9% of shoulder girdle injuries
Generally occurs in males age 20-30
Anatomy
Classification
Allman and Tossy modified by Rockwood
Type 1

• Sprain of AC Lgt
• Coracoclavicular Lgts
normal
Classification
Allman and Tossy modified by Rockwood
Type 2

• AC Lgts disrupted
• Coracoclavicular Lgts
sprained
Classification
Allman and Tossy modified by Rockwood
Type 3

• AC Lgts disrupted
• Coracoclavicular Lgts
disrupted
Classification
Allman and Tossy modified by Rockwood
Type 4
• AC Lgts disrupted
• Coracoclavicular Lgts
disrupted
• Clavic...
Classification
Allman and Tossy modified by Rockwood
Type 5
• AC Lgts disrupted
• Coracoclavicular Lgts
disrupted
• Clavic...
Classification
Allman and Tossy modified by Rockwood
Type 6
• AC Lgts disrupted
• Coracoclavicular Lgts
disrupted
• Inferi...
Diagnosis
 Fall onto the adducted
shoulder
 Fall on Point of
shoulder
 Prominent distal clavicle
 Tenderness over the ...
Whiplash Injury shoulder
(Levy et al 2002)

• As a result of Whiplash mechanism in a car accident
• The injury originates ...
X ray

• AP view
• Stress View

• Zanca View
• (AP with 100 cephalic tilt)
ZANCA`S VIEW
Treatment
Type 1 and 2 Conservative
Rest Ice analgesics sling and mobilsation as patient
tolerates
Type 3 Treatment Contro...
Acromioclavicular dislocation : Conservative or surgical
therapy : Controversies in Skeletal Trauma- CORR 1998
AM Phillips...
• Ceccarelli et al. reviewed the literature on the evidence
for management of Grade 3 (Allman) dislocations and
concluded:...
Surgery versus Sling for AC Joint
Dislocations
(AAOS Now December 2012 .Maureen Leahy)

• Study finds hook plate fixation ...
Treatment Algorithm
Instructional Course Lecture, International Conference of Shoulder & Elbow
Surgery, Japan, 2013

• Acu...
Treatment Algorithm
Instructional Course Lecture, International Conference of Shoulder & Elbow
Surgery, Japan, 2013

• 3 w...
Treatment Algorithm
Instructional Course Lecture, International Conference of Shoulder & Elbow
Surgery, Japan, 2013

• 3 m...
Surgical Management
Phemister technique
Surgical Management
Phemister technique Complication
Surgical Management
Bosworth technique
Surgical management
Clavicular hook plates
Surgical Management
Repair+Tightrope augmentation
Surgical Management
Tightrope

• 2 buttons
• Flat for clavicle
• Oblong for coracoid
• Connected by
#5 fibre wire
LARS Ligament reconstruction
(Ligament Augmentation Reconstruction System)
LARS Ligament
• Synthetic Ligament
• Made of polyethylene terephthalate
• Have longitudinal-running fibres that match the ...
LARS Ligament reconstruction
(Ligament Augmentation Reconstruction System)
Surgilig reconstruction
• Surgilig is an artificial ligament
• It is made of double braided polyester with a patented
weav...
Surgilig reconstruction
Other Neo ligaments
• Rota Lok system
• Keio Leeds system
•

are all poly ester artificial ligaments marketed by
different...
Reconstruction for neglected cases
Grafts used
Semitendinosis
Gracilis
Allografts
• This can be used as a single or double...
Surgical Management
Modified Weaver-Dunn Procedure
Arthroscopic/Assisted/Open
Complications of AC Joint
dislocations
‼ AC joint Arthritis
‼ Cosmetic
‼ Scapular Dyskinesia and SICK scapula syndrome

‼
...
SICK Scapula syndrome
•
•
•
•

S capular malposition
I nferomedial prominence of Scapula
C oracoid pain
K inesial abnormal...
Ac joint
Ac joint
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Ac joint

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Ac joint

  1. 1. 9% of shoulder girdle injuries Generally occurs in males age 20-30
  2. 2. Anatomy
  3. 3. Classification Allman and Tossy modified by Rockwood Type 1 • Sprain of AC Lgt • Coracoclavicular Lgts normal
  4. 4. Classification Allman and Tossy modified by Rockwood Type 2 • AC Lgts disrupted • Coracoclavicular Lgts sprained
  5. 5. Classification Allman and Tossy modified by Rockwood Type 3 • AC Lgts disrupted • Coracoclavicular Lgts disrupted
  6. 6. Classification Allman and Tossy modified by Rockwood Type 4 • AC Lgts disrupted • Coracoclavicular Lgts disrupted • Clavicle posteriorly displaced into or through the trapezius
  7. 7. Classification Allman and Tossy modified by Rockwood Type 5 • AC Lgts disrupted • Coracoclavicular Lgts disrupted • Clavicle displaced superiorly more than 100%
  8. 8. Classification Allman and Tossy modified by Rockwood Type 6 • AC Lgts disrupted • Coracoclavicular Lgts disrupted • Inferior dislocation of clavicle below the coracoid
  9. 9. Diagnosis  Fall onto the adducted shoulder  Fall on Point of shoulder  Prominent distal clavicle  Tenderness over the AC joint
  10. 10. Whiplash Injury shoulder (Levy et al 2002) • As a result of Whiplash mechanism in a car accident • The injury originates from the whiplash movement of the shoulder where the clavicle and the body are retained by the seatbelt. • AC Injuries are a common injury sustained
  11. 11. X ray • AP view • Stress View • Zanca View • (AP with 100 cephalic tilt)
  12. 12. ZANCA`S VIEW
  13. 13. Treatment Type 1 and 2 Conservative Rest Ice analgesics sling and mobilsation as patient tolerates Type 3 Treatment Controversial Conservative/ Surgical Surgical for young, athletic individuals, heavy labourers, and those who do overhead work
  14. 14. Acromioclavicular dislocation : Conservative or surgical therapy : Controversies in Skeletal Trauma- CORR 1998 AM Phillips,Smart.Groom (1998) Sugathan and Ronald Martin Dodenhoff (2012) Overall, 88% of surgically treated patients and 87% of nonsurgically treated patients had a satisfactory outcome. Complications most commonly listed were (surgically treated versus nonsurgically treated): need for further surgery (59% versus 6%), infection (6% versus 1%), and deformity (3% versus 37%). Return to activity was no quicker with surgery. Pain was not any more common without surgery. Range of movement was more frequently normal or near normal without surgery (95% versus 86% if surgically treated) and so was strength (92% versus 87%). There does not seem to be any reason to recommend an operative procedure to a patient with Type 3 injury based on the evidence currently available.
  15. 15. • Ceccarelli et al. reviewed the literature on the evidence for management of Grade 3 (Allman) dislocations and concluded: “From the literature evaluation, clinical results seem to be comparable between the operative and the conservative treatments, but complications are more evident in the surgery group.” • There does not appear to be a clear association between the degree of displacement and on-going symptoms and disability of patient except cosmetic.
  16. 16. Surgery versus Sling for AC Joint Dislocations (AAOS Now December 2012 .Maureen Leahy) • Study finds hook plate fixation is not superior to nonsurgical treatment for acute injuries • DASH scores better in non surgical group at 3 months and 6 months and same at 1 year and 2 years.
  17. 17. Treatment Algorithm Instructional Course Lecture, International Conference of Shoulder & Elbow Surgery, Japan, 2013 • Acute injury (< 1week): • Assess and diagnose. • Sling and analgesia. Surgery only if:  Clavicle button-holed through trapezius;  Locked clavicle;  Neurovascular injury;  Open injury Review in three weeks
  18. 18. Treatment Algorithm Instructional Course Lecture, International Conference of Shoulder & Elbow Surgery, Japan, 2013 • 3 week review: • Settling and improving – continue symptomatic management and gradually reintroduce sports and manual activities. • Not coping – offer early surgical stabilisation • Review 3 months
  19. 19. Treatment Algorithm Instructional Course Lecture, International Conference of Shoulder & Elbow Surgery, Japan, 2013 • 3 month review: • Returned to sports and little symptoms – discharge • Not coping – offer surgical stabilisation
  20. 20. Surgical Management Phemister technique
  21. 21. Surgical Management Phemister technique Complication
  22. 22. Surgical Management Bosworth technique
  23. 23. Surgical management Clavicular hook plates
  24. 24. Surgical Management Repair+Tightrope augmentation
  25. 25. Surgical Management Tightrope • 2 buttons • Flat for clavicle • Oblong for coracoid • Connected by #5 fibre wire
  26. 26. LARS Ligament reconstruction (Ligament Augmentation Reconstruction System)
  27. 27. LARS Ligament • Synthetic Ligament • Made of polyethylene terephthalate • Have longitudinal-running fibres that match the structure of native human tissue. They therefore are able to act as a scaffold for fibroblasts. • Biopsies done on the LARS ligament have shown complete cellular and connective tissue ingrowth, along with the presence of some endothelial cells suggesting vascularisation of the tissue • LARS ligament reproduces the anatomy and mechanics of the torn coracoclavicular ligament
  28. 28. LARS Ligament reconstruction (Ligament Augmentation Reconstruction System)
  29. 29. Surgilig reconstruction • Surgilig is an artificial ligament • It is made of double braided polyester with a patented weave design which acts as a scaffold encouraging tissue in-growth (predominantly scar tissue).
  30. 30. Surgilig reconstruction
  31. 31. Other Neo ligaments • Rota Lok system • Keio Leeds system • are all poly ester artificial ligaments marketed by different companies which work on the same principle
  32. 32. Reconstruction for neglected cases Grafts used Semitendinosis Gracilis Allografts • This can be used as a single or double bundle to reconstruct the coracoclavicular ligament. Tight ropes used to augment the reconstruction. Or • synthetic ligaments like LARS or Surgilig can be used for reconstruction
  33. 33. Surgical Management Modified Weaver-Dunn Procedure Arthroscopic/Assisted/Open
  34. 34. Complications of AC Joint dislocations ‼ AC joint Arthritis ‼ Cosmetic ‼ Scapular Dyskinesia and SICK scapula syndrome ‼ ‼ ‼ ‼ ‼ ‼ # Clavicle # Coracoid Implant Failure Infection Shoulder stiffness Rotator cuff problems
  35. 35. SICK Scapula syndrome • • • • S capular malposition I nferomedial prominence of Scapula C oracoid pain K inesial abnormalities of scapula
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