N
Naughty Nurse
Guest
Acromioclavicular Joint Injuries
Identifying and Treating 'Separated Shoulder' and Other Conditions
Robert J. Johnson, MD
Excerpt from: THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO.11 - NOVEMBER 2001
In Brief: The acromioclavicular (AC) joint is vulnerable to injury in collision sports and in activities requiring repetitive overhead motions. The spectrum of injury includes sprains and osteoarthritis of the AC joint and osteolysis and fracture of the distal clavicle. With the exception of severe sprains and fractures, most conditions can be managed nonoperatively. The key to successful treatment is prompt and accurate recognition of the severity of AC injuries.
Acromioclavicular (AC) joint injuries are common among athletes involved in collision sports, throwing sports, and overhead activities such as upper-extremity strength training. Though AC injuries are common, the treatments for some of the specific injuries are subject to controversy. From the perspective of the sports medicine physician, the ability to distinguish the AC injuries that can be effectively managed nonoperatively from those best managed by surgical intervention is crucial to optimize the care of the injured athlete.
AC Separation
Most AC injuries occur from falling directly on the adducted shoulder. The force of the fall dictates the degree of injury. If the history involves a direct blow to the adducted shoulder, the physical exam is likely to confirm the diagnosis. Radiographs are helpful in clarifying the type of injury. The series should consist of an anteroposterior (AP) view, lateral Y view, and an axillary view to determine AP displacement and associated shoulder injuries. When an AC joint injury is suspected, a 15? cephalad AP view is useful. Weighted views are generally of little value and are no longer recommended.
AC dislocations have been divided into six classifications. The most commonly used system is the one modified by Rockwood. The importance of identifying the injury type cannot be overemphasized because the treatment and prognosis hinge on an accurate diagnosis. Typically, type 1 and 2 injuries are easily managed by the primary care physician. Early recognition of types 4, 5, and 6 is essential because these patients benefit from early surgical consultation and intervention. Management of type 3 injuries remains somewhat controversial.
Types 1 and 2.
The patient with a type 1 injury will demonstrate local tenderness but no anatomic deformity. All the other types of AC dislocations are characterized by localized tenderness with a deformity or asymmetry to the uninvolved AC joint. Active adduction of the injured shoulder (patient reaches across the chest to grasp the uninjured shoulder) with additional passive adduction by the examiner (crossed-arm adduction test) usually exacerbates the pain.
Type 1 and 2 injuries are treated nonoperatively. An arm sling, ice, and analgesics for comfort are the usual initial treatments. Range-of-motion exercises and strength training to restore normal motion and strength are instituted as the patient's symptoms permit. Return to sport is allowed when the patient reestablishes nearly normal range of motion and strength, typically within 2 to 3 weeks of injury. When a patient returns to practice and competition in collision sports, protection of the AC joint with special padding is important. A simple "doughnut" cut from foam or felt padding can provide effective protection. Special shoulder injury pads can be placed beneath the regular shoulder pads, or off-the-shelf shoulder orthoses can be used to protect the AC joint after injury.
Type 3.
The treatment of a type 3 injury is less controversial than in past years. In the 1970s, most orthopedists recommended surgery for type 3 AC sprains. By 1991, most type 3 injuries were treated conservatively. This change in treatment philosophy was prompted by a series of retrospective studies that showed no outcome differences between operative and nonoperative groups. Furthermore, the patients treated nonoperatively returned to full activity (work or athletics) sooner than the surgically treated groups. The exceptions to this recommendation include those who perform repetitive, heavy lifting, those who work with their arms above 90?, and thin patients who have prominent lateral ends of the clavicles. These patients may benefit from surgical repair.
Nonoperative treatment of a type 3 AC sprain involves the use of a sling for comfort followed by range-of-motion and strengthening exercises when tolerated. The time to return to full activity, typically 6 to 12 weeks, is much longer than for type 1 and 2 injuries. Upon return to practice and play, the AC joint should be protected as suggested for type 1 and 2 injuries. Protection may be used as long as the athlete or athletic trainer feels its use is warranted.
Types 4, 5, and 6.
Radiographic findings are the primary method used to diagnose type 4, 5, or 6 fractures. When the injury is diagnosed, an orthopedic surgeon should be consulted for surgical reduction and stabilization. Return to athletic practice and play depends on healing and restoration of near-normal strength and range of motion.
Distal Clavicle Fractures
Fractures of the distal third of the clavicle are much less common than midthird clavicle fractures. Estimates range from 10% to 20% of all clavicle fractures. The usual mechanism of injury is a lateral force directed against the point of the shoulder.
When a distal clavicle fracture is suspected, appropriate x-rays include a standard shoulder series (AP view, axillary view, and scapular Y view). Anterior and posterior 45? oblique views and/or a view with 20? to 45? cephalic tilt are recommended to more effectively assess anterior-posterior displacement.
Understanding and applying fracture classification is essential for making treatment recommendations and timely, appropriate orthopedic consultations. The classification originally made by Neer was later modified to include four distinct injuries.
Type 1 fractures involve the clavicle that is lateral to the coracoclavicular ligaments and thus remain stable and nondisplaced. Treatment involves use of a sling until clinical and radiographic evidence of healing is seen. Rehabilitation is best supervised by a physical therapist or athletic trainer and should include range-of-motion and strengthening exercises that target the rotator cuff and scapular stabilizers. After proper rehabilitation of the shoulder, the athlete can return to play, including collision sports.
Type 2 fractures are more controversial. They have been divided into two subsets, 2a and 2b. Type 2a fractures occur medial to the coracoclavicular ligaments and usually result in fragment displacement. Type 2b fractures occur between the conoid and trapezoid ligaments and also tend to displace, leading to a high incidence of nonunion (22% to 44%) and delayed union (45%) after more than 3 months. Since the results of open reduction and internal fixation have generally been favorable, most orthopedic surgeons recommend surgery for type 2 fractures. Since several treatment strategies exist for the management of type 2 clavicle fractures, I encourage discussion of these fractures with an orthopedist.
Type 3 fractures include intra-articular fractures that leave all stabilizing ligaments intact. This fracture can be treated in a manner similar to type 1 fractures. Other fracture types have been described, but their infrequent occurrence does not warrant discussion.
Identifying and Treating 'Separated Shoulder' and Other Conditions
Robert J. Johnson, MD
Excerpt from: THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO.11 - NOVEMBER 2001
In Brief: The acromioclavicular (AC) joint is vulnerable to injury in collision sports and in activities requiring repetitive overhead motions. The spectrum of injury includes sprains and osteoarthritis of the AC joint and osteolysis and fracture of the distal clavicle. With the exception of severe sprains and fractures, most conditions can be managed nonoperatively. The key to successful treatment is prompt and accurate recognition of the severity of AC injuries.
Acromioclavicular (AC) joint injuries are common among athletes involved in collision sports, throwing sports, and overhead activities such as upper-extremity strength training. Though AC injuries are common, the treatments for some of the specific injuries are subject to controversy. From the perspective of the sports medicine physician, the ability to distinguish the AC injuries that can be effectively managed nonoperatively from those best managed by surgical intervention is crucial to optimize the care of the injured athlete.
AC Separation
Most AC injuries occur from falling directly on the adducted shoulder. The force of the fall dictates the degree of injury. If the history involves a direct blow to the adducted shoulder, the physical exam is likely to confirm the diagnosis. Radiographs are helpful in clarifying the type of injury. The series should consist of an anteroposterior (AP) view, lateral Y view, and an axillary view to determine AP displacement and associated shoulder injuries. When an AC joint injury is suspected, a 15? cephalad AP view is useful. Weighted views are generally of little value and are no longer recommended.
AC dislocations have been divided into six classifications. The most commonly used system is the one modified by Rockwood. The importance of identifying the injury type cannot be overemphasized because the treatment and prognosis hinge on an accurate diagnosis. Typically, type 1 and 2 injuries are easily managed by the primary care physician. Early recognition of types 4, 5, and 6 is essential because these patients benefit from early surgical consultation and intervention. Management of type 3 injuries remains somewhat controversial.
Types 1 and 2.
The patient with a type 1 injury will demonstrate local tenderness but no anatomic deformity. All the other types of AC dislocations are characterized by localized tenderness with a deformity or asymmetry to the uninvolved AC joint. Active adduction of the injured shoulder (patient reaches across the chest to grasp the uninjured shoulder) with additional passive adduction by the examiner (crossed-arm adduction test) usually exacerbates the pain.
Type 1 and 2 injuries are treated nonoperatively. An arm sling, ice, and analgesics for comfort are the usual initial treatments. Range-of-motion exercises and strength training to restore normal motion and strength are instituted as the patient's symptoms permit. Return to sport is allowed when the patient reestablishes nearly normal range of motion and strength, typically within 2 to 3 weeks of injury. When a patient returns to practice and competition in collision sports, protection of the AC joint with special padding is important. A simple "doughnut" cut from foam or felt padding can provide effective protection. Special shoulder injury pads can be placed beneath the regular shoulder pads, or off-the-shelf shoulder orthoses can be used to protect the AC joint after injury.
Type 3.
The treatment of a type 3 injury is less controversial than in past years. In the 1970s, most orthopedists recommended surgery for type 3 AC sprains. By 1991, most type 3 injuries were treated conservatively. This change in treatment philosophy was prompted by a series of retrospective studies that showed no outcome differences between operative and nonoperative groups. Furthermore, the patients treated nonoperatively returned to full activity (work or athletics) sooner than the surgically treated groups. The exceptions to this recommendation include those who perform repetitive, heavy lifting, those who work with their arms above 90?, and thin patients who have prominent lateral ends of the clavicles. These patients may benefit from surgical repair.
Nonoperative treatment of a type 3 AC sprain involves the use of a sling for comfort followed by range-of-motion and strengthening exercises when tolerated. The time to return to full activity, typically 6 to 12 weeks, is much longer than for type 1 and 2 injuries. Upon return to practice and play, the AC joint should be protected as suggested for type 1 and 2 injuries. Protection may be used as long as the athlete or athletic trainer feels its use is warranted.
Types 4, 5, and 6.
Radiographic findings are the primary method used to diagnose type 4, 5, or 6 fractures. When the injury is diagnosed, an orthopedic surgeon should be consulted for surgical reduction and stabilization. Return to athletic practice and play depends on healing and restoration of near-normal strength and range of motion.
Distal Clavicle Fractures
Fractures of the distal third of the clavicle are much less common than midthird clavicle fractures. Estimates range from 10% to 20% of all clavicle fractures. The usual mechanism of injury is a lateral force directed against the point of the shoulder.
When a distal clavicle fracture is suspected, appropriate x-rays include a standard shoulder series (AP view, axillary view, and scapular Y view). Anterior and posterior 45? oblique views and/or a view with 20? to 45? cephalic tilt are recommended to more effectively assess anterior-posterior displacement.
Understanding and applying fracture classification is essential for making treatment recommendations and timely, appropriate orthopedic consultations. The classification originally made by Neer was later modified to include four distinct injuries.
Type 1 fractures involve the clavicle that is lateral to the coracoclavicular ligaments and thus remain stable and nondisplaced. Treatment involves use of a sling until clinical and radiographic evidence of healing is seen. Rehabilitation is best supervised by a physical therapist or athletic trainer and should include range-of-motion and strengthening exercises that target the rotator cuff and scapular stabilizers. After proper rehabilitation of the shoulder, the athlete can return to play, including collision sports.
Type 2 fractures are more controversial. They have been divided into two subsets, 2a and 2b. Type 2a fractures occur medial to the coracoclavicular ligaments and usually result in fragment displacement. Type 2b fractures occur between the conoid and trapezoid ligaments and also tend to displace, leading to a high incidence of nonunion (22% to 44%) and delayed union (45%) after more than 3 months. Since the results of open reduction and internal fixation have generally been favorable, most orthopedic surgeons recommend surgery for type 2 fractures. Since several treatment strategies exist for the management of type 2 clavicle fractures, I encourage discussion of these fractures with an orthopedist.
Type 3 fractures include intra-articular fractures that leave all stabilizing ligaments intact. This fracture can be treated in a manner similar to type 1 fractures. Other fracture types have been described, but their infrequent occurrence does not warrant discussion.
