This document discusses the anatomy, physical exam findings, imaging, and classification and treatment of acromioclavicular (AC) joint dislocations. It describes the Rockwood classification system for AC joint injuries from Types I-VI. Treatment options include non-operative management with sling immobilization for lower grade injuries or operative fixation with techniques like ligament reconstruction using grafts or fixation methods like screws or hook plates for higher grade injuries. Complications of treatment can include residual pain, AC arthritis, and hardware issues.

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

6. Axillary
lateral view

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

8. Stryker
notch view

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 .

11. Rockwood
Classification

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

27. ORIF with CC
screw
fixation
(Bosworth
screw

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