American Shoulder and Elbow Surgeons
Please rate topic.
Average 4.3 of 42 Ratings
A 58-year-old right-hand dominant accountant falls off a bicycle 4 days ago and injured his left non-dominant shoulder. A radiograph is shown in Figure A. The axillary radiograph shows no antero-posterior translation. What is the most appropriate next step in treatment?
Coracoclavicular ligament reconstruction
Acromioclavicular capsular reconstruction
Sling and early ROM exercises
Arthroscopic distal clavicle excision
Select Answer to see Preferred Response
The radiograph demonstrates an acromio-clavicular (AC) separation. Whether this is graded as either a Type II or III, non-operative treatment is recommended for this patient. A Type II shows partial separation at the AC and no widening of the coracoclavicular (CC) space, which can be difficult to assess without an image of the uninjured side. Type II is generally treated non-operatively. A Type III has generally has 100% displacement at the AC and widening of the CC space (widened 20-100%). While the treatment of type III may be controversial in athletes or laborers, the treatment of this patient (non-dominant shoulder, non-laborer and non-athlete) should be non-operative initially.
Schlegel et al prospectively followed 25 patients treated conservatively with grade III AC separations and showed that at 1 year there was no limitation of shoulder motion and no difference between sides in rotational shoulder muscle strength.
Schlegel TF, Burks RT, Marcus RL, Dunn HK
Am J Sports Med. 2001 Nov-Dec;29(6):699-703. PMID: 11734479 (Link to Abstract)
Schlegel, AJSM 2001
Please rate question.
Average 3.0 of 15 Ratings
For Grade III AC joint separations, surgical treatment results in which of the following when compared to non-operative management?
Faster return to play
Increased range of motion
Increased functional rotator cuff strength
Decreased funtional rotator cuff strength
Higher complication rate
Treatment of grade III AC separations remains somewhat controversial. A recent systematic review by Spencer concluded that the results of surgical treatment were not clearly any better than non-operative, had a higher complication rate, and a longer recovery prior to return to sport/work.
Clin. Orthop. Relat. Res.. 2007 Feb;455:38-44. PMID: 17179783 (Link to Abstract)
Spencer, CORR 2007
Average 3.0 of 17 Ratings
A football player sustains a suspected shoulder separation. In addition to a true AP and an axillary lateral, which of the following additional radiographic views is most appropriate to evaluate the AC joint?
Stryker notch view
West Point view
Supraspinatus outlet view
A Zanca view is the most accurate view to evaluate suspected AC joint injuries. Proper radiographic evaluation of the AC joint requires 1/3 to 1/2 of the x-ray penetration needed for glenohumeral joint exposure. This explains why, in a standard anteroposterior view of the shoulder, the AC joint will be over-penetrated (dark) and small or subtle lesions may be overlooked. When the history and physical examination indicate possible AC joint injury, specific directions must be given to the radiology technician in obtaining the appropriate view. AP, lateral, and axial views are standard views taken for the shoulder; however, a Zanca view is the most accurate view to look at the AC joint.
Mazzocca provides a review of AC injuries and states that the "Zanca view is the most accurate view to look at the AC joint". This view is performed by tilting the x-ray beam 10° to 15° toward the cephalic direction and using only 50% of the standard shoulder anteroposterior penetration strength.
The paper by Bradley & Elkousy discusses using plain films to make the diagnosis and determine the type on Rockwood classification to use as a guide for determining nonoperative treatment (Types 1 & 2), operative (Types 4-6), while Type 3 remains controversial. Obtaining views of both AC joints may be helpful.
Illustrations A-E demonstrate the radiographic technique and example of a radiograph for each of the answer options 1-5, respectively.
Mazzocca AD, Arciero RA, Bicos J.
Am J Sports Med. 2007 Feb;35(2):316-29. PMID: 17251175 (Link to Abstract)
Mazzocca, AJSM 2007
Bradley JP, Elkousy H.
Clin Sports Med. 2003 Apr;22(2):277-90. PMID: 12825530 (Link to Abstract)
Average 3.0 of 28 Ratings
What is the preferred treatment for a symptomatic acute acromioclavicular separation where there is a 20% increase in the coracoclavicular distance on AP radiograph compared to the opposite uninjured side?
Anatomic coracoclavicular ligament reconstruction
Acute repair of acromioclavicular capsule
Sling followed by early physical therapy
Reduction and retrograde pinning of the acromioclavicular joint
Distal clavicle excision
A 20% increase in the coracoclavicular distance on AP radiograph compared to the uninjured side would classify this AC separation as a Type II based on the Rockwood classification. The preferred treatment for a type II AC separation is non-operative with a sling and early physical therapy.
The reference by Mouhsine et al outlines the typically successful outcomes of non-operative treatment of type I and II AC separations. They found good results but many patients (48%) remained symptomatic after 6 years with activity related pain or AC tenderness and 84% of these patients had radiographic evidence of AC degeneration, distal clavicle lysis, or CC ligament ossification.
The reference by Clarke and McCann reviews the diagnosis and treatment of AC separations. They argue Type I and Type II AC separations are treated nonoperatively, while types IV-VI are nearly always treated surgically. The treatment of Type III remains controversial.
Illustration A depicts the different types of AC separations.
Mouhsine E, Garofalo R, Crevoisier X, Farron A
J Shoulder Elbow Surg. 2003 PMID: 14671526 (Link to Abstract)
Mouhsine, JSES 2003
Clarke HD, McCann PD.
Orthop Clin North Am. 2000 Apr;31(2):177-87. PMID: 10736388 (Link to Abstract)
Average 4.0 of 19 Ratings
This video demonstrates an All-Arthroscopic Double-Bundle Coracoclavicular Ligam...
An arthroscopic Weaver-Dunn procedure.
Arthroscopic distal clavicle procedure (Mumford procedure).
An overview of the anatomy and pathology of AC joint separation.
Open AC joint reconstruction performed with ST allograft and fiber tape.
Open reconstruction of the AC joint using Graftrope