Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint Andrew H. Schmidt, M.D. Revised October 2010 Andrew H. Schmidt, MD & T. J. McElroy, MD; Created March 2004; Revised January 2007 & October 2010

Goals 1) Review anatomy of clavicle, AC joint, and sternoclavicular joint 2) Review imaging of these areas. 3) Clavicle Fractures Nonoperative RX Surgical Repair Nonunions and Malunions 4) AC Joint Injuries 5) Sternoclavicular joint injuries

Clavicle “S”-shaped bone Medial - sternoclavicular joint Lateral - acromioclavicular joint and coracoclavicular ligaments Muscle attachments: Medial: sternocleidomastoid Lateral: Trapezius, pectoralis major

AC Joint Diarthrodial joint between medial facet of acromion and the lateral (distal) clavicle. Contains intra-articular disk of variable size. Thin capsule stabilized by ligaments on all sides: AC ligaments control horizontal (anteroposterior ) displacement Superior AC ligament most important

Distal Clavicle Coracoclavicular ligaments “Suspensory ligaments of the upper extremity” Two components: Trapezoid Conoid Stronger than AC ligaments Provide vertical stability to AC joint

Mechanism of Injury Direct impact to the anterior - superior shoulder of moderate – high force. Fall from height Motor vehicle accident Sports injury Blow to the point of the shoulder Rarely, a direct injury to the clavicle

Physical Examination Inspection Evaluate deformity and/or displacement Beware of rare inferior or posterior displacement of distal or medial ends of clavicle Compare to opposite side.

Look for instability with stress Physical Examination Palpation Evaluate pain Look for instability with stress

Physical Examination Neurovascular examination Must be done thoroughly and documented! Evaluate upper extremity motor and sensation Measure shoulder range-of-motion

Radiographic Evaluation of the Clavicle Anteroposterior View 30-degree Cephalic Tilt View

Radiographic Evaluation of the Clavicle Quesana View 45-degree angle superiorly and a 45-degree angle inferiorly Provide better assessment of the extent of displacement

Radiographic Evaluation of the AC Joint Zanca View AP view centered at AC joint with 10 degree cephalic tilt Less voltage than used for AP shoulder

Stress Views of the Distal Clavicle & AC Joint Rationale: demonstrate instability and differentiate grade III AC separations from partial Grade I-II injuries. Performed by having patient hold 10# weight with injured arm. Rarely used today, since most Grade I-III AC joint injuries are treated the same anyway, and management of distal clavicle fractures depends on initial displacement and location of fracture.

Radiographic Evaluation of the Medial One Third X-ray: Cephalic tilt view of 40 to 45 degrees CT scan usually indicated to best assess degree and direction of displacement S=sternum C= medial clavicle E= esophagus

Clavicle Fractures

Classification of Clavicle Fractures Group I : Middle third Most common (80% of clavicle fractures) Group II: Distal third 10-15% of clavicle injuries Group III: Medial third Least common (approx. 5%)

Titanium elastic nails (usually inserted medial to lateral) Treatment Options Nonoperative Sling Brace Surgical Plate Fixation Screw or Pin Fixation Titanium elastic nails (usually inserted medial to lateral)

Nonoperative Treatment “Standard of Care” for most clavicle fractures. Unclear about the need to wear a specialized brace.

Simple Sling vs. Figure-of-8 Bandage Prospective randomized trial of 61 patients Simple sling Less discomfort Functional and cosmetic results identical Alignment of healed fractures unchanged from the initial displacement in both groups Andersen et al., Acta Orthop Scand 58: 71-4, 1987.

Nonoperative Treatment It is difficult to reduce clavicle fractures by closed means. Most clavicle fractures unite rapidly despite displacement. Significantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion.

Nonoperative Treatment There is new evidence that the outcome of nonoperative management of displaced middle-third clavicle fractures is not as good as traditionally thought, with many patients having significant functional problems.

Deficits following nonoperative treatment of displaced midshaft clavicular fractures A patient-based outcome questionnaire and muscle-strength testing were used to evaluate 30 patients after nonoperative care of a displaced midshaft fracture of the clavicle. At a minimum of twelve months (mean 55 mos), outcomes were measured with the Constant shoulder score and the DASH patient questionnaire. In addition, shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control. McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

Deficits following nonoperative treatment of displaced midshaft clavicular fractures The strength of the injured shoulder was: 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all). Mean Constant score = 71 points Mean DASH score = 24.6 points, indicating substantial residual disability. McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.

Conclusion of McKee study Displaced midshaft clavicle fractures can cause significant, persistent disability, even if they heal uneventfully.

Definite Indications for Surgical Treatment of Clavicle Fractures 1) Open fractures 2) Associated neurovascular injury

Relative Indications for Acute Treatment of Clavicle Fractures 1) Widely displaced fractures 2) Multiple trauma 3) Displaced distal-third fractures

Relative Indications for Acute Treatment of Clavicle Fractures 4) Floating shoulder 5) Seizure disorder 6) Cosmetic deformity 7) Earlier return to work.

Clavicular Displacement Literature < 5 mm shortening: acceptable results at 5 years (Nordqvist et al, Acta Orthop Scand 1997;68:349-51. > 20 mm shortening associated with increased risk of nonunion and poor functional outcome at 3 years (Hill et al, JBJS 1997;79B: 537-9)

Plate Fixation Traditional means of ORIF Plate applied superiorly or inferiorly Inferior plating associated with lower risk of hardware prominence. Used for acute displaced fractures and nonunions.

May dissect out supraclavicular sensory nerves Courtesy T. Higgins

Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A multicenter, randomized clinical trial 132 patients 67 ORIF 65 sling Constant and DASH scores significantly improved in ORIF group. Time to union 16 vs 28 weeks in favor of ORIF 9 patients in sling group had symptomatic malunion 9 patients in ORIF group had hardware complications Canadian Orthopedic Trauma Society; JBJS Am;2007:89A: 1-10

Intramedullary Fixation Large threaded cannulated screws Flexible elastic nails K-wires Associated with risk of migration Useful when plate fixation contra-indicated Bad skin Severe osteopenia Fixation less secure

Titanium Elastic Nails Same as used in pediatric femur fractures. Accommodate three-dimensional anatomy of the clavicle. Typically inserted “retrograde” (from medial to lateral) Best in fractures without comminution Small incision at fracture site may be needed.

31 cases evaluated 26 mos avg (6-46 mos) Three groups: Minimally Invasive Intramedullary Nailing of Midshaft Clavicular Fractures Using Titanium Elastic Nails 31 cases evaluated 26 mos avg (6-46 mos) Three groups: Isolated, n=9 Additional injuries, n=15 Multiple injuries, n=7 Mueller M, et al. J Trauma 2008;64:1528-1534

Minimally Invasive Intramedullary Nailing of Midshaft Clavicular Fractures Using Titanium Elastic Nails No nonunions or refractures in any group. 7 cases medial migration; 1 case lateral perforation in 1 case req’d shortening of nail. No differences in outcome between groups in subjective outcome and objective scores (DASH, Constant and Murley). Mueller M, et al. J Trauma 2008;64:1528-1534

30 patients: simple shoulder sling 90% union 2 symptomatic malunions req’d OR 30 patients elastic nail 100% union 7 cases medial nail protrusion 2 refractures Better DASH and Constant outcome scores, significantly different during first 18 weeks. Patients more satisfied with cosmetic appearance and overall outcome.

Comparison of Techniques No studies available that compare one operative technique to another. Both elastic nails and plates seem equivalent in stable fractures; benefits of minimally invasive approach used in elastic nailing awaiting study. Plate fixation best in comminuted fractures, but again no evidence.

Does Timing of Surgery Matter? Matched group comparison of 15 patients who underwent early compression plate fixation to 15 other patients who had operative repair of a malunion/nonunion at avg of 63 months. Potter JM, et al. J Shoulder Elbow Surg 2007;16:514-8

Does Timing of Surgery Matter? Outcome Early Delayed Strength = = Endurance 109% 80% (p=.05) Constant score 95 89 (p=.02) DASH score 3.0 7.2 (p=.15) Satisfaction exc exc Potter JM, et al. J Shoulder Elbow Surg 2007;16:514-8

Does Timing of Surgery Matter? Conclusion: Late reconstruction provides outcome similar to acute repair, except for subtle decreases in endurance strength. Such information might be of value in initial decision-making. Potter JM, et al. J Shoulder Elbow Surg 2007;16:514-8

Complications of Clavicular Fractures and its Treatment Nonunion Malunion Neurovascular Sequelae Post-Traumatic Arthritis

Risk Factors for the Development of Clavicular Nonunions Location of Fracture (outer third) Degree of Displacement (marked displacement) Primary Open Reduction

Principles for the Treatment of Clavicular Nonunions Restore length of clavicle May need intercalary bone graft Rigid internal fixation, usually with a plate Iliac crest bone graft Role of bone-graft substitutes not yet defined.

Correction of symptomatic nonunion with IM screw

Clavicular Malunion Symptoms of pain, fatigue, cosmetic deformity. Initially treat with strengthening, especially of scapulothoracic stabilizers. Consider osteotomy, internal fixation in rare cases in which nonoperative treatment fails. Correction of malunion with thoracic outlet sx

Neurologic Sequelae Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms. Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions.

Osteotomy for Clavicular Malunion 15 patients with malunion after nonoperative treatment of a displaced midshaft clavicle fracture of the clavicle. Average clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm). Mean time from the injury to presentation was three years (range, 1 to 15 years). Outcome scores revealed major functional deficits. All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation. McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7

Osteotomy for Clavicular Malunion At follow-up (mean 20 months postoperatively) the osteotomy site had united in 14 of 15 patients. All 14 patients satisfied with the result. Mean DASH score for all 15 patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001). Mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01). There was 1 nonunion, and 2 patients had elective removal of the plate. McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7

Functional Outcome of Surgical Treatment of Symptomatic Nonunion and Malunion of Midshaft Clavicle Fractures 13 cases plate fixation / autogenous grafting of a clavicle nonunion / malunion, followed mean 41 months. All united 46% returned to previous job and sport Constant scores remained lower than opposite arm <25% free of pain. Rosenberg N, et al. J Shoul Elbow Surg 2007;16:510-513

Distal Third Clavicle Fractures

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Classification of Distal Clavicular Fractures (Group II Clavicle Fractures) Type I-nondisplaced Between the CC and AC ligaments with ligament still intact From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Classification of Distal Clavicular Fractures Type II Typically displaced secondary to a fracture medial to the coracoclavicular ligaments, keeping the distal fragment reduced while allowing the medial fragmetn to displace superiorly Highest rate of nonunion (up to 30%) Two Types

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Type IIA A. Conoid and trapezoid attached to distal fragment From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Type IIB Type IIB: Conoid torn, trapezoid attached From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Classification of Distal Clavicular Fractures Type III:articular fractures From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Treatment of Distal-Third (Type II) Clavicle Fractures Nonoperative treatment 22 to 33% failed to unite 45 to 67% took more than three months to heal Operative treatment 100% of fractures healed within 6 to 10 weeks after surgery

Displaced Type II fractures of the distal clavicle are often treated more aggressively because of the increased risk of nonunion with nonoperative treatment

Techniques for Acute Operative Treatment of Distal Clavicle Fractures Kirschner wires inserted into the distal fragment Dorsal plate fixation CC screw fixation Tension-band wire or suture Transfer of coracoid process to the clavicle Clavicular Hook Plate

For most techniques of clavicular fixation, coracoclavicular fixation is also needed to prevent redisplacement of the medial clavicle.

The Hook Plate (Synthes USA, Paoli, PA) was specifically designed to avoid this problem of redisplacement.

Hook Plate - Results Recent series of distal clavicle fractuers treated with the Hook Plate document high union rates of 88% - 100%. Complications are rare but potentially significant, including new fracture about the implant, rotator cuff tear, and frequent subacromial impingement.

Manual reduction of fracture Preferred technique for fixation of acute distal third clavicle fractures Horizontal incision Manual reduction of fracture Dorsal tension band suture and reconstruction/augmentation of coracoclavicular ligaments.

Look for avulsion fracture of CC ligament attachment If present, this fragment can be sutured to proximal (eg. medial) clavicle to restore stability, without need for hardware. Jackson WFM, et al. J Trauma 2006;61:222-225

Indications For Late Surgery For Distal Clavicle Fractures Pain Weakness Deformity

Techniques For Late Surgery For Distal Clavicle Fractures Excision of distal clavicle With or without reconstruction of coracoclavicular ligaments (Modified Weaver-Dunn procedure) Reduction and fixation of fracture

Case Example 1

Case Example 1 Medial Clavicle Distal Clavicle

Case Example 1 Fixation to Acromion Coracoclavicular fixation not visible

Case Example 2 This fragment likely has CC ligament attached; need to reduce and hold clavicle shaft to this piece.

Case Example 2 Sutures passed into this fragment (not visible) This fragment likely has CC ligament attached; need to reduce and hold clavicle shaft to this piece.

Case Example 2 Sutures passed into this fragment (not visible) This fragment likely has CC ligament attached; need to reduce and hold clavicle shaft to this piece. 4 months

Case Example 2 Sutures passed into this fragment (not visible) This fragment likely has CC ligament attached; need to reduce and hold clavicle shaft to this piece. 2 years

Acromioclavicular Joint

Mechanism Sports injury or trauma. Impact to superior acromion, driving the arm down and rupturing the AC joint capsule (first) and then the the coracoclavicular ligaments (second).

Physical Findings Pain over lateral clavicle / AC joint May have prominent distal clavicle May have skin abrasions Unwilling to lift arm. Should have full passive ROM of the shoulder.

Radiographic Evaluation of the Acromioclavicular Joint Proper exposure of the AC joint requires one-third to one-half the x-ray penetration of routine shoulder views Initial Views: Anteroposterior view Zanca view (15 degree cephalic tilt) Other views: Axillary: demonstrates anterior-posterior displacement Stress views: not generally relevant for treatment decisions.

Classification For Acromioclavicular Joint Injuries Initially classified by both Allman and Tossy et al. into three types (I, II, and III). Rockwood later added types IV, V, and VI, so that now six types are recognized. Classified depending on the degree and direction of displacement of the distal clavicle. Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. JBJS 49A: 774-784, 1967. Rockwood CA Jr and Young DC. Disorders of the acromioclavicular joint, In Rockwood CA, Matsen FA III: The Shoulder, Philadelphia, WB Saunders, 1990, pp. 413-476.

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Type I Sprain of acromioclavicular ligament AC joint intact Coracoclavicular ligaments intact Deltoid and trapezius muscles intact From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Type II AC joint disrupted < 50% Vertical displacement Sprain of the coracoclavicular ligaments CC ligaments intact Deltoid and trapezius muscles intact From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Type III AC ligaments and CC ligaments all disrupted AC joint dislocated and the shoulder complex displaced inferiorly CC interspace greater than the normal shoulder(25-100%) Deltoid and trapezius muscles usually detached from the distal clavicle From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Type III Variants “Pseudo-dislocation” through an intact periosteal sleeve Physeal injury Coracoid process fracture

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Type IV AC and CC ligaments disrupted AC joint dislocated and clavicle displaced posteriorly into or through the trapezius muscle Deltoid and trapezius muscles detached from the distal clavicle From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Type V AC ligaments disrupted CC ligaments disrupted AC joint dislocated and gross disparity between the clavicle and the scapula (100-300%) Deltoid and trapezius muscles detached from the distal half of clavicle From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997 Type VI AC joint dislocated and clavicle displaced inferior to the acromion or the coracoid process AC and CC ligaments disrupted Deltoid and trapezius muscles detached from the distal clavicle From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Treatment Options For Types I - II Acromioclavicular Joint Injuries Nonoperative: Ice and protection until pain subsides (7 to 10 days). Return to sports as pain allows (1-2 weeks) No apparent benefit to the use of specialized braces.

Type II operative treatment Generally reserved only for the patient with chronic pain. Treatment is resection of the distal clavicle and reconstruction of the coracoclavicular ligaments.

Treatment Options For Type III-VI Acromioclavicular Joint Injuries Nonoperative treatment Closed reduction and application of a sling and harness to maintain reduction of the clavicle Short-term sling and early range of motion Operative treatment Primary AC joint fixation Primary CC ligament reconstruction (usually with allograft, often with augmentation) Excision of the distal clavicle Dynamic muscle transfers

Type III Injuries: Need for acute surgical treatment remains very controversial. Most surgeons recommend conservative treatment except in the throwing athlete or overhead worker. Repair generally avoided in contact athletes because of the risk of reinjury.

Literature unable to support operative or nonoperative treatment as superior Functional outcomes appear similar. Cosmesis not different (scar vs bump) Only 50% of surgical cases reduced at follow-up. 10% complications after surgery. Ceccarelli et al. J Orthopaed Traumatol 2008;9:105-108.

Indications for Acute Surgical Treatment of Acromioclavicular Injuries Type III injuries in highly active patients Type IV, V, and VI injuries

Surgical Options for AC Joint Instability Coracoid process transfer to distal transfer (Dynamic muscle transfer) Primary AC joint fixation Primary Coracoclavicular Fixation CC ligament reconstruction +/- distal clavicle excision.

Weaver-Dunn Procedure The distal clavicle is excised. The CA ligament is transferred to the distal clavicle. The CC ligaments are repaired and/or augmented with a coracoclavicular screw or suture. Repair of deltotrapezial fascia From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

Indications for Late Surgical Treatment of Acromioclavicular Injuries Pain Weakness Deformity

Techniques for Late Surgical Treatment of Acromioclavicular Injuries Reduction of AC joint and repair of AC and CC ligaments Resection of distal clavicle and reconstruction of CC ligaments (Weaver-Dunn Procedure)

Case Example AP View Zanca View

Case Example After Weaver-Dunn procedure

Sternoclavicular Joint From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

The Anatomy of the Sternoclavicular Joint Diarthrodial Joint “Saddle shaped” Poor congruence Intra-articular disc ligament. Divides SC joint into two separate joint spaces. Costoclavicular ligament- (rhomboid ligament) Short and strong and consist of an anterior and posterior fasciculus

Interclavicular ligament- Connects the superomedial aspects of each clavicle with the capsular ligaments and the upper sternum Capsular ligament- Covers the anterior and posterior aspects of the joint and represents thickenings of the joint capsule. The anterior portion of the ligament is heavier and stronger than the posterior portion.

Epiphysis of the Medial Clavicle Medial Physis- Last of the ossification centers to appear in the body and the last epiphysis to close. Does not ossify until 18th to 20th year Does not unite with the clavicle until the 23rd to 25th year

Radiographic Techniques for Assessing Sternoclavicular Injuries 40-degree cephalic tilt view CT scan- Best technique for sternoclavicular joint problems From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

Injuries Associated with Sternoclavicular Joint Dislocations Mediastinal Compression Pneumothorax Laceration of the superior vena cava Tracheal erosion From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996

Treatment of Anterior Sternoclavicular Dislocations Nonoperative treatment Analgesics and immobilization Functional outcome usually good Closed reduction Often not successful Direct pressure over the medial end of the clavicle may reduce the joint

Treatment of Posterior Sternoclavicular Dislocations Careful examination of the patient is extremely important to rule out vascular compromise. Consider CT to rule out mediastinal compression Attempt closed reduction - it is often successful and remains stable.

Closed Reduction Techniques Abduction traction Adduction traction “Towel Clip” - anterior force applied to clavicle by percutaneously applied towel clip

Operative techniques Resection arthroplasty May result in instability of remaining clavicle unless stabilization is done. Suggest minimal resection of bone and fixation of medial clavicle to first rib. Sternoclavicular reconstruction with suture, tendon graft.

Literature – For those interested in further review. Clavicle Fractures Andersen K; Jensen PO; Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand 1987 Feb;58(1): p71-4. Canadian Orthopaedic Trauma Society. Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A multicenter, randomized clinical trial. J Bone Joint Surg 2007;89-A:1-10. McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg 2006;88-A:35-40. Mueller M, Rangger C, Striepens N, Burger C. Minimally Invasive Intramedullary Nailing of Midshaft Clavicular Fractures Using Titanium Elastic Nails. J Trauma 2008;1528-1534. Nowak J, Holgersson M, Larsson S. Can we predict long-term sequelae after fractures of the clavicle based on initial findings? A prospective study with nine to ten years of follow up. J Shoudler Elbow Surg 2004;13:479-486. Potter JM, Jones C, Wild LM, Schemitsch EH, McKee MD. Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle. J Shoulder Elbow Surg 2007;16:514-518. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004;86-A:1359-1365. Smekal V, Irenberger A, Struve P, Wambacher M, Krappinger D, Kralinger FS. Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures—A Randomized, Controlled, Clinical Trial. J Orthop Trauma 2009;23:106-112.

Literature – For those interested in further review. Distal – Third (lateral) Clavicle Fractures Jackson WF, Bayne G, Gregg-Smith SJ. Fractures of the lateral third of the clavicle: an anatomic approach to treatment. J Trauma;61(1):222-225. Meda PV, Machani B, Sinopidis C, et al. Clavicular hook plate for lateral end fractures:- a prospective study. Injury;2006:37(3):277-283.

Literature – For those interested in further review. Acromioclavicular Joint Injuries Calvo E, Lopez-Franco M, Arribas IM. Clinical and radiologic outcomes of surgical and conservative treatment of type III acromioclavicular joint injury. J Shoulder Elbow Surg. 2006;15(3):300-305. Ceccarelli E, Bondi R, Alviti F, et al. Treatment of acute grade III acromioclavicular dislocation: a lack of evidence. J Orthopaed Traumatol 2008;9:105-108. Lizaur A, Marco L, Cebrian R. Acute dislocation of the acromioclavicular joint. Traumatic anatomy and the importance of deltoid and trapezius. JBJS 1994;76B: 602-606. Mikek M. Long-term shoulder function after type I and II acromioclavicular joint disruption. Am J Sports Med. 2008;36:2147-2150. Nadarajah R, Mahaluxmivala J, Amin A, Goodier DW. Clavicular hook—plate: complications of retaining the implant. Injury 2005;36:681-683. Spencer EE. Treatment of grade III acromioclavicular joint injuries: a systematic review. Clin Orthop Relat Res. 2007;455:38-44.

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