Ac joint dislocation.pptx

a slight presentation for students and resident , a quick review for management and planning.

1. Acromio -clavicular joint dislocation Dr mateen Qaiser butt Resident orthopedic surgery Aziz Bhatti shahed teaching hospital

2. Anatomy

3. Physical exam AC joint tenderness Abnormal contour of the shoulder as compared to the opposite. Obriens test Cross body adduction test

4. Imaging Bilateral ap views of the AC joint

5. Axillary lateral view

6. Stryker Notch View A variant of an AC joint injury involves a fracture of the coracoid process. This injury should be suspected when there is an AC joint dislocation on the AP projection but the coracoclavicular distance is normal, or equal to that on the opposite, uninvolved side. A Stryker notch view, taken appropriately, puts the coracoid in profile and is the best view for evaluating this injury. Technique for taking the Stryker notch view to show fractures of the base of the coracoid. The patient is supine with a cassette placed posterior to the shoulder. The humerus is flexed approximately 120 degrees so the patient's hand can be placed on top of the head. The x-ray beam is directed 10 degrees superior

7. Stryker notch view

8. Zanca view

9. weighted stress views usually no longer used may help differentiate Type II from Type III A 10–15-pound weight is attached to the wrist of the affected side and an AP view can be taken .

10. Rockwood Classification

11. Type 3 The key to the diagnosis of a type III injury is that the defect can be reduced with upward pressure under the elbow

12. type 4

13. Type 4 The clavicle usually is displaced so severely posteriorly that it becomes “buttonholedâ € through the trapezius muscle and tents the posterior skin .

14. Type 5

15. Type 5 The distal clavicle is subcutaneous and cannot be manually reduced. Occasionally, there is so much inferior displacement of the upper extremity that the patient will develop symptoms of traction on the brachial plexus. The clavicle appears to be grossly displaced superiorly away from the acromion .However, x-rays reveal that the clavicle on the injured side is actually at approximately the same level as the clavicle on the normal side, and the scapula is displaced inferiorly

16. Type 6

17. Treatment

18. Non operative brief sling immobilization, rest, ice, physical therapy indications type I and II type III in most individuals ,good results when clavicle displaced < 2cm.

19. Rehabilitation early shoulder range of motion regain functional motion by 6 weeks return to normal activity at 12 weeks consider corticosteroid injections

20. Operative treatment Indications Acute type 4 , 5 and 6 injuries acute type III injuries in laborers, elite athletes, patients with cosmetic concerns chronic type III injuries that failed non-op treatment however, new studies have shown no difference in outcomes in types III injuries treated surgically after 6 weeks non-op treatment versus immediate surgery

21. Techniques Two types ligament reconstruction with soft tissue graft Fixation methods

22. ligament reconstruction with soft tissue graft Modified weaver dunn Autograft Allograft Modified weaver dunn CC ligament reconstruction with coracoacromial (CA) ligament cons coracoacromial ligament only 20% as strong as normal CC ligament lack of internal fixation risks failure of soft tissue repair

23. autograft palmaris longus semitendinosus allograft tibialis anterior technique figure-of-eight passage of graft, looping around coracoid and fixation through clavicular tunnels reinforce with internal fixation pros graft reconstruction more closely recreates strength of native CC ligament cons standard risks of allograft use or autograft harvest lack of internal fixation risks failure of soft tissue repair

24. Fixation methods suture hook plate CC screw (Bosworth) cortical flip button ( e.g Dog Bone)(+/- arthroscopic assistance) K-wire

25. ORIF with CC screw fixation (Bosworth screw

26. pros rigid internal fixation cons danger of screw being too long and damage to critical structure below coracoid routine screw removal at 8-12 weeks is advised to prevent screw breakage due to normal motion between clavicle and scapula complications hardware irritation at level of screw purchase in coracoid hardware failure at level of screw purchase in coracoid

27. ORIF with CC suture fixation pros no risk of hardware failure or migration cons suture not as strong as screw fixation requires careful suture passage inferior to coracoid due to proximity of crucial neurovascular structures complications suture erosion causing distal third clavicle fracture

28. ORIF with AC hook plate fixation

29. pros rigid fixation cons may require second surgery for plate removal if symptomatic complications acromial erosion hook pullout

30. ORIF with AC pin fixation (Phemister Technique)

31. technique smooth wire or pin fixation directly across AC joint cons hardware irritation complications high incidence of pin migration generally not performed due to high complication rates

32. Complications 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

33. thankyou