II. Definitions
- Acromioclavicular Dislocation
- Acromioclavicular joint dislocation or "Separation"
III. Epidemiology
- Ages to 20 to 49 years old
- More common in males
- More common in athletes, esp. Contact Sports (football, hockey)
IV. Mechanism
V. Grading: AC joint dislocation (Rockwood Classification)
- Incomplete dislocation (Types I to II, 70-90% of cases, non-operative, conservative management)
- Type I: Simple AC joint Contusion or sprain, no clavicle displacement
- Type II: AC joint ligament rupture, slight clavicle elevation (<25%)
- Complete dislocation (Types III to V)
- Type III: Rupture of coracoclavicular ligaments, moderate clavicle elevation (25-75%)
- Type IV: Joint posteriorly displaced (uncommon), into the trapezius Muscle
- Type V: Overlying Muscle penetrated (uncommon), distal clavicle elevated 100-300%
- Type VI: Clavicle displaced behind biceps (rare), associated with Rib Fractures and neurovascular injury
VI. Symptoms
- Tenderness and swelling over AC joint
- Pain on lifting arm
VII. Signs
- See Hand Neurovascular Exam
- Lateral or distal clavicle elevated
- Deformity if Grade III or higher
- Provocative Maneuvers eliciting pain
- Downward traction on arm
- Shoulder Crossover Maneuver (cross-body adduction of arm)
VIII. Differential Diagnosis
- Rotator Cuff Tear
-
Acromioclavicular Osteoarthritis
- Older patients, with non-Traumatic pain
IX. Imaging: XRay
- Views
- Anteroposterior View (with other side for comparison)
- Highest yield initial XRay
- Zanca View (10-15 degrees cephalic tilt)
- Axillary View
- May better identify posterior AC Dislocations (Type IV)
- Cross Body Adduction View
- Hand on the affected side reaches across the chest to grasp the opposite Shoulder
- Increases clavicle elevation in coracoclavicular ligament injury
- Internal rotation of affected arm
- Consider in Type III rotation
- Anteroposterior View (with other side for comparison)
- Indications
- Differentiate incomplete from complete AC Dislocation
- Evaluate for Clavicle Fractures and other complications
- Obtain opposite side for comparison if laxity is present
- Weighted views are no longer indicated
- Diagnosis is clinical and XRay may be diagnostic with step-off seen
- Comparison films with opposite side are still helpful
- Old protocol used XRay taken with 10 kg weights hanging from each arm
- Measured coracoid process to clavicle distance
- Discrepancy between sides suggested AC Dislocation
- Diagnosis is clinical and XRay may be diagnostic with step-off seen
- Advanced Imaging (e.g. CT Chest) Indications
- Type IV to VI AC Dislocations
- Neurovascular compromise
X. Management
- Orthopedic referral for Type III to VI AC Separations
- Symptomatic relief
- Immobilize with sling for 3 days depending on pain (limiting to short duration is best)
- Avoid sling use >1-2 weeks to prevent Frozen Shoulder
- See RICE-M
- Analgesics as needed
- Clavicle tip often prominent, but usually painless
- Anticipate symptom duration based on type of AC Separation
- Type I: 1-3 weeks of symptoms
- Type II: 4-6 weeks of symptoms
- Type III: 3 months of symptoms
- May require surgical management in active patients (athletes, laborers, military)
- Good outcome in 80% without surgery
- Type IV to VI: Surgical management
- Immobilize with sling for 3 days depending on pain (limiting to short duration is best)
- Active range of motion of strengthening (non-surgical, Type I to III cases)
- Begin range of motion as soon as possible (for non-surgical cases)
- See Shoulder Range of Motion Exercises
- See Shoulder Strengthening Exercises
- Physical therapy to optimize range of motion, Shoulder strength and Scapular stability
- Return to sport when pain free activity that matches the unaffected side
- Other Non-invasive Measures in Refractory Pain Cases
- Acromioclavicular Joint Injection
- Controversial Corticosteroid use (risk of Soft Tissue Injury)
- Acromioclavicular Joint Injection
- Surgery Indications
- Type 4 to 6 AC Dislocation
- Type 3 AC Dislocation if physically active or symptoms persist 3-6 months
XI. Management: Taping Technique (consider in Wilderness)
- Realignment
- Examiner 1 pushes down on clavicle
- Examiner 2 pushes up on upper arm from elbow
- Taping technique
XII. Complications
- Clavicle Fracture (lateral third)
- Coracoid process Fracture
- Sternoclavicular Dislocation
- Brachial Plexus Injury (rare)
- Acromioclavicular joint degenerative changes (AC Arthritis)
XIII. References
- Dolbec (2019) Crit Dec Emerg Med 33(1): 17-25
- Kiel and Koneru (2019) Crit Dec Emerg Med 33(9): 17-27
- Lin and Silverio in Herbert (2018) EM:Rap 18(1):14-16
- Wirth in Greene (2001) Musculoskeletal Care, p.115-7
- Monica (2016) Am Fam Physician 94(2): 119-27 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Concepts | Injury or Poisoning (T037) |
ICD10 | S43.1 |
SnomedCT | 157259008, 269325002, 263019000 |
English | Disloc acromioclav joint, dislocation of acromioclavicular joint (physical finding), dislocation of acromioclavicular joint, dislocation of AC joint, acromioclavicular joint dislocation, dislocation of acromioclavicular joint (diagnosis), Acromioclavicular joint disloc, Dislocation of acromioclavicular joint, Dislocation of acromioclavicular joint (disorder), dislocation of the AC joint, Dislocation;AC joint |
German | Luxation des Akromioklavikulargelenkes |
Korean | 봉우리빗장관절의 탈구 |
Dutch | Luxatie van acromioclaviculair gewricht |
Spanish | luxación de articulación acromioclavicular (trastorno), luxación de articulación acromioclavicular |
Ontology: Sprain of acromioclavicular ligament (C0272870)
Concepts | Injury or Poisoning (T037) |
ICD9 | 840.0 |
ICD10 | S43.5 |
SnomedCT | 27182002, 209411006 |
English | Sprn lig acromioclavic joint, Sprain acromioclavicular joint, Sprain of acromioclavicular joint AND/OR ligament, sprain of acromioclavicular joint (diagnosis), sprain of acromioclavicular ligament, sprained acromioclavicular joint, sprained acromioclavicular ligament, sprain of acromioclavicular ligament (diagnosis), sprain of acromioclavicular joint, Sprain acromioclavicular, acromioclavicular sprain, acromioclavicular sprains, Acromioclavicular (joint) (ligament) sprain, Sprain of ligament of acromioclavicular joint (disorder), Sprain of ligament of acromioclavicular joint, Sprain of acromioclavicular joint, Sprain of acromioclavicular ligament (disorder), Sprain of acromioclavicular ligament, Sprain of acromioclavicular joint or ligament, Sprain of acromioclavicular joint AND/OR ligament (disorder), Acromioclavicular joint sprain, Acromioclavicular ligament sprain, Acromioclavicular sprain |
Spanish | Esguince (articular) (ligamentoso) acromioclavicular, esguince del ligamento de la articulación acromioclavicular (trastorno), esguince del ligamento de la articulación acromioclavicular, esguince del ligamento Y/O de la articulación acromioclavicular (trastorno), esguince del ligamento Y/O de la articulación acromioclavicular, esguince del ligamento acromioclavicular (trastorno), esguince del ligamento acromioclavicular, estrema del ligamento o de la articulación acromioclavicular |
Portuguese | Entorse acromioclavicular (articulação) (ligamentos) |
Dutch | acromioclaviculair (gewricht) (ligament)-verstuiking |
French | Entorse du ligament de l'articulation acromio-claviculaire |
German | Akromioklavikulargelenk, -ligament, Verstauchung |
Hungarian | Acromioclavicularis (ízület) (szalag) rándulás |
Czech | Podvrtnutí (vazu) akromioklavikulárního kloubu |
Italian | Distorsione acromioclavicolare (articolazione) (legamento) |
Japanese | 肩鎖(関節)(靱帯)捻挫, ケンサカンセツジンタイネンザ |
Ontology: Acromioclavicular separation (C2363930)
Concepts | Injury or Poisoning (T037) |
English | Acromioclavicular separation |
Spanish | Separación acromioclavicular |
Dutch | acromioclaviculaire scheiding |
Italian | Separazione acromioclavicolare |
German | Luxation des Akromioklavikulargelenkes |
French | Séparation acromio-claviculaire |
Portuguese | Separação acromioclavicular |
Czech | Akromioklavikulární separace |
Japanese | 肩鎖関節離開, ケンサカンセツリカイ |
Hungarian | Acromioclavicularis szétválás |