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AC Joint Dislocation Treatment Options
- 1. Acromio- clavicular joint dislocation Dr mateen Qaiser butt Resident orthopedic surgery Aziz Bhatti shahed teaching hospital
- 2. Anatomy
- 4. Physical exam • AC joint tenderness • Abnormal contour of the shoulder as compared to the opposite. • Obriens test • Cross body adduction test
- 5. Imaging • Bilateral ap views of the AC joint
- 7. Stryker Notch View • A variant of an AC joint injury involves a fracture of the coracoid process. This injury should be suspected when there is an AC joint dislocation on the AP projection but the coracoclavicular distance is normal, or equal to that on the opposite, uninvolved side. • A Stryker notch view, taken appropriately, puts the coracoid in profile and is the best view for evaluating this injury. • Technique for taking the Stryker notch view to show fractures of the base of the coracoid. The patient is supine with a cassette placed posterior to the shoulder. The humerus is flexed approximately 120 degrees so the patient's hand can be placed on top of the head. The x-ray beam is directed 10 degrees superior
- 9. Zanca view
- 10. weighted stress views • usually no longer used • may help differentiate Type II from Type III • A 10–15-pound weight is attached to the wrist of the affected side and an AP view can be taken .
- 13. Type 3 • The key to the diagnosis of a type III injury is that the defect can be reduced with upward pressure under the elbow
- 14. type 4
- 15. Type 4 • The clavicle usually is displaced so severely posteriorly that it becomes “buttonholed― through the trapezius muscle and tents the posterior skin .
- 16. Type 5
- 17. Type 5 • The distal clavicle is subcutaneous and cannot be manually reduced. Occasionally, there is so much inferior displacement of the upper extremity that the patient will develop symptoms of traction on the brachial plexus. • The clavicle appears to be grossly displaced superiorly away from the acromion .However, x-rays reveal that the clavicle on the injured side is actually at approximately the same level as the clavicle on the normal side, and the scapula is displaced inferiorly
- 18. Type 6
- 19. Treatment
- 20. Non operative • brief sling immobilization, rest, ice, physical therapy • indications • type I and II • type III in most individuals ,good results when clavicle displaced < 2cm.
- 21. Rehabilitation • early shoulder range of motion • regain functional motion by 6 weeks • return to normal activity at 12 weeks • consider corticosteroid injections
- 22. Operative treatment • Indications • Acute type 4 , 5 and 6 injuries • acute type III injuries in laborers, elite athletes, patients with cosmetic concerns • chronic type III injuries that failed non-op treatment • however, new studies have shown no difference in outcomes in types III injuries treated surgically after 6 weeks non-op treatment versus immediate surgery
- 23. Techniques Two types 1. ligament reconstruction with soft tissue graft 2. Fixation methods
- 24. ligament reconstruction with soft tissue graft 1. Modified weaver dunn 2. Autograft 3. Allograft Modified weaver dunn CC ligament reconstruction with coracoacromial (CA) ligament • cons • coracoacromial ligament only 20% as strong as normal CC ligament • lack of internal fixation risks failure of soft tissue repair
- 25. • autograft • palmaris longus • semitendinosus • allograft • tibialis anterior • technique • figure-of-eight passage of graft, looping around coracoid and fixation through clavicular tunnels • reinforce with internal fixation • pros • graft reconstruction more closely recreates strength of native CC ligament • cons • standard risks of allograft use or autograft harvest • lack of internal fixation risks failure of soft tissue repair
- 26. Fixation methods 1. suture 2. hook plate 3. CC screw (Bosworth) 4. cortical flip button (e.g Dog Bone)(+/- arthroscopic assistance) 5. K-wire
- 28. • pros • rigid internal fixation • cons • danger of screw being too long and damage to critical structure below coracoid • routine screw removal at 8-12 weeks is advised to prevent screw breakage due to normal motion between clavicle and scapula • complications • hardware irritation at level of screw purchase in coracoid • hardware failure at level of screw purchase in coracoid
- 29. ORIF with CC suture fixation • pros • no risk of hardware failure or migration • cons • suture not as strong as screw fixation • requires careful suture passage inferior to coracoid due to proximity of crucial neurovascular structures • complications • suture erosion causing distal third clavicle fracture
- 30. ORIF with AC hook plate fixation
- 31. • pros • rigid fixation • cons • may require second surgery for plate removal if symptomatic • complications • acromial erosion • hook pullout
- 32. ORIF with AC pin fixation (Phemister Technique)
- 33. • technique • smooth wire or pin fixation directly across AC joint • cons • hardware irritation • complications • high incidence of pin migration • generally not performed due to high complication rates
- 34. Complications • Residual pain at AC joint 30-50% • AC arthritis more common with surgical management than with nonoperative treatment • Hardware failure CC screw breakage/pullout • Coracoid fracture can occur with coracoid tunnel drilling
- 35. •thankyou