The document discusses injuries to the acromioclavicular (AC) joint. It provides details on the anatomy and biomechanics of the AC joint and surrounding ligaments. Common mechanisms of injury include falling on an outstretched arm or direct force to the lateral shoulder. Injuries are classified using the Rockwood system from Type I to VI based on the degree of ligament disruption and bone displacement. Treatment options include nonoperative measures for lower grades and surgery for higher grades or failed nonoperative treatment. Surgical techniques and associated conditions are also reviewed.
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Dislocation of joint is very tricky. In this presentation radiological evaluation of Dislocation of various joints will be discussed.
This is one of the best pictoral review of important joint dislocations
JOINT DISLOCATION of hip knee and shoulder PART-2.pptxrammmramm000
JOINT DISLOCATION of hip knee and shoulder
JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder
JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder
JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder
JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder
JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder
JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip knee and shoulder JOINT DISLOCATION of hip kn
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
3. Applied Anatomy
• A plane synovial joint, located between medial margin
of acromion and lateral end of clavicle
• Within the AC joint, there is a fibro cartilaginous disc
4.
5. Acromioclavicular Ligaments
• Consists of anterior, posterior, superior, and inferior
ligaments, surround the AC joint
• Stabilize the joint in horizontal plane
• Superior AC ligament- strongest of capsular ligaments,
blend with fibers of the deltoid and trapezius muscles
adding stability to AC joint.
6. Coracoclavicular Ligament
• Very strong ligament from outer inferior surface of
clavicle to base of the coracoid process of scapula.
• Two components—conoid and trapezoid ligaments
• Vertical stability of AC joint
7. • The only connection between the upper extremity
and the axial skeleton is through the clavicular
articulations at the AC and SC joints.
• SC ligaments support clavicles suspended away from
the body
• CC ligament suspend upper extremities from distal
clavicles
8. • CC ligament helps to
couple glenohumeral
abduction/flexion to
scapular rotation on thorax
during overhead elevation
• Clavicle rotates around 40-
50 degrees during full
overhead elevation--
simultaneous scapular
rotation and AC joint
motion
9. Overview
• Injuries to either AC or SC joints can result in a wide
range of shoulder dysfunction.
• Both can be injured by similar mechanisms, present
with overlapping clinical complaints, and in some
cases result in injury to both locations
• Acromioclavicular injures are more common, and
sternoclavicular injuries are rare
10. Risk groups
• often occur in male patients less than 30 years of age
• associated with contact sports or athletic activity in which direct blow
to lateral aspect of shoulder occurs.
• The contact or collision athlete represents a “high-risk” individual
(football, rugby, and hockey)
• AC joint injuries accounted for 4.5% of all injuries (and 32% of all
shoulder injuries) in a population of NCAA football players followed
for 5 years. Of the 748 injuries to the AC joint recorded, the vast
majority (96%) were “low-grade” injuries, classified as type I or II
sprains
11. Mechanisms of Injury
• Falling on an outstretched arm, locked in extension at
the elbow, can drive humeral head superiorly into
acromion--low-grade AC joint injuries
• A medially directed force to lateral shoulder that
drives acromion into and underneath the distal
clavicle(when getting checked into the boards during
a hockey game)- higher degrees of injury and
subsequently more displacement.
12. • More commonly described pattern- falling or being
tackled onto lateral aspect of the shoulder with the arm
in an adducted position which produces a compressive
(medial) and shear (vertical) force across the joint-
typically produces higher degree of displacement enough
to tear both AC and CC ligaments.
13. • The injury force which drives acromion medially and downward
produces a progressive injury pattern; first disruption of AC ligaments,
followed by disruption of CC ligaments, and finally disruption of fascia
overlying the clavicle that connects deltoid and trapezius muscle
attachments.
• Complete AC dislocation- the upper extremity has lost its suspensory
support from clavicle and scapula- inferior displacement of the
shoulder secondary to forces of gravity.
14. Nontraumatic or Chronic Overuse
• AC joint arthrosis—weight lifting, laborer, repetitive overhead activity
• Repetitive low-grade AC joint injuries
• Medical cause: rheumatoid arthritis, hyperparathyroidism,
scleroderma
15. Clinical presentation
• Young-aged male
• Contact or collision athlete
• H/O direct trauma
• Clinical deformity, focal tenderness and swelling
• Commonly the patient describes pain originating from the anterior-
superior aspect of the shoulder
16. Diagnosis
• Examination should be in sitting or standing w/o support for the injured
arm
• Check for tenderness to palpation at the AC joint and the CC interspace
• If patient can tolerate check joint for stability
• Check to see if reducible
• Examine SC joint as well
• Neurologic exam to r/o brachial plexus injury
19. Clinical triad
• point tenderness at the AC joint,
• pain exacerbation with cross-arm adduction, and
• relief of symptoms by injection of local anesthetic
agent confirm injury to the AC joint.
20. Imaging
• Good-quality radiographs of the AC joint require one-
third to one-half the beam penetration to image the
glenohumeral joint.
• Radiographs of the AC joint taken using routine
shoulder technique will be overpenetrated (i.e.dark),
and small fractures may be overlooked.
Therefore,specifically requested to take radiographs
of “AC joint” rather than the “shoulder.”
21. Radiographic Normal Joints
• Width and configuration of AC joint in coronal plane
may vary significantly from individual to individual. So,
a normal variant should not be mistaken as an injury.
• Normal width of AC joint in coronal plane is 1 to 3 mm.
AC joint space diminishes with increasing age (0.5 mm
in older than 60 years is conceivably normal). Joint
space of greater than 7 mm in men and 6 mm in
women is pathologic.
• Average CC distance 1.1 to 1.3 cm. An increase in CC
distance of 50% over normal side signifies Complete AC
dislocation (has been seen with as little as 25% increase
in CC distance).
22. Zanca View
• Beam placed 10
degrees cephalad
• Obtained using soft
tissue technique in
which voltage is cut
into half
• quantifying CC
distance, and
percentage
displacement of distal
clavicle above
acromion.
29. Type of Injury Clinical Features Radiological Features
Type I minimal to moderate tenderness to palpation over the AC joint
mild swelling over the AC joint
minimal pain with arm movements
respond very well to local anesthetic/ corticosteroid injections
No widening,separation or
deformity
Type II • moderate to severe tenderness with palpation of the joint
• Distal end of clavicle slightly superior to acromion
• Adduction motion of the shoulder produces pain in the AC joint
• Difficulty sleeping
• AC horizontal Instability
• Tenderness at CC space
<50% width of clavicle
displacement at AC joint
Increased CC distance < 25% of
contralateral
Type III • Upper extremity held adducted in elevated position
• shoulder droop sign
• Clavicle may be prominent enough to tent the skin.
• Moderate pain -any motion of the arm, particularly abduction
• Tenderness at AC joint, CC interspace, and along superior aspect
of lateral clavicle.
• AC joint instability in both the horizontal and vertical planes
• “shrug test” (vs type V)
Distal clavicle Displaced
Increased CC distance 25-100% of
contralateral
May be accompanied by Fracture
coracoid > Stryker View
30. Type of Injury Clinical Features Radiological Features
Type IV • All clinical findings of type III injury.
• clavicle is translated posteriorly compared with uninjured
shoulder may be “buttonholed” through trapezius muscle
and tents posterior skin.
• AC joint cannot be reduced manually
• Examine SC joint “bipolar” or “floating clavicle” injuries,
Best Observed in Axillary View
Lateral clavicle displaced posterior through
trapezius
Type V • Distal end of clavicle grossly superiorly displaced, tenting
the skin
• Downward Displacement of Upper Extremity
• More Pain than Type III secondary to more soft tissue
disruption.
• Shoulder musculature becomes weak secondary to disuse
or as part of the injury pattern-scapular dyskinesis
Zanca View
Increased CC distance > 100% of contralateral
Type VI • superior aspect of shoulder has flat appearance
• acromion is prominent
• associated fractures of clavicle,upper ribs or injury to upper
roots of brachial plexus
• Mechanism :Severe Hyperabduction and ER + retraction of
scapula
Subacromial type - decreased CC distance,
distal clavicle in subacromial location.
Subcoracoid type - reversed CC distance,
clavicle displaced inferior to coracoid process
31.
32.
33.
34. • Children and adolescents may
sustain a variant of complete
AC dislocation (most often
Salter–Harris type I or II)
• Radiographs reveal
displacement of distal
clavicular metaphysis
superiorly (through a dorsal
rent in periosteal sleeve) with
increase in CC interspace.
Epiphysis and intact AC joint
remain in their anatomic
locations
35. Treatment goals
• Pain-free shoulder movement in a range-of-motion arc approaching
normal
• Unimpaired daily activities
36. Treatment Options
Nonoperative Treatment
• Indications-
Type I,II,III AC injuries
• Relative contraindications-
-Chronic symptomatic injury
-Failed nonoperative management, athlete, polytrauma, heavy
laborers
37. During 1st week of treatment
• Immobilization device (Arm slings, adhesive tape strappings, braces
and plaster)-
To support the weight of upper extremity and reduce the stress
placed upon the injured ligaments
• Ice and analgesics
To reduce pain and inflammation
38. After 1 to 2 weeks
• Strengthening exercises commenced with particular focus on
periscapular muscles that are important to shoulder
biomechanics.
• Heavy stresses, lifting, and contact sports should be delayed
until there is full range of motion and no pain to joint palpation.
This process can take up to 2 to 4 weeks
• Athletes who desire an earlier return to sports should be
encouraged to use protective padding over the AC joint. An
earlier return to sports that sustains a second injury to the AC
joint, prior to complete ligament healing, can change a partially
subluxated AC joint into a complete AC dislocation. Given this
possible sequela, a forewarning must be provided to all athletes
wishing to return to play at an earlier time. This decision is a
balance between the desire to return to play early and the risk
of reinjury.
39. DISADVANTAGES OF NON OPERATIVE
TREATMENT
• SKIN PRESSURE AND ULCERATION
• RECURRENCE OF DEFORMITY
• WEARING A BRACE FOR LONG TIME(8
WEEKS)
• POOR PATIENT COOPERATION
• INTERFERENCE WITH DAILY ACTIVITIES
• LOSS OF SHOULDER AND ELBOW MOTION
• SOFT TISSUE CALCIFICATIONS
• LATE ACROMIOCLAVICULAR ARTHRITIS
• LATE MUSCULAR ATROPHY,FATIGUE AND
WEAKNESS.
40. Type III- operative or nonoperative ?
• In prospective randomized studies between operative and
nonoperative treatment of type III AC joint injuries, patients treated
nonoperatively demonstrated a quicker return of function and
sustained fewer complications than patients treated operatively.
• Patients treated conservatively returned to work on average 2.1
weeks from injury and the strength and ROM of the injured shoulder
were comparable to the contralateral uninjured shoulder with a
mean follow-up of 2.6 years (Wojtys and Nelson)
• Operatively treated AC injuries showed a significantly higher
incidence of osteoarthritis and CC ligament ossification
• A proportion of conservatively treated patients will have persistent
pain and inability to return to their sport or job. Subsequent surgical
stabilization has allowed return to sport or work in such cases
41. Reasons for lower-grade AC joint injuries being
symptomatic –
• posttraumatic arthritis
• posttraumatic osteolysis of the distal clavicle,
• recurrent AP subluxation,
• torn capsular ligaments trapped within the joint,
• loose pieces of articular cartilage,
• detached intra-articular meniscus or associated intra-
articular fracture fragment.
42. Chronic Acromioclavicular Injuries
• Chronic pain after type I and II injuries- NSAIDS, avoidance of painful
activity or positions, and intra-articular injection with corticosteroid
• Type I-
Operative excision of distal clavicle (limited to less than 10 mm )-open or
arthroscopic
• Type II-
Distal clavicle excision + AC capsular reconstruction or coracoacromial
ligament transfer
• Chronic pain and instability after types III, IV, and V- Distal clavicle
excision + Transfer of acromial attachment of coracoacromial ligament to
the resected surface of distal clavicle and concurrent CC stabilization
43. Operative Treatment
Indications -
• Patients (types I,II,III) who have failed a minimum 6
weeks of shoulder stabilization–directed physical
therapy (delayed surgical reconstruction using a
tendon graft)
• Active healthy patients with complete AC joint injuries
(types IV, V, and VI)- significant morbidity associated
with the injury pattern- persistently dislocated,
unstable AC joint, with change in scapular kinematics,
and shoulder dysfunction.
• Fracture of coracoid extending intra-articularly into
glenoid (5 mm or more of glenoid displacement )
44. • Fixation across AC joint
• Fixation between coracoid and
clavicle
• Ligament reconstruction
• Distal clavicle excision
45. ANY SURGICAL PROCEDURE FOR AC JOINT
DISLOCATION SHOULD FULFILL THREE REQUIREMENTS
• AC JOINT MUST BE EXPOSED AND DEBRIDED
• CC AND AC LIGAMENTS MUST BE
REPAIRED OR RECONSTRUCTED
• STABLE REDUCTION OF THE AC JOINT MUST BE
OBTAINED
Achievingthese three goals , no matter how the joint is
fixed , should give acceptable results.
46. DISADVANTAGES OF SURGICAL
MANAGEMENT
• INFECTION
• HEMATOMA FORMATION
• ANAESTHETIC RISK
• SCAR FORMATION
• RECURRENCE OF DEFORMITY
• METAL BREAKAGE,
LOOSENING,MIGRATION
• SECOND SURGERY FOR REMOVAL
• BREAKAGE OR LOOSENING OF
SUTURES
• EROSION OR FRACTURE OF DISTAL
CLAVICLE
50. Fixation between coracoid and clavicle
• Bosworth popularized the use of a screw for fixation
of the clavicle to the coracoid
• This technique initially did not include
recommendation for repair or reconstruction of the CC
ligaments
• Today the use of screws and suture loops has been
described alone and in combo with ligament
reconstruction
• Placement of synthetic loops between the coracoid and
clavicle can be done arthroscopically, main advantage:
doesn’t require staged screw removal
53. Ligament reconstruction
• Weaver and Dunn were the 1st to describe transfer for the
native CA ligament to reestablish AC joint stability
• Their technique described excision of the distal clavicle with this
ligament transfer
• Construct can be augmented with a suture loop for protection until
the
transferred ligament heals
Open or Arthroscopy
55. Anatomic Ligament Reconstruction
• Alternative technique is use of semitendinosus autograft for
reconstruction
– Loop around or fix into coracoid, then fix through two separate clavicle
bone tunnels to approximate normal anatomic location of CC
ligaments
• Recent biomechanical studies have demonstrated the superiority
of this
construct
56. Anatomic Coracoclavicular Ligament Reconstruction
• ACCR technique attempts to restore biomechanics of
AC joint complex as treatment for painful or unstable
dislocations
• Rationale- to reconstruct both CC ligaments by
anatomically fixing a tendon graft in two clavicle
tunnels placed in the anatomic insertion site of conoid
and trapezoid ligaments.
• In addition, AC ligaments are reconstructed with the
remaining limb of the graft exiting the more lateral
trapezoid tunnel.
57. ACCR technique: patient positioning
• Far lateral position with shoulder free to extend, small
scapula bump along medial scapula border, and head
position extended and rotated away from operative side.
58. ACCR-Steps
• Vertical incision centered on clavicle (starting from
posterior clavicle to just medial of coracoid process
)approx 3.5 cm medial to AC joint.
• Subperiosteal flaps raised to ensure that trapezius and
deltoid attachments are elevated off. Tagging stitches can
be placed to aid in tight closure of this layer during
closure.
59. • Conoid tunnel position marked at least 45 mm from
distal clavicle
• Trapezoid tunnel position marked with at least 25 mm
of bone bridge between tunnels
• Tunnels drilled
60. • Graft passed through
tunnel,beneath coracoid
• Interference fixation with
PEEK screws
(polyetheretherketone)
• Continue brace for 8 weeks
• Strengthening exercises
from 12 weeks
61. • Graft options- semitendinosus allograft/autograft, Anterior tibialis
allograft.
• Semi-tendinosus allograft preferred -simplification of patient
positioning, no donor site morbidity, decreased operative time,
consistency in graft tissue size
• The minimal length needed to ensure graft available for AC ligament
reconstruction approx 110 mm.
63. • Glenohumeral Intra-Articular Pathology Pauly et al. noted a 15%
incidence of intra-articular pathology, SLAP and PASTA(Partial articular
supraspinatus tendon avulsion) lesions, in their series of 40
consecutive patients undergoing arthroscopic-assisted reconstruction
of grade III to V AC joint dislocations
64. Fractures
• lateral clavicle fracture
• base or neck of coracoid process fracture
• concomitant injury to medial clavicular epiphysis (less than 30 years
of age)
• Fracture of midshaft of clavicle with either anterior or posterior
subluxation/dislocation of SC joint (uncommon)
65. Secondary osteoarthritis
• late complication
• usually be managed conservatively,
• If pain is marked, the outer 2 cm of clavicle can be excised.
66. Case
• 30 yrs/ F with history of fall from
scotter sustaining injury to left
shoulder
69. Rockwood Classification
Type AC
ligament
CC ligament Exam Radiographs Reducibility Treatment
Type I Sprain Normal AC
tenderness
No AC
instability
Normal Reducible Sling
Type Il Torn Sprain AC horizontal
instability
AC joint disrupted Increased CC
distance < 25% of contralateral
Reducible Sling
Type III Torn Torn AC joint disrupted Increased CC
distance 25-100% of contralateral
Reducible Controversial
IIIA AC vertical
instability No
horizontal
stability
IIIB AC vertical
instability
Horizontal
instability
70. Type AC ligament CC ligament Exam Radiographs Reducibility Treatment
Type IV Torn Torn Skin tenting
Posterior
fullness
Lateral clavicle
displaced
posterior
through
trapezius on the
axillary lateral
XR
Not reducible Surgery
Type V Torn Torn Severe shoulder
droop, does not
improve with
shrug
. Increased CC
distance > 100%
of contralateral
Not reducible Surgery
Type VI Torn Torn Rare; Associated
injuries;
paresthesias
. Inferior
dislocation of
lateral clavicle,
lying either in
subacromial or
subcoracoid
position
Not reducible Surgery
71. References
• Rockwood and Greens Fractures in Adult, Ninth edition
• Campbell Orthopaedics ,14th edition
• Apley and Solomon’s System of Orthopaedics and Trauma, Tenth
Edition
• https://www.orthobullets.com/shoulder-and-
elbow/3047/acromioclavicular-joint-injury
conoid ligament, the more medial of the two ligaments, is cone shaped, with the apex of the cone attaching on the posteromedial side of the base of the coracoid process. The base of the cone attaches onto the conoid tubercle on the posterior undersurface of the clavicle.
The O'Brien test may be particularly helpful when attempting to differentiate symptoms of AC joint arthrosis from intra-articular lesions, especially those of the superior glenoid labrum.
In a study of 100 radiographs of normal shoulders, Urist found that
49% of the AC joints were inclined superolateral to inferomedial, with articular surface of clavicle overriding acromion;
27% were vertical
3% were inclined superomedial to inferolateral, with the articular surface of clavicle underriding acromion
21% were incongruent, with clavicle lying either superior or inferior to acromial articular surface.
Bankert lesion
Based on anatomic severity of the injury.
III- Radiographic findings include a 25–100% increase in the coracoclavicular space in comparison to the normal shoulder
V- increased greater than 100%, stripping of deltotrapezial fascia
Controversy-Several studies advocate operative management over nonoperative based on functional outcome, while other recommend conservative. But the auther of rockwood recommend nonoperative
Surgical management may be indicated in such conditions
Obsolete- fixation failure, loss of reduction, and disastrous migration of hardware
Resections should be limited to less than 10 mm of distal clavicle as to limit the disruption of the superior and posterior capsular/ligament structures .
Attached by transosseous sutures
Risk of Clavicle fracture if bone bridge not maintained, if tunnel drilled with >5.5mm
Graft prepared with a continuous running locked stitch of high-strength nonabsorbable suture.
brachial plexus neurapraxia after sustaining a type III AC separation. The patient responded well to CC stabilization.
Coracoclavicular Ossification -intrinsic healing response within this area following injury to the CC ligaments. Usually, it has no effect on the functional outcome but if present may require removal to facilitate full reduction of the AC joint and CC distance at the time of operative intervention.
Osteolysis of the Distal Clavicle -a radiographic finding, due to repeated microtrauma with a recurrent inflammatory process following low-grade AC separations
Scapulothoracic Dissociation -lateral displacement of the scapula resulting in a traction injury to the neurovascular structures of the shoulder
The patient will be aware of some weakness during strenuous overarm activities and pain is often not completely abolished