Acromio-clavicular joint injuries - Chinmay Gupte 20/2/2001

Overview

 

Incidence:   3-4/1000

 

Anatomy: joint stabilised by:   

acromioclavicular-horizontal stabilitycoraco-clavicular- vertical stability

 

Mechanism: fall on adducted arm driving scapula inferiorly; clavicle maintains position due to strong sternoclavicular ligaments.

 

Radiology: stress views and transaxillary lateral

 

Classification: three systems: Allman; Tossy; Rockwood.   All assess coracoclavicular distance and infer damage to AC and CC ligaments.

 

Rockwood classification:

Type I              AC ligament sprain

Type II               Complete ACL rupture and CCL sprain

Type III Complete ACL and CCL rupture

Type IV             Posterior translation of clavicle (axillary view)

Type V similar to type III but with grossly increased CC distance

Type VI             distal clavicle driven beneath coracoid or acromion

 

Treatment:      Type I and II                  broad arm sling 10 days

                        Type III              controversial

                        Type IV, V, VI    coraco- or acromioclavicular fixation.

 

Surgery:           Over 40 techniques described!!                     

[1] ACJ fixation                         )            Threaded pins or                     

[2] CCJ fixation                         )                        screws

[3] Dynamic muscle transfer- transfer of coracoid process to under surface of clavicle.   Muscle origin acts as dynamic depressor of lateral clavicle.

 

Excellent review: Richards-RR; Instr-Course-Lect. 1993; 42: 259-69: Acromioclavicular joint injuries;

 

ACJ dislocation type III

 

Author

Bannister et al

Title

The management of acute ACJ dislocation- an RCT

Reference

JBJS(Br)   1989 71(5) 848-50

Summary

RCT 60 patients 1980-83; surgery c AO coracoclavicular screw

Imatani evaluation;after 4 yrs 100% excellent/ good result in conservatively managed; 84% in surgical.   Early sx better in severe dislocation (>2cm) (12 patients)

Critique

Good randomisation; no description of grade of injury

 

 

Author

Larsen et al

Title

Conservative or surgical treatment of ACJ dislocation? an RCT

Reference

JBJS 68A 1986 552-555

Summary

RCT 79 patients;surgery (41 patients)c Phemister procedure (2 crossed threaded K wires to Acj with ligament reconstruction); quicker recovery time in cons mx at 13mths; 50% complication rate in operated; recommend operation in thin c prominent lateral clavicle

Critique

Excellent RCT; ?choice of operative technique

 

Author

Rawes and Dias (Leciester)

Title

Long term results of conservatively treated ACJ dislocation

Reference

JBJS 1996 76B 410-412

Summary

30/46 patients 12.5 yr follow-up; grade III injuries; Inatani scores excellent/ good in 29/30; jts remained subluxed/dislocated in all;   good outcome despite no anatomical reduction (?atrophy/ ossification helps)

Critique

Longest f/u of all the studies; 16 lost to f/u

 

Author

Phillips et al

Title

Acromioclavicular dislocation conservative or surgical therapy?

Reference

Clin orth rel res 1998 353 p10-17

Summary

Metaanalysis of studies;   1172 patients type III injuries

  833 treated surgically

Good outcome in 88% surgically treated, 87% conservative

Further sx in 59% surgical gp compared with 6% cons

Normal ROM in 87% surg vs 95% cons

No evidence for surgical rx of type III injuries

 

Critique

Metaanalysis

 



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