Acromioclavicular joint dislocation Examination corner
Rockwood classification (1984)4
Or more simply the “Six S’s”
Types I–III account for 98% of these injuries.
Controversies of surgical versus nonsurgical man
agement surround type III fractures, which make up
40% of all ACJ injuries.
4 Rockwood CA Jr. (1984) Subluxations and dislocations
about the shoulder. Injuries to the acromioclavicular joint.
In: Rockwood CA Jr., Green DP (eds.) Fractures, edn. 2, vol. 1.
Philadelphia: JB Lippincott, pp. 860–910.
Imaging
• AP with 10°–15° cephalic tilt – outlines joint/loose
bodies
• Stress radiograph with 4kg weight suspended
from patient’s wrist – helps differentiate between
type II and III injuries
Management
Types I and II are managed nonoperatively; types
IV–VI, with surgery. Controversy surrounds the type
III injury, as to whether to manage operatively or
nonoperatively. There is possibly a case for surgery
in a heavy manual labourer or an athlete.
A wide variety of operative procedures have been
described but none has been shown to be clearly
superior to the others. Newer arthroscopic tech
niques to manage ACJ injuries are evolving, they
cause less disruption to the soft tissue envelope but
there is a steep learning curve.
Non-operative management
• Sling or brace for 6–8 weeks
• Loss of shoulder and elbow motion
• Softtissue calcification
• Interference with ADLs
• Late ACJ osteoarthritis
Operative management
• The use of Kwires to fix the ACJ is now contraindi
cated. It is dangerous as pin breakage and migration
can occur, it gives relatively poor fixation and a sec
ond procedure for hardware removal is required
• Steinman pin across the ACJ. Given the wider
range of better implants now available, this is not
recommended
• Coracoclavicular lag screw (Bosworth screw) with
repair of CCL and plication of the torn deltoid and
trapezius. Gone out of favour as concerns with
loss of screw fixation or screw breakage, etc.
• Dynamic muscle transfers. Transfer of the lateral
half of the conjoined tendon to the distal clavicle
augmented by EndoButton fixation of the ACJ. A
major procedure with more risks involved than
are necessary such as musculocutaneous nerve
injury and loss of fixation
• Coracoclavicular cerclage. A wellestablished
technique, materials include tendons, wire loops
and synthetic ligament substitutes such as Dacron
or Mersilene tape
• Clavicular hook plate. Needs removing after heal
ing of the soft tissues
• Arthroscopic techniques. The CCL is dissected
from the undersurface of the acromion and is
reinserted on the inferior clavicle by transosseous
suture fixation. Other techniques involve the use
of a semitendinosus allograft to reconstruct the
CCL. The accuracy of reduction of the joint is
more difficult to assess arthroscopically
Complications of conservative management
• Cosmetic “bump” on the distal clavicle
• Painful ACJ with degenerative changes. If severe,
it is managed with excision of the distal clavicle
and reconstruction of the CCL by using the cora
coacromial ligament (Weaver–Dunn procedure)
Prognosis
• Up to 100% good/excellent results with type I/II
injuries
• Patients with nonoperative management of type
III injuries may experience mild discomfort, but
no reduction of strength or endurance compared
to the noninjured side at 4 years
• Return to work and rehabilitation are quicker with
nonoperative management for type I–III injuries
ACROMIOCLAVICULAR DISLOCATION
RELATED LINK
