1) Acromioclavicular (AC) and sternoclavicular (SC) joint injuries are caused by direct or indirect trauma and can range from minor sprains to severe dislocations. 2) Imaging such as X-rays and CT scans are used to classify AC injuries using the Rockwood classification and assess severity of SC injuries. 3) Non-operative treatment is usually sufficient for minor AC injuries while more severe or unstable injuries may require surgery such as ligament reconstruction or joint stabilization. Operative treatment is often needed for acute SC dislocations to reduce risk of complications.

1. Acromioclavicular and
Sternoclavicular Joint Injuries
Presentor : Dr Sushil Pokhrel
Orthopeadics resident( T U)

2. Anatomy of AC Joint
Acromion process :
lateral apex of the triangle
S,A,L S,M,P
20° Gliding
Biceps,coracobarchilais ,pectoralis
Minor,CH ligament

3. Epidemology
• 40% of shoulder injuries involve the ACJ injury
• ACJ dislocations represent 12% to 15% of all
dislocations of the shoulder girdle
• ACJ dislocations :8% of all joint dislocations in
the body

4. Mechanism of injury ACJ
Direct injury Indirect
Fig: fall onto the adducted upper limb

5. Pathoanatomy and classification (Roockwood)

6. Symptoms and Signs
• H/o trauma – Pain ,Swelling , Tendreness
• Pain aggravated by movement or loss of ROM
or maneuvers that load the upper limb
• Asymmerty , ecchymosis,abrasion : +/-
• Lateral clavicle : prominent beneath the skin &
drooping of shoulder (>grade III)

7. Anteroposterior stress test :+ (type II)
Type III: possible to reduce or nearly reduce by
placing the hand beneath the flexed elbow and
applying a superiorly directed force sufficient to
obliterate visible deformity. Test for DT fascia.

8. Type III injury Posterior displacement : clavicle grade IV
Type V injury

9. • Type VI injuries: the normal sloping
appearance of the superior shoulder flattens.
• Acromion becomes unusually prominent

10. Imaging

11. • Weighted-stress view of the AC joint : AP view
- maneuver to differenciate type II from III
5 kg

12. deltotrapezial
TYPE VI :
subacromial :- distal clavicle is in a subacromial
subcoracoid : distal clavicle displaced inferior coracoid
trapezial

13. T
Type II
TYPE III

14. TYPE IV
TYPE V

15. Type VI: subcoracoid

16. Management
Nolte et a:Optimal Management of Acromioclavicular Dislocation: Current Perspectives:Orthopedic Research and Reviews 2020:1

17. Non operative for type I ,II,III
• Immobilization : arm pouch sling
till pain free -usually 1-2 week
• Ice and analgesics: pain and inflammation
• Physiotherapy : periscapular muscles
strengthening
: once pain subside -2 weeks

18. • Heavy stresses, lifting, and contact sports
: delayed until full ROM
: no tendreness
:usually 2 to 4 weeks
follow up : 6-8 weeks

19. Operative treatment
• Goals :pain-free shoulder movement in a
range-of-motion arc approaching normal
• Principle : accurate reduction of the AC joint
in both coronal and sagittal plane
• Indications :
Type III : High demand patient
Type : IV,V,VI

20. Operative treatment
1.AC joint satabilization after reduction
2.Coraco-calvicular satbilization after reduction
3. Mixed procedure
3.Ligament reconstruction

21. 1.JOINT STABILIZATION
1.Transarticular fixation :eg :- pins or K wires
AIM:enhance temporary reduction allowing the
native soft tissue an opportunity to heal with
the AC joint in a reduced position

22. 1.JOINT STABILIZATION
2.AC hook plates:
more biomechanical then trasarticular
fixatation
holds clavicle in reduced position by “hooking”
under the acromion
elevating the glenohumeral joint

23. 2.CC space stabilization
1.Extra-articular transient fixation: SCREW
provide enough stability to allow CC ligament
healing or scar formation
eg:1. Bosworth “screw suspension” technique
2. Suture or tape, cortical button, suture
anchor

24. 3.Ligament Reconstruction:
1.CC suspension techniques:
allow for motion with less rigid construct
provide enough fixation to hold the CC
distance reduced and allow for AC- and CC-
ligament healing
Eg: Weaver and Dunn
-nonanatomic technique
-inferior biomechanically

25. Modified D W

26. 3.Ligament reconstruction:
2.Anatomic coracoclavicular ligament
reconstruction (ACCR) :
principle :
1. Reconstruct both CC ligaments by anatomically
fixing a tendon graft in two clavicle tunnels
placed in the anatomic insertion site of the
conoid and trapezoid ligaments.
2. AC ligaments are reconstructed with the
remaining limb of the graft exiting the more
lateral trapezoid tunnel.

27. Anatomic coracoclavicular ligament
Reconstruction (ACCR)(mazzocca et al.)

28. Method of garft harvesting-hamestring

29. • Arthroscopic: .Anatomic coracoclavicular
ligament reconstruction
- done for type III and V : acute /chronic

30. .
In 39 patient the study concluded that, coracoclavicular ligaments reconstruction by conjoint
tendon transfer - tenodesis technique achieves excellent results and could be considered a
valid surgical option of management in acute high grade acromioclavicular dislocations

31. Chronic Acromioclavicular Injuries
H/O: >3 weeks
Examination :
Deformity +
Cross-arm adduction test
Paxinos test: A/P stability

32. Chronic Acromioclavicular Injuries
• Type I and II AC joint injuries: may develop
degenerative changes
• Analgesics
• Avoidance of painful activity or positions
• Intra-articular injection with corticosteroids

33. Chronic :Type I AND Type II
Mumford procedure
resection of lateral 2.5 cm
<1 cm resection recommended

34. LIGAMENT RECONSTRUCTIONS:
Chronic :Type III,IV,V,VI
Coracoclavicular ligament reconstruction
conoid ligament
trapeziodal laigement
Acromio-clavicular ligament
usually after distal resection of clavicle

35. Reconstruction of superior AC ligament
DON’T RECONSTRUCT
CC LIGAMENT
INDICATION:
REDISLOCATION
NEVIASER TECHNIQUE

36. ACCL reconstruction -endobutton

39. Arthoscopic Rconstruction
Arthoscopic :
Weaver dubb-
chuinard
With double
button fixatation

40. Postoperative Care
First 6 to 8 weeks:
arm pouch sling
After 8 weeks:
upright range-of-motion exercises
At 12 weeks:
or pain-free normal range of motion,
strengthening exercises
At 3 to 5 months :Weight training exercise

41. Anatomy of SC joint

43. Sternoclavicular joint injury
• Traumatic SC joint dislocation
:distraction/compression forces
:direct trauma to the joint proper
eg :seat belt,
:direct trauma to anteromedial aspect of
clavicle
• Distraction force :indirect injury to the SC joint

44. Mechanisms
A.compression force is applied to the posterolateral aspect of the shoulder,:posteriorly.
B:compression force is directed from the anterior position:anteriorly

45. Incidence of SC dislocation:-3%
Injuries Associated with Sternoclavicular Joint
Injuries :
Tracheal compression ,Pleura injury
Laceration/compression of the great vessels
Esophageal perforation/rupture , vagus nerve

46. Imaging
• C -Xray AP view:
• Serendipity view :

47. • CT scan:Investigation of choice
espically in posterior disloaction

49. Traumatic SC joint injury

50. Management
Mild (type I): Sparin
Ligaments -intact,
Joint - stable
RX: Analgesics
Ice compresson

51. Moderate(type II):subluxation
partially disruption: capsular, intra-articular
disk, and costoclavicular ligaments
Instability : anterior or posterior +/-
Reduced by drawing the shoulders backward

52. Stable:-clavicle strap - first 4 to 6 weeks
Arm sling:support shoulder
prevent motion of the arm
• For unstable or chronic subluxation :
Resection arthroplasty
Ligament reconstruction

53. • Severe (type III): dislocation
• Complete disruption :-
capsular ,intra-articular ligaments
dislocation of the SC joint (anterior or
posterior)

54. Anterior disloaction :-
• majority of surgeons would not perform an
open reduction in an acute situation even if
closed reduction failed or redislocation
occurred.

55. • Posterior SC dislocation:
acute :- orthopedic emergency
vascular injuries suspected:- CT
angiography
Management :-
Closed reduction :operating room
with capacity for cardiac bypass,
with cardiothoracic team available

56. Closed Reduction of Acute
Sternoclavicular Joint Dislocation
• Technique: Abduction Traction Technique
A.Traction is applied to the arm in an abducted
and slightly extended position.
B.anterior dislocations: direct pressure
over the medial end of the clavicle
B.posterior dislocations,: manipulate the
medial end of the clavicle with the fingers to
dislodge the clavicle from behind the
manubrium
C.posterior dislocation: a sterile towel clip to
grasp around the medial clavicle to lift it back

57. Adduction Traction Technique

58. Posterior physeal injuries:-
should be reduced when they present acutely.
Stable reduction:-
figure-of-eight dressing or calvicular barce
Immobilization - 3 to 4 weeks.

59. Operative indication
Anterior SC joint disloaction :
• Symptom of post-traumatic arthritis for 6 to
12 months following dislocation
• Subcortical cystic changes and
• Symptoms can be completely relieved by
injection of local anesthesia

60. Operative indication
Posterior sc displacement :
• Symptomatic and cannot be reduced by closed
means
physeal separations eg the type II Salter–Harris
fracture
• Chronic :>48 hours closed reduction becomes
less likely to succeed
• Complications: late thoracic outlet syndrome,
late and significant vascular problems, respiratory
compromise, and dyspnea on exertion

61. Reconstruction Techniques of the SC joint
• Local Tendon Transfers :
to recreate anterior SC ligament
- Subclavius Tendon
- Sternocleidomastoid Tendon

62. Reconstruction Techniques of the SC
joint
sc/costoclavicular ligament reconstruction
Autograft
Allograft
biomechanically
figure of“8 “
has better result

63. Reconstruction Techniques of the
SC joint
Using Synthetic Materials :
• suture anchors
• nonabsorbable synthetic ligament
• combined suture-ligament constructs
Reconstruction of sc ligament
with suture anchor

64. Open Reduction and Internal Fixation
Interpositional Arthroplasty:
graft is placed within a bony trough created
after medial clavicle excision and fixed

65. • Resection of the Medial Clavicle (With and
Without Costoclavicular Ligament
Reconstruction)
usually done for post trauma OA
medial clavicle of no more than 1 cm in men
and 0.9 cm in women

67. Post op care
• Shoulder sling : 6 weeks
• Active range of motion of the hand, wrist, and
elbow and passive shoulder exercises below
the horizontal plane (e.g.pendulum)
• After 6-week : active-assisted shoulder range
of motion exercises in all planes
• After 3 months: progressive strengthening
program begins