This document discusses the classification and treatment of acromioclavicular (AC) joint dislocations. It classifies AC joint injuries using the Rockwood classification system, which involves 6 types of injuries based on the degree of ligament disruption and bone displacement. For types 1 and 2 injuries, conservative treatment with rest, ice, and sling is usually recommended. Treatment for type 3 injuries is controversial but often involves initial conservative treatment with possible later surgery. Surgical treatment is described for more severe injuries. Overall, the document indicates that outcomes are often comparable between conservative and surgical treatment, but surgery carries higher risks of complications.

2. 9% of shoulder girdle injuries
Generally occurs in males age 20-30

3. Anatomy

4. Classification
Allman and Tossy modified by Rockwood
Type 1
• Sprain of AC Lgt
• Coracoclavicular Lgts
normal

5. Classification
Allman and Tossy modified by Rockwood
Type 2
• AC Lgts disrupted
• Coracoclavicular Lgts
sprained

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

7. Classification
Allman and Tossy modified by Rockwood
Type 4
• AC Lgts disrupted
• Coracoclavicular Lgts
disrupted
• Clavicle posteriorly
displaced into or
through the trapezius

8. Classification
Allman and Tossy modified by Rockwood
Type 5
• AC Lgts disrupted
• Coracoclavicular Lgts
disrupted
• Clavicle displaced
superiorly more than
100%

9. Classification
Allman and Tossy modified by Rockwood
Type 6
• AC Lgts disrupted
• Coracoclavicular Lgts
disrupted
• Inferior dislocation
of clavicle below the
coracoid

10. Diagnosis
 Fall onto the adducted
shoulder
 Fall on Point of
shoulder
 Prominent distal clavicle
 Tenderness over the AC joint

11. 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

12. X ray
• AP view
• Stress View
• Zanca View
• (AP with 100 cephalic tilt)

13. ZANCA`S VIEW

14. 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

15. 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.

16. • 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.

17. 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.

18. 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

19. 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

20. 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

21. Surgical Management
Phemister technique

22. Surgical Management
Phemister technique Complication

23. Surgical Management
Bosworth technique

24. Surgical management
Clavicular hook plates

25. Surgical Management
Repair+Tightrope augmentation

26. Surgical Management
Tightrope
• 2 buttons
• Flat for clavicle
• Oblong for coracoid
• Connected by
#5 fibre wire

27. LARS Ligament reconstruction
(Ligament Augmentation Reconstruction System)

28. 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

29. LARS Ligament reconstruction
(Ligament Augmentation Reconstruction System)

30. 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).

31. Surgilig reconstruction

32. 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

33. 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

34. Surgical Management
Modified Weaver-Dunn Procedure
Arthroscopic/Assisted/Open

35. 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

36. SICK Scapula syndrome
•
•
•
•
S capular malposition
I nferomedial prominence of Scapula
C oracoid pain
K inesial abnormalities of scapula