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How do you know if you had a
      bad weekend ?
Ac joint
What is adaptive golf?
Ac joint
Who won for the first time in
       two years?
Ac joint
What is a wheelchair dunk?
Ac joint
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).
What type of Injury?
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.
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.
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
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.
Severe Separation
• The most severe
  shoulder separation
  completely tears both
  the AC and CC
  ligaments and puts the
  AC joint noticeably out
  of position.
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.
• Sometimes having the
  patient hold a weight in
  the hand can increase
  the deformity, which
  makes the injury more
  obvious on X-rays.
Timeout
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
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
What is Paxinos Sign?
Paxinos Sign
• Pushes the acromium
  into the clavicle with
  the thumb

• Positive if there is pain
  increases
• 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
What is Rockwood Scale?
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:
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.
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
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.
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.
• 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.
Type IV Shoulder Separation



• A type IV shoulder
  separation is an
  unusual injury where
  the clavicle is pushed
  behind the AC joint.
• 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.
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)
• 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.
Grade 6


• involves full rupture of
  both AC and CC
  ligaments with the
  clavicle being displaced
  inferiorly.
Treatment

• Whether treated
  conservatively or with
  surgery, the shoulder
  will require
  rehabilitation to
  restore and rebuild
  motion, strength, and
  flexibility.
Treatment – depend on the type of
               injury


• The initial treatment of
  a separated shoulder
  consists of controlling
  the inflammation, and
  resting the joint.
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.
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.
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.
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.
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,'
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.
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.
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’.
•
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.
Physiatric Prescription?

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Ac joint

  • 1. How do you know if you had a bad weekend ?
  • 5. Who won for the first time in two years?
  • 7. What is a wheelchair dunk?
  • 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).
  • 10. What type of Injury?
  • 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.