II. Definitions

  1. Acromioclavicular Dislocation
    1. Acromioclavicular joint dislocation or "Separation"

III. Mechanism

  1. Fall on an outstretched hand
  2. Direct Trauma
    1. Top of Shoulder or
    2. Shoulder or acromion with arm adducted

IV. Grading: AC joint dislocation (Rockwood Classification)

  1. Incomplete dislocation (Types I to II, non-operative, conservative management)
    1. Type I: Simple AC joint Contusion or sprain, no clavicle displacement
    2. Type II: AC joint ligament rupture, slight clavicle elevation (<25%)
  2. Complete dislocation (Types III to V)
    1. Type III: Rupture of coracoclavicular ligaments, moderate clavicle elevation (25-75%)
    2. Type IV: Joint posteriorly displaced (uncommon), into the trapezius Muscle
    3. Type V: Overlying Muscle penetrated (uncommon), distal clavicle elevated 100-300%
    4. Type VI: Clavicle displaced behind biceps (rare), associated with Rib Fractures and neurovascular injury

V. Symptoms

  1. Tenderness and swelling over AC joint
  2. Pain on lifting arm

VI. Signs

  1. See Hand Neurovascular Exam
  2. Lateral or distal clavicle elevated
    1. Deformity if Grade III or higher
  3. Provocative Maneuvers eliciting pain
    1. Downward traction on arm
    2. Shoulder Crossover Maneuver (cross-body adduction of arm)

VII. Differential Diagnosis

VIII. Imaging: XRay

    1. Anteroposterior View (with other side for comparison)
      1. Highest yield initial XRay
    2. Zanca View (10-15 degrees cephalic tilt)
    3. Axillary View
      1. May better identify posterior AC Dislocations (Type IV)
    4. Cross Body Adduction View
      1. Hand on the affected side reaches across the chest to grasp the opposite Shoulder
      2. Increases clavicle elevation in coracoclavicular ligament injury
    5. Internal rotation of affected arm
      1. Consider in Type III rotation
  2. Indications
    1. Differentiate incomplete from complete AC Dislocation
    2. Evaluate for Clavicle Fractures and other complications
  3. Obtain opposite side for comparison if laxity is present
    1. Ibrahim (2015) Injury 46(10): 1900-5 [PubMed]
  4. Weighted views are no longer indicated
    1. Diagnosis is clinical and XRay may be diagnostic with step-off seen
      1. Comparison films with opposite side are still helpful
    2. Old protocol used XRay taken with 10 kg weights hanging from each arm
      1. Measured coracoid process to clavicle distance
      2. Discrepancy between sides suggested AC Dislocation
  5. Advanced Imaging (e.g. CT Chest) Indications
    1. Type IV to VI AC Dislocations
    2. Neurovascular compromise

IX. Management

  1. Orthopedic referral for Type III to VI AC Separations
  2. Symptomatic relief
    1. Immobilize with sling for 3 days based on pain
      1. Avoid sling use >1-2 weeks to prevent Frozen Shoulder
    2. See RICE-M
    3. Analgesics as needed
      1. Clavicle tip often prominent, but usually painless
    4. Anticipate symptom duration based on type of AC Separation
      1. Type I: 1-3 weeks of symptoms
      2. Type II: 4-6 weeks of symptoms
      3. Type III: 3 months of symptoms (may require surgical management in active patients)
      4. Type IV to VI: Surgical management
  3. Active range of motion of strengthening (non-surgical, Type I to III cases)
    1. Begin range of motion as soon as possible (for non-surgical cases)
    2. See Shoulder Range of Motion Exercises
    3. See Shoulder Strengthening Exercises
    4. Physical therapy to optimize range of motion, Shoulder strength and Scapular stability
    5. Return to sport when pain free activity that matches the unaffected side
  4. Surgery Indications
    1. Type 4 to 6 AC Dislocation
    2. Type 3 AC Dislocation if physically active or symptoms persist 3-6 months

X. Management: Taping Technique (consider in Wilderness)

  1. Realignment
    1. Examiner 1 pushes down on clavicle
    2. Examiner 2 pushes up on upper arm from elbow
  2. Taping technique
    1. Start Tape from just medial and superior to nipple
      1. Extend tape over Shoulder and onto mid Scapula
      2. Repeat with overlapping strips moving laterally
    2. Secure above taping with tape over ends
    3. Start tape perpendicularly to above
      1. Run over top of Shoulder from medial to lateral

XI. Complications

  1. Clavicle Fracture (lateral third)
  2. Coracoid process Fracture
  3. Sternoclavicular Dislocation
  4. Brachial Plexus Injury (rare)
  5. Acromioclavicular joint degenerative changes (AC Arthritis)

XII. References

  1. Dolbec (2019) Crit Dec Emerg Med 33(1): 17-25
  2. Kiel and Koneru (2019) Crit Dec Emerg Med 33(9): 17-27
  3. Lin and Silverio in Herbert (2018) EM:Rap 18(1):14-16
  4. Wirth in Greene (2001) Musculoskeletal Care, p.115-7
  5. Monica (2016) Am Fam Physician 94(2): 119-27 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Dislocation of acromioclavicular joint (C0149820)

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