acromion, displaced anterior, posterior or simply resting on top of the acromion.* –*(Schwartz & Kuderna, 1988, Shildhaus & Meyers, 1987, & Leonard & Capen, 1983).

15 Diagnosis of Injury Weighted x-raysWeighted x-rays – bilateral Basic anteroposterior and axillary viewsBasic anteroposterior and axillary views

16 Treatment Two types of treatments can be utilized to treat AC separations.Two types of treatments can be utilized to treat AC separations. –Conservative Usually used for types I-III. Usually used for types I-III. –Surgical Most often used for types III-VI. Most often used for types III-VI. Treatment options are controversial and highly debated.Treatment options are controversial and highly debated.

17 Conservative Treatment Conservative treatment has been proven effective in grades I-III.Conservative treatment has been proven effective in grades I-III. –Gazielly (1995) found that surgery can be postponed for 2 to 3 months. Conservative methods include:Conservative methods include: –Taping/Strapping –Ice/NSAIDs –Modalities: E-Stim & Ultrasound –Muscle strengthening

18 Conservative Treatment Basic strapping technique using a modified sling.Basic strapping technique using a modified sling. When taping, the same principle applies.When taping, the same principle applies. Generally it is best to support the arm as shown to limit stress placed on the AC joint.*Generally it is best to support the arm as shown to limit stress placed on the AC joint.* * (Rockwood et al., 1998)

19 Surgical Procedures Four basic types of procedures used:Four basic types of procedures used: –Primary Acromioclavicular Joint Fixation –Primary Coracoclavicular Ligament Fixation –Excision of the Distal Clavicle –Dynamic Muscle Transfer With each of these procedures it is often necessary to remove devices used for reduction.With each of these procedures it is often necessary to remove devices used for reduction.

20 Primary Acromioclavicular Joint Fixation Most popular procedures used today (Rockwood et al., 1998).Most popular procedures used today (Rockwood et al., 1998). Maintain reduction of the AC joint while the injured ligaments heal.Maintain reduction of the AC joint while the injured ligaments heal. It is a common practice to repair damaged ligaments after joint fixation has occurred.It is a common practice to repair damaged ligaments after joint fixation has occurred.

21 Primary Acromioclavicular Joint Fixation Pins, screws, suture wires and metal plates are used to bring the clavicle and acromion together.Pins, screws, suture wires and metal plates are used to bring the clavicle and acromion together. –Steinmann pins (Rockwood et al., 1998). –Wolter & Balser metal “crook” plates (Habernak, Weinstabl, Schmid & Fialka, 1993).

22 Primary Coracoclavicular Ligament Fixation Screws, ligament transfers, and synthetic & metal loopsScrews, ligament transfers, and synthetic & metal loops –Fix CC ligament –Suspend the clavicle from the coracoid process. Examples include:Examples include: –Bosworth screw (Bosworth, 1941). –GORE-TEX loop (Morrison & Lemos, 1995). –PDS bands (Hessman, Gotzen, Gehling & Ricter, 1995).

23 Surgical Procedures Examples of various surgical techniques (Rockwood et al., 1998).Examples of various surgical techniques (Rockwood et al., 1998). –A. Pins or screws across the joint. –B. Loops between the clavicle and coracoid. –C. A coracoclavicular lag screw.

24 Excision of the Distal Clavicle Origin unknown (Rockwood et al., 1998).Origin unknown (Rockwood et al., 1998). Usually done in conjunction with ligament transfer and fixation.Usually done in conjunction with ligament transfer and fixation. –Weaver and Dunn (1972) Treatment for chronic pain (Morrison & Lemos, 1995).Treatment for chronic pain (Morrison & Lemos, 1995).

25 Dynamic Muscle Transfer Severely chronic cases.Severely chronic cases. Transfer of the trapezius and deltoid muscles.Transfer of the trapezius and deltoid muscles. Rarely used.Rarely used. The actual procedure is not clear, and the findings vary (Rockwood et al., 1998)The actual procedure is not clear, and the findings vary (Rockwood et al., 1998)

26 Complications Conservative:Conservative: –Calcification –Arthritis –Loss of strength –Removal of the device –Skin irritation Surgical:Surgical: –Wound infection –Migration of pins, screws, etc. –Scarring –Additional fractures –Excision due to wires –Removal of devices

27 Rehabilitation Following Surgery Limited motionLimited motion Sling for 1 to 2 weeksSling for 1 to 2 weeks Patients are to refrain from heavy lifting after removal of sling.Patients are to refrain from heavy lifting after removal of sling. Muscle strengthening, and stretching at 6 weeks.Muscle strengthening, and stretching at 6 weeks. ModalitiesModalities –E-Stim –Ultrasound Rehabilitation can be more difficult and longer if devices must be removed (Habernek et al., 1993).Rehabilitation can be more difficult and longer if devices must be removed (Habernek et al., 1993).

28 Conclusion Considerable disagreement in the literature regarding classification and treatment.Considerable disagreement in the literature regarding classification and treatment. Type III remains the most controversial.Type III remains the most controversial. Various methods of treatment are available and administered with no standard.Various methods of treatment are available and administered with no standard. Types IV, V and VI are rare.Types IV, V and VI are rare. Necessary to revert back to the initial Tossy system.Necessary to revert back to the initial Tossy system.

29 Questions?


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