acromioclavicular joint dislocation.pptx

acj dislocation

1. Acromioclavicular Joint Injuries Presenter- Dr Raazik Moderator- Dr Ch Navya Asst prof

2. Co n t e n ts Applied anatomy Overview Mechanism of injury Classification Clinical presentation Imaging Treatment options Surgical techniques Associated conditions

3. Applied Anatomy A plane synovial joint, located between medial margin of acromion and lateral end of clavicle Within the AC joint, there is a fibro cartilaginous disc

4. Acromioclavicular Ligaments Consists of anterior, posterior, superior, and inferior ligaments, surround the AC joint Stabilize the joint in horizontal plane Superior AC ligament- strongest of capsular ligaments, blend with fibers of the deltoid and trapezius muscles adding stability to AC joint.

5. Coracoclavicular Ligament Very strong ligament from outer inferior surface of clavicle to base of the coracoid process of scapula. Two components—conoid and trapezoid ligaments Vertical stability of AC joint

6. The only connection between the upper extremity and the axial skeleton is through the clavicular articulations at the AC and SC joints. SC ligaments support clavicles suspended away from the body CC ligament suspend upper extremities from distal clavicles

7. CC ligament helps to couple glenohumeral abduction/flexion to scapular rotation on thorax during overhead elevation Clavicle rotates around 40- 50 degrees during full overhead elevation-- simultaneous scapular rotation and AC joint motion

8. Overview Injuries to either AC or SC joints can result in a wide range of shoulder dysfunction. Both can be injured by similar mechanisms, present with overlapping clinical complaints, and in some cases result in injury to both locations Acromioclavicular injures are more common, and sternoclavicular injuries are rare

9. Risk groups often occur in male patients less than 30 years of age associated with contact sports or athletic activity in which direct blow to lateral aspect of shoulder occurs. The contact or collision athlete represents a “high-risk” individual (football, rugby, and hockey) RTA

10. Mechanisms of Injury Direct force on acromium or direct fall on the dome of shoulder Falling on an outstretched arm, locked in extension at the elbow, can drive humeral head superiorly into acromion--low-grade AC joint injuries A medially directed force to lateral shoulder that drives acromion into and underneath the distal clavicle(when getting checked into the boards during a hockey game)- higher degrees of injury and subsequently more displacement.

11. More commonly described pattern- falling or being tackled onto lateral aspect of the shoulder with the arm in an adducted position which produces a compressive (medial) and shear (vertical) force across the joint- typically produces higher degree of displacement enough to tear both AC and CC ligaments.

12. The injury force which drives acromion medially and downward produces a progressive injury pattern; first disruption of AC ligaments, followed by disruption of CC ligaments, and finally disruption of fascia overlying the clavicle that connects deltoid and trapezius muscle attachments. Complete AC dislocation- the upper extremity has lost its suspensory support from clavicle and scapula- inferior displacement of the shoulder secondary to forces of gravity.

13. Nontraumatic or Chronic Overuse AC joint arthrosis—weight lifting, laborer, repetitive overhead activity Repetitive low-grade AC joint injuries Medical cause: rheumatoid arthritis, hyperparathyroidism, scleroderma

14. Clinical presentation Young-aged male Contact or collision athlete H/O direct trauma Clinical deformity, focal tenderness and swelling Commonly the patient describes pain originating from the anterior- superior aspect of the shoulder

15. Diagnosis Examination should be in sitting or standing w/o support for the injured arm Check for tenderness to palpation at the AC joint and the CC interspace If patient can tolerate check joint for stability Check to see if reducible Examine SC joint as well Neurologic exam to r/o brachial plexus injury

16. Clinical triad point tenderness at the AC joint, pain exacerbation with cross-arm adduction, and relief of symptoms by injection of local anesthetic agent confirm injury to the AC joint.

17. Imaging Good-quality radiographs of the AC joint require one- third to one-half the beam penetration to image the glenohumeral joint. Radiographs of the AC joint taken using routine shoulder technique will be overpenetrated (i.e.dark), and small fractures may be overlooked. Therefore,specifically requested to take radiographs of “AC joint” rather than the “shoulder.” AP VIEW ZANCA VIEW STRESS VIEW

18. Radiographic Normal Joints Width and configuration of AC joint in coronal plane may vary significantly from individual to individual. So, a normal variant should not be mistaken as an injury. Normal width of AC joint in coronal plane is 1 to 3 mm. AC joint space diminishes with increasing age (0.5 mm in older than 60 years is conceivably normal). Joint space of greater than 7 mm in men and 6 mm in women is pathologic. Average CC distance 1.1 to 1.3 cm. An increase in CC distance of 50% over normal side signifies Complete AC dislocation (has been seen with as little as 25% increase in CC distance).

19. Zanca View Beam placed 10 degrees cephalad Obtained using soft tissue technique in which voltage is cut into half quantifying CC distance, and percentage displacement of distal clavicle above acromion.

20. AP weighted stress view (with wt. 4 to 7kg ) can be used in suspected injury

21. Biplanar Instability/Displacement Vertical translation Horizontal

22. Tossy- Rockwood Class i fi c a tion

23. Children and adolescents may sustain a variant of complete AC dislocation (most often Salter–Harris type I or II) Radiographs reveal displacement of distal clavicular metaphysis superiorly (through a dorsal rent in periosteal sleeve) with increase in CC interspace. Epiphysis and intact AC joint remain in their anatomic locations

24. Treatment goals Pain-free shoulder movement in a range-of-motion arc approaching normal Unimpaired daily activities

25. Treatment Options Nonoperative Treatment Immobilisation with strapping and sling for 3 weeks No lifting of weights for 6 weeks Indications- Type I,II,III AC injuries Relative contraindications- -Chronic symptomatic injury -Failed nonoperative management, athlete, laborers polytrauma, heavy

26. During 1st week of treatment Immobilization device (Arm slings, adhesive tape strappings, braces and plaster)- To support the weight of upper extremity and reduce the stress placed upon the injured ligaments Ice and analgesics To reduce pain and inflammation

27. After 1 to 2 weeks Strengthening exercises commenced with particular focus on periscapular muscles that are important to shoulder biomechanics. Heavy stresses, lifting, and contact sports should be delayed until there is full range of motion and no pain to joint palpation. This process can take up to 2 to 4 weeks Athletes who desire an earlier return to sports should be encouraged to use protective padding over the AC joint. An earlier return to sports that sustains a second injury to the AC joint, prior to complete ligament healing, can change a partially subluxated AC joint into a complete AC dislocation. Given this possible sequela, a forewarning must be provided to all athletes wishing to return to play at an earlier time. This decision is a balance between the desire to return to play early and the risk of reinjury.

28. DISADVANTAGES OF NON OPERATIVE TREATMENT S K IN P R E S S U RE AN D U L CER A T I O N RECURRENCE OF DEFORMITY WE A RING A BR A CE F O R L O N G TIM E(8 WEEKS) POOR PA T I E N T C OO PE R A T IO N INT E R F E R E N CE WITH D A I L Y A C T I V I T I E S LOSS OF SHOULDER AND ELBOW MOTION SOFT TISSUE CALCIFICATIONS LATE ACROMIOCLAVICULAR ARTHRITIS LATE MUSCULAR ATROPHY,FATIGUE AND WEAKNESS.

29. Type III- operative or nonoperative ? In prospective randomized studies between operative and nonoperative treatment of type III AC joint injuries, patients treated nonoperatively demonstrated a quicker return of function and sustained fewer complications than patients treated operatively. Patients treated conservatively returned to work on average 2.1 weeks from injury and the strength and ROM of the injured shoulder were comparable to the contralateral uninjured shoulder with a mean follow-up of 2.6 years (Wojtys and Nelson) Operatively treated AC injuries showed a significantly higher incidence of osteoarthritis and CC ligament ossification A proportion of conservatively treated patients will have persistent pain and inability to return to their sport or job. Subsequent surgical stabilization has allowed return to sport or work in such cases

30. Reasons for lower-grade AC joint injuries being symptomatic – posttraumatic arthritis posttraumatic osteolysis of the distal clavicle, recurrent AP subluxation, torn capsular ligaments trapped within the joint, loose pieces of articular cartilage, detached intra-articular meniscus or associated intra- articular fracture fragment.

31. Chronic Acromioclavicular Injuries Chronic pain after type I and II injuries- NSAIDS, avoidance of painful activity or positions, and intra-articular injection with corticosteroid Type I- Operative excision of distal clavicle (limited to less than 10 mm )-open or arthroscopic Type II- Di s t al cl a vicle e x cision + A C c a p sula r r e c on s tru c tion o r c o r a c oac r o m ial ligament transfer Chronic pain and instability after types III, IV, and V- Distal clavicle excision + Transfer of acromial attachment of coracoacromial ligament to the resected surface of distal clavicle and concurrent CC stabilization

32. Operative Treatment Indications - Patients (types I,II,III) who have failed a minimum 6 weeks of shoulder stabilization–directed physical therapy (delayed surgical reconstruction using a tendon graft) Active healthy patients with complete AC joint injuries (types IV, V, and VI)- significant morbidity associated with the injury pattern- persistently dislocated, unstable AC joint, with change in scapular kinematics, and shoulder dysfunction. Fracture of coracoid extending intra-articularly into glenoid (5 mm or more of glenoid displacement )

33. F i x a tio n a c ro ss A C jo i nt Fixation between coracoid and clavicle Ligament reconstruction Distal clavicle excision

34. ANY SURGICAL PROCEDURE FOR AC JOINT DISLOCATION SHOULD FULFILL THREE REQUIREMENTS AC JO I NT MU S T B E E X PO S ED AN D D E B R ID E D CC AND AC LIGAMENTS MUST BE R E P A I R E D OR R E C O N S T RUC T ED STABLE REDUCTION OF THE AC JOINT MUST BE OBTAINED Achievingthese three goals , no matter how the joint is fixed , should give acceptable results.

35. DISADVANTAGES OF SURGICAL MANAGEMENT INFECTION H E M A T OM A F O R M A T IO N ANAESTHETIC RISK SCAR FORMATION RECURRENCE OF DEFORMITY M E T A L B R E A K A GE, L OO SE N I N G , M IG R A T IO N SECOND SURGERY FOR REMOVAL BREAKAGE OR LOOSENING OF SUTURES EROSION OR FRACTURE OF DISTAL CLAVICLE

36. Acromioclavicular Fixation Pin fixation Has been abandoned since reports of rare pin migration – Heart, Lung, G r e at v e s s e l s

37. Acromioclavicular fixation Hook Plate Only used for acute injury Requires subsequent surgery for removal

38. Fixation between coracoid and clavicle Bosworth popularized the use of a screw for fixation of the clavicle to the coracoid This technique initially did not include recommendation for repair or reconstruction of the CC ligaments T oda y the use of sc r e w s an d s u t u re l o ops has be e n described alone and in combo with ligament reconstruction Placement of synthetic loops between the coracoid and clavicle can be done arthroscopically, main advantage: doesn’t require staged screw removal

39. Bosworth “screw suspension” technique

40. Repair+Tightrope augmentation

41. Ligament reconstruction Weaver and Dunn were the 1 st to describe transfer for the native CA ligament to reestablish AC joint stability Their technique described excision of the distal clavicle with this ligament transfer Construct can be augmented with a suture loop for protection until the transferred ligament heals Open or Arthr o s c op y

42. Modified Weaver and Dunn Procedure

43. Anatomic Ligament Reconstruction MAZZOCCA ET AL Alternative technique is use of semitendinosus autograft for reconstruction – Loop around or fix into coracoid, then fix through two separate clavicle bone tunnels to approximate normal anatomic location of CC ligaments Recent biomechanical studies have demonstrated the superiority of this construct

44. Anatomic Coracoclavicular Ligament Reconstruction ACCR technique attempts to restore biomechanics of AC joint complex as treatment for painful or unstable dislocations Rationale- to reconstruct both CC ligaments by anatomically fixing a tendon graft in two clavicle tunnels placed in the anatomic insertion site of conoid and trapezoid ligaments. In addition, AC ligaments are reconstructed with the remaining limb of the graft exiting the more lateral trapezoid tunnel.

45. ACCR technique: patient positioning Far lateral position with shoulder free to extend, small scapula bump along medial scapula border, and head position extended and rotated away from operative side.

46. ACCR-Steps Vertical incision centered on clavicle (starting from posterior clavicle to just medial of coracoid process )approx 3.5 cm medial to AC joint. Subperiosteal flaps raised to ensure that trapezius and deltoid attachments are elevated off. Tagging stitches can be placed to aid in tight closure of this layer during closure.

47. Conoid tunnel position marked at least 45 mm from distal clavicle Trapezoid tunnel position marked with at least 25 mm of bone bridge between tunnels Tunnels drilled

48. Graft passed through tunnel,beneath coracoid Interference fixation with PEEK screws (polyetheretherketone) Continue brace for 8 weeks Strengthening exercises from 12 weeks

49. Graft options- semitendinosus allograft/autograft, Anterior tibialis allograft. Semi-tendinosus allograft preferred -simplification of patient positioning, no donor site morbidity, decreased operative time, consistency in graft tissue size The minimal length needed to ensure graft available for AC ligament reconstruction approx 110 mm.

50. Associated conditions Glenohumeral Intra-Articular Pathology Fractures Brachial Plexus Abnormalities Coracoclavicular Ossification Osteolysis of the Distal Clavicle Scapulothoracic Dissociation

51. Glenohumeral Intra-Articular Pathology Pauly et al. noted a 15% incidence of intra-articular pathology, SLAP and PASTA(Partial articular supraspinatus tendon avulsion) lesions, in their series of 40 consecutive patients undergoing arthroscopic-assisted reconstruction of grade III to V AC joint dislocations

52. Fractures lateral clavicle fracture base or neck of coracoid process fracture concomitant injury to medial clavicular epiphysis (less than 30 years of age) Fracture of midshaft of clavicle with either anterior or posterior subluxation/dislocation of SC joint (uncommon)

53. Secondary osteoarthritis late complication usually be managed conservatively, If pain is marked, the outer 2 cm of clavicle can be excised.

54. ACROMIOPLASTY

55. INDICATIOS TYPE 2 OR 3 ACROMION ROTATOR CUFF IMPINGEMENT

56. OPEN SUBACROMIAL DECOMPRESSION ARTHOSCOPIC ACROMIOPLASTY

57. R e f e r ences Rockwood and Greens Fractures in Adult, Ninth edition Campbell Orthopaedics ,14 th edition Apley and Solomon’s System of Orthopaedics and Trauma, Tenth Edition https://www.orthobullets.com/shoulder-and- elbow/3047/acromioclavicular-joint-injury

58. Thank you