9. Shoulder Separation
• Shoulder separation is
not truly an injury to
the shoulder joint.
• The injury actually
involves the
acromioclavicular joint
(also called the AC
joint).
11. AC Separation
• The most common
cause for a separation
of the AC joint is from a
fall directly onto the
shoulder.
• The fall injures the
ligaments that
surround and stabilize
the AC joint.
12. Injury
If the force is severe enough,
the ligaments attaching to the
underside of the clavicle are
torn.
• This causes the
"separation" of the
collarbone and wingbone.
• The wingbone actually
moves downward from the
weight of the arm.
• This creates a "bump" or
bulge above the shoulder.
13. Injury
• injury can range from a
little change in
configuration with mild
pain, to quite deforming
and very painful.
• Good pain-free function
often returns even with a
lot of deformity.
• The greater the deformity,
the longer it takes for pain-
free function to return
14. Types of Separation
• .
• A mild shoulder separation
involves a sprain of the AC
ligament that does not move
the collarbone and looks
normal on X-rays.
• A more serious injury tears
the AC ligament and sprains
or slightly tears the
coracoclavicular (CC)
ligament, putting the
collarbone out of alignment
to some extent.
15. Severe Separation
• The most severe
shoulder separation
completely tears both
the AC and CC
ligaments and puts the
AC joint noticeably out
of position.
16. Injury
• Injury is easy to
identify when it causes
deformity.
• When there is less
deformity, the location
of pain and X-rays help
the doctor make the
diagnosis.
17. • Sometimes having the
patient hold a weight in
the hand can increase
the deformity, which
makes the injury more
obvious on X-rays.
19. Symptoms
• Pain at the end of the collar
bone
• Pain may feel widespread
throughout the shoulder
until the initial pain
resolves, following this it is
more likely to be a very
specific site of pain over
the joint itself
• Swelling often occurs
20. Symptoms
• Depending on the extent
of the injury a step-
deformity may be visible.
This is an obvious lump
where the joint has been
disrupted and is visible
on more severe injuries
• Pain on moving the
shoulder, especially
when trying to raise the
arms above shoulder
Cross Body Adduction Test
height
22. Paxinos Sign
• Pushes the acromium
into the clavicle with
the thumb
• Positive if there is pain
increases
23. • AC joint injuries are
graded from 1-6 using
the Rockwood scale
which classifies injuries
in relation to the extent
of ligament damage
and the space between
the acromion and
clavicle
25. Rockwood Scale
• Separated shoulders are graded according to
the severity of the injury and the position of
the displaced bones.
• Shoulder separations are graded from type I
to VI:
26. Grades
• Grade 1 is a simple sprain
to the AC joint, grade 2
involves rupture of the AC
ligament and grade 3
rupture of both AC and CC
ligaments which often
results in a superior
displacement.
• From this point onwards
the scale and grade of
injury depends on the
degree of displacement of
the clavicle.
27. Type I Shoulder Separation
• Injury to the capsule that
surrounds the AC joint.
• The bones are not out of
position and the primary
symptom is pain.
•
• Sprain of
acromioclavicular
ligament only
28. Type II Shoulder Separation
• Involves an injury to the AC joint
capsule as well as one of the
important ligaments that stabilizes
the clavicle.
• This ligament, the coracoclavicular
ligament, is partially torn.
• Patients with a type II separated
shoulder may have a small bump
over the injury.
• Acromioclavicular ligaments and
joint capsule disrupted.
Coracoclavicular ligaments intact.
50% vertical subluxation of clavicle.
29. Type III Shoulder Separation
• Involves the same type of injury as
a type II separated shoulder, but
the injury is more significant.
• These patients usually have a large
bump over the injured AC joint.
• Acromioclavicular ligaments and
capsule disrupted.Coracoclavicular
ligaments disrupted.
Acromioclavicular joint dislocation
with clavicle displaced superiorly
and complete loss of contact
between clavicle and acromion.
30. • Grade 4, 5, and 6 separations are severe
injuries with high degree of displacement of
the clavicle with respect to the acromion and
usually require surgery.
31. Type IV Shoulder Separation
• A type IV shoulder
separation is an
unusual injury where
the clavicle is pushed
behind the AC joint.
32. • Type V Shoulder
Separation:
• A type V shoulder
separation is an
exaggerated type III
injury. In this type of
separated shoulder, the
muscle above the AC joint
is punctured by the end
of the clavicle causing a
significant bump over the
injury.
33. Type VI Shoulder Separation
• Rare.
• In this type of injury the clavicle is
pushed downwards, and becomes
lodged below the corocoid (part of
the scapula
• Acromioclavicular ligaments and
capsule disrupted. Coracoclavicular
ligaments disrupted.
• Acromioclavicular joint dislocation
and clavicle displaced posteriorly
into or through trapezius muscle
(posterior displacement confirmed
on axillary radiograph)
34. • Grade 4 involves
posterior displacement
and grade 5 superior
displacement, to a
greater degree than
grade 3, with an increase
in coracoclavicular space
by 3-5 times the norm.
•
• A step deformity may be
apparent with grade 3, 4
& 5 injuries.
35. Grade 6
• involves full rupture of
both AC and CC
ligaments with the
clavicle being displaced
inferiorly.
36. Treatment
• Whether treated
conservatively or with
surgery, the shoulder
will require
rehabilitation to
restore and rebuild
motion, strength, and
flexibility.
37. Treatment – depend on the type of
injury
• The initial treatment of
a separated shoulder
consists of controlling
the inflammation, and
resting the joint.
38. Icing the Injury
• The inflammation from a
separated shoulder can
be controlled with ice
placed on the joint every
four hours for a period of
15 minutes.
• Icing can be done for the
first several days until
the swelling around the
joint has subsided.
39. Rest the AC joint
• A sling to rest the joint
can be worn until the
pain has subsided and
you can begin some
simple exercises.
Resting the joint will
help minimize painful
symptoms and allow
healing to begin.
40. Anti-inflammatory Medication
• Anti-inflammatory
medication such as
Advil or Motrin will
also help to minimize
the pain and
inflammation--check
with your doctor
before using these
medications.
41. Grade I and II Injuries
• underestimated and may lead to more chronic disability
than previously recognised
• especially in athletes and heavy labourers who stress their
shoulder daily.
•
• Some late surgery as AC joint resection arthroplasty may be
needed.
• However, more than 50% of the patients having a good or
excellent shoulder 6 years after injury.
42. Surgery
• not in most cases.
• Type I and type II shoulder separations are by far the most common
types of separated shoulders, and these types of injuries rarely need
surgery--and only if there are problems with non-operative treatment.
• Type IV, V, and VI shoulder separations almost always require surgery,
but these are very uncommon injuries.
• The difficult decisions arise with patients with a type III shoulder
separation. There is controversy among orthopedic surgeons as to how
to best manage patients with a type III shoulder separation.
• there is no 'right answer,'
43. Surgical Treatment
• Surgery can be considered if pain persists or the deformity
is severe.
• A surgeon might recommend trimming back the end of
the collarbone so that it does not rub against the
acromion.
• Where there is significant deformity, reconstructing the
ligaments that attach to the underside of the collarbone is
helpful.
• This type of surgery works well even if it is done long after
the problem started.
44. Non-Surgical Treatment for type III
Shoulder Separations...
• Most evidence suggests that patients with
type III shoulder separations do just as well
without surgery, and avoid the potential risks
of surgical treatment.
• These patients return to sports and work
faster than patients who have surgery for this
type of injury.
45. Type III and IV
• Furthermore, AC joint instability symptoms may persist, with
impingement symptoms secondary to the drop down of the
shoulder and the abnormal biomechanics.
• Patient may complain of severe deformity in the AC joint and
traction symptoms with neck pain and neural brachial plexus
symptoms.
• There is significant decrease (24%) in horizontal abduction
strength at fast speeds.
• However, overall 87% with type III dislocation showed satisfactory
outcome with conservative treatment of ‘Skilful neglect’.
•
46. Surgery for type III Shoulder
Separations...
• Recent studies have suggested that some athletes and
heavy laborers may benefit from early surgical
treatment of type III shoulder separations.
• These include athletes who participate in sports that
require overhead throwing such as baseball.
• The potential benefit of early surgical treatment for
type III shoulder separations remains unproven.