Archives of Orthopaedic and Trauma Surgery

, Volume 133, Issue 7, pp 985–995 | Cite as

Management of acute acromioclavicular joint dislocations: current concepts

Arthroscopy and Sports Medicine

Abstract

Acromioclavicular joint (ACJ) injuries represent a common injury to the shoulder girdle. In the management algorithm of acute ACJ injuries complete radiological evaluation represents the key to a successful therapy. According to the classification of Rockwood the presence of a horizontal component in addition to vertical instability has to be detected. Using axillary functional views or Alexander views dynamic horizontal ACJ instability can be diagnosed in a simple, efficient and cost-effective manner reducing the number of mis-/underdiagnosed ACJ injuries. MRI should not be the imaging modality of first choice. The treatment of ACJ dislocations must consider two aspects. In addition to the correct type of injury therapy strategies should be adapted to patient’s demands and compliance. Low grade AC injuries types I and II are treated non-operatively in terms of “skilful-neglect”. High-grade injuries types IV–VI should be treated operatively within a time frame of 2–3 weeks after injury. A certain debate is still ongoing regarding type III injuries. Out from the literature, non-operative treatment of type III injuries results to provide at least equal functional outcomes as compared to surgical treatment associated with less complications and earlier return to professional and sports activities. If surgical treatment is indicated, open surgical procedures using pins, PDS-slings or hook plates are still widely used concurring with recently raising minimally invasive, arthroscopic techniques using new implants designed to remain in situ. Combined coracoclavicular and acromioclavicular repair are gaining in importance to restore horizontal as well as vertical ACJ stability.

Keywords

Acute acromioclavicular joint dislocation Rockwood classification Horizontal instability Axillary functional radiographs Arthroscopic coracoclavicular stabilization 

Notes

Conflict of interest

The author declares that he has no conflict of interest.

References

  1. 1.
    Emery R (1997) Acromioclavicular and sternoclavicular joints. In: Copeland S (ed) Shoulder surgery. WB Saunders, LondonGoogle Scholar
  2. 2.
    Riand N, Sadowski C, Hoffmeyer P (1999) Acute acromioclavicular dislocations. Acta Orthop Belg 65(4):393–403PubMedGoogle Scholar
  3. 3.
    Cave EF (1961) Fractures and other injuries. Year Book, ChicagoGoogle Scholar
  4. 4.
    Nordqvist A, Petersson CJ (1995) Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 4(2):107–112PubMedCrossRefGoogle Scholar
  5. 5.
    Sage FP, Salvatore JE (1963) Injuries of the acromioclavicular joint: a study of results in 96 patients. South Med J 56:486–495PubMedCrossRefGoogle Scholar
  6. 6.
    Webb J, Bannister G (1992) Acromioclavicular disruption in first class rugby players. Br J Sports Med 26(4):247–248PubMedCrossRefGoogle Scholar
  7. 7.
    Dias JJ, Gregg PJ (1991) Acromioclavicular joint injuries in sport. Recommendations for treatment. Sports Med 11(2):125–132PubMedCrossRefGoogle Scholar
  8. 8.
    Rowe CR (1962) Acute and recurrent dislocations of the shoulder. J Bone Joint Surg Am 44A:998–1008Google Scholar
  9. 9.
    Daly PJ, Sim FH, Simonet WT (1990) Ice hockey injuries. A review. Sports Med 10(2):122–131PubMedCrossRefGoogle Scholar
  10. 10.
    Thorndike A, Quigley TB (1942) Injuries to the ACJ: a plea for conservative treatment. Am J Surg 55:250–261CrossRefGoogle Scholar
  11. 11.
    Kocher MS, Feagin JA Jr (1996) Shoulder injuries during alpine skiing. Am J Sports Med 24(5):665–669PubMedCrossRefGoogle Scholar
  12. 12.
    Weaver JK (1987) Skiing-related injuries to the shoulder. Clin Orthop Relat Res 216:24–28PubMedGoogle Scholar
  13. 13.
    Stuart MJ, Smith A (1995) Injuries in junior a ice hockey. A three-year prospective study. Am J Sports Med 23(4):458–461PubMedCrossRefGoogle Scholar
  14. 14.
    Headey J, Brooks JH, Kemp SP (2007) The epidemiology of shoulder injuries in English professional rugby union. Am J Sports Med 35(9):1537–1543PubMedCrossRefGoogle Scholar
  15. 15.
    Arenas AJ, Pampliega T, Iglesias J (1993) Surgical management of bipolar clavicular dislocation. Acta Orthop Belg 59(2):202–205PubMedGoogle Scholar
  16. 16.
    Lyons FA, Rockwood CA Jr (1990) Migration of pins used in operations on the shoulder. J Bone Joint Surg Am 72(8):1262–1267PubMedGoogle Scholar
  17. 17.
    Porral MA (1831) Observation d’ une double luxation de la clavicle droite. J Univ Habd Med Chir Prat 2:78–82Google Scholar
  18. 18.
    Rockwood CA (1984) Injuries to the acromioclavicular joint. In: Rockwood CA, Green, DP (eds) Fractures in adults. 2nd edn. JB Lippincott, Philadelphia, pp 860–910Google Scholar
  19. 19.
    Cadenet FM (1917) The treatment of dislocations and fractures of the outer end of the clavicle. Int Clin 1:24Google Scholar
  20. 20.
    Tossy JD, Mead NC, Sigmond HM (1963) Acromioclavicular separations: useful and practical classification for treatment. Clin Orthop Relat Res 28:111–119PubMedGoogle Scholar
  21. 21.
    Zanca P (1971) Shoulder pain: involvement of the acromioclavicular joint. (analysis of 1,000 cases). Am J Roentgenol Radium Ther Nucl Med 112(3):493–506PubMedCrossRefGoogle Scholar
  22. 22.
    Sluming VA (1995) A comparison of the methods of distraction for stress examination of the acromioclavicular joint. Br J Radiol 68(815):1181–1184PubMedCrossRefGoogle Scholar
  23. 23.
    Bucholz RW, Heckmann, JD (2001) Acromioclavicular joint injuries. In: Rockwood and Green’s fractures in adults, vol 1, 5th edn. Lippincott Williams & Wilkins, Philadelphia, pp 1210–1244Google Scholar
  24. 24.
    Alexander OM (1954) Radiography of the acromioclavicular articulation. Med Radiogr Photogr 30(2):34–39PubMedGoogle Scholar
  25. 25.
    Tauber M, Koller H, Hitzl W, Resch H (2010) Dynamic radiologic evaluation of horizontal instability in acute acromioclavicular joint dislocations. Am J Sports Med 38(6):1188–1195PubMedCrossRefGoogle Scholar
  26. 26.
    Mazzocca AD, Spang JT, Rodriguez RR, Rios CG, Shea KP, Romeo AA, Arciero RA (2008) Biomechanical and radiographic analysis of partial coracoclavicular ligament injuries. Am J Sports Med 36(7):1397–1402PubMedCrossRefGoogle Scholar
  27. 27.
    Schaefer FK, Schaefer PJ, Brossmann J, Hilgert RE, Heller M, Jahnke T (2006) Experimental and clinical evaluation of acromioclavicular joint structures with new scan orientations in MRI. Eur Radiol 16(7):1488–1493PubMedCrossRefGoogle Scholar
  28. 28.
    Antonio GE, Cho JH, Chung CB, Trudell DJ, Resnick D (2003) Pictorial essay. MR imaging appearance and classification of acromioclavicular joint injury. AJR Am J Roentgenol 180(4):1103–1110PubMedCrossRefGoogle Scholar
  29. 29.
    Barnes CJ, Higgins LD, Major NM, Basamania CJ (2004) Magnetic resonance imaging of the coracoclavicular ligaments: its role in defining pathoanatomy at the acromioclavicular joint. J Surg Orthop Adv 13(2):69–75PubMedGoogle Scholar
  30. 30.
    Alyas F, Curtis M, Speed C, Saifuddin A, Connell D (2008) MR imaging appearances of acromioclavicular joint dislocation. Radiographics 28(2):463–479 quiz 619PubMedCrossRefGoogle Scholar
  31. 31.
    Urist MR (1946) Complete dislocations of the acromiclavicular joint; the nature of the traumatic lesion and effective methods of treatment with an analysis of forty-one cases. J Bone Joint Surg Am 28(4):813–837PubMedGoogle Scholar
  32. 32.
    Darrow JC Jr, Smith JA, Lockwood RC (1980) A new conservative method for treatment of Type III acromioclavicular separations. Orthop Clin North Am 11(4):727–733PubMedGoogle Scholar
  33. 33.
    Giannestras NJ (1944) A method of immobilization of acute AC separation. J Bone Joint Surg Am 26:597–599Google Scholar
  34. 34.
    Spigelman L (1969) A harness for acromioclavicular separation. J Bone Joint Surg Am 51(3):585–586PubMedGoogle Scholar
  35. 35.
    Varney JH, Coker JK, Cawley JJ (1952) Treatment of acromioclavicular dislocation by means of a harness. J Bone Joint Surg Am 34-A(1):232–233PubMedGoogle Scholar
  36. 36.
    Glick JM, Milburn LJ, Haggerty JF, Nishimoto D (1977) Dislocated acromioclavicular joint: follow-up study of 35 unreduced acromioclavicular dislocations. Am J Sports Med 5(6):264–270PubMedCrossRefGoogle Scholar
  37. 37.
    Nicoll EE (1954) Annotation: miners or mannequins [editorial]. J Bone Joint Surg Br 36:171–172Google Scholar
  38. 38.
    Glick J (1972) AC dislocation in athletes. Auto arthroplasty of the joint. Orthop Rev 1:131–134Google Scholar
  39. 39.
    Taft TN, Wilson FC, Oglesby JW (1987) Dislocation of the acromioclavicular joint. An end-result study. J Bone Joint Surg Am 69(7):1045–1051PubMedGoogle Scholar
  40. 40.
    Bosworth BM (1941) Acromioclavicular separation: a new method of repair. Surg Gynecol Obstet 76:866–871Google Scholar
  41. 41.
    Assaghir YM (2011) Outcome of exact anatomic repair and coracoclavicular cortical lag screw in acute acromioclavicular dislocations. J Trauma 71(3):E50–E54PubMedCrossRefGoogle Scholar
  42. 42.
    Balser D (1976) Eine neue Methode zur operativen Behandlung der akromioklavikularen Luxation. Chir Prax 24:275Google Scholar
  43. 43.
    Wolter D (1984) EC: reposition und fixation der acromioclaviculären luxation mit hilfe einer hakenplatte. Hefte Unfallheilkd 170:80–86PubMedGoogle Scholar
  44. 44.
    Kienast B, Thietje R, Queitsch C, Gille J, Schulz AP, Meiners J (2011) Mid-term results after operative treatment of rockwood grade III-V acromioclavicular joint dislocations with an AC-hook-plate. Eur J Med Res 16(2):52–56PubMedCrossRefGoogle Scholar
  45. 45.
    Constant CR, Murley AH (1987) A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 214:160–164PubMedGoogle Scholar
  46. 46.
    Gstettner C, Tauber M, Hitzl W, Resch H (2008) Rockwood type III acromioclavicular dislocation: surgical versus conservative treatment. J Shoulder Elbow Surg 17(2):220–225PubMedCrossRefGoogle Scholar
  47. 47.
    Salem KH, Schmelz A (2009) Treatment of Tossy III acromioclavicular joint injuries using hook plates and ligament suture. J Orthop Trauma 23(8):565–569PubMedCrossRefGoogle Scholar
  48. 48.
    Di Francesco A, Zoccali C, Colafarina O, Pizzoferrato R, Flamini S (2012) The use of hook plate in type III and V acromio-clavicular Rockwood dislocations: clinical and radiological midterm results and MRI evaluation in 42 patients. Injury 43(2):147–152PubMedCrossRefGoogle Scholar
  49. 49.
    Chiang CL, Yang SW, Tsai MY, Kuen-Huang Chen C (2010) Acromion osteolysis and fracture after hook plate fixation for acromioclavicular joint dislocation: a case report. J Shoulder Elbow Surg 19(4):e13–e15PubMedCrossRefGoogle Scholar
  50. 50.
    Eskola A, Vainionpaa S, Korkala S, Santavirta S, Gronblad M, Rokkanen P (1991) Four-year outcome of operative treatment of acute acromioclavicular dislocation. J Orthop Trauma 5(1):9–13PubMedCrossRefGoogle Scholar
  51. 51.
    Kazda S, Pasa L, Pokorny V (2011) Clinical outcomes of surgical management of acromioclavicular dislocation with and without ligament suturing. Rozhl Chir 90(10):561–564PubMedGoogle Scholar
  52. 52.
    Leidel BA, Braunstein V, Kirchhoff C, Pilotto S, Mutschler W, Biberthaler P (2009) Consistency of long-term outcome of acute Rockwood grade III acromioclavicular joint separations after K-wire transfixation. J Trauma 66(6):1666–1671PubMedCrossRefGoogle Scholar
  53. 53.
    Bathis H, Tingart M, Bouillon B, Tiling T (2001) The status of therapy of acromioclavicular joint injury. Results of a survey of trauma surgery clinics in Germany. Unfallchirurg 104(10):955–960PubMedCrossRefGoogle Scholar
  54. 54.
    Leidel BA, Braunstein V, Pilotto S, Mutschler W, Kirchhoff C (2009) Mid-term outcome comparing temporary K-wire fixation versus PDS augmentation of Rockwood grade III acromioclavicular joint separations. BMC Res Notes 2:84PubMedCrossRefGoogle Scholar
  55. 55.
    Eschler A, Gradl G, Gierer P, Mittlmeier T, Beck M (2012) Hook plate fixation for acromioclavicular joint separations restores coracoclavicular distance more accurately than PDS augmentation, however presents with a high rate of acromial osteolysis. Arch Orthop Trauma Surg 132(1):33–39PubMedCrossRefGoogle Scholar
  56. 56.
    Greiner S, Braunsdorf J, Perka C, Herrmann S, Scheffler S (2009) Mid to long-term results of open acromioclavicular-joint reconstruction using polydioxansulfate cerclage augmentation. Arch Orthop Trauma Surg 129(6):735–740PubMedCrossRefGoogle Scholar
  57. 57.
    Weaver JK, Dunn HK (1972) Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am 54(6):1187–1194PubMedGoogle Scholar
  58. 58.
    Grutter PW, Petersen SA (2005) Anatomical acromioclavicular ligament reconstruction: a biomechanical comparison of reconstructive techniques of the acromioclavicular joint. Am J Sports Med 33(11):1723–1728PubMedCrossRefGoogle Scholar
  59. 59.
    Mazzocca AD, Santangelo SA, Johnson ST, Rios CG, Dumonski ML, Arciero RA (2006) A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med 34(2):236–246PubMedCrossRefGoogle Scholar
  60. 60.
    Costic RS, Labriola JE, Rodosky MW, Debski RE (2004) Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations. Am J Sports Med 32(8):1929–1936PubMedCrossRefGoogle Scholar
  61. 61.
    Tauber M, Gordon K, Koller H, Fox M, Resch H (2009) Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a prospective comparative study. Am J Sports Med 37(1):181–190PubMedCrossRefGoogle Scholar
  62. 62.
    Wolf EM, Pennington WT (2001) Arthroscopic reconstruction for acromioclavicular joint dislocation. Arthroscopy 17(5):558–563PubMedCrossRefGoogle Scholar
  63. 63.
    Rolla PR, Surace MF, Murena L (2004) Arthroscopic treatment of acute acromioclavicular joint dislocation. Arthroscopy 20(6):662–668PubMedCrossRefGoogle Scholar
  64. 64.
    Elser F, Chernchujit B, Ansah P, Imhoff AB (2005) A new minimally invasive arthroscopic technique for reconstruction of the acromioclavicular joint. Unfallchirurg 108(8):645–649PubMedCrossRefGoogle Scholar
  65. 65.
    Zooker CC, Parks BG, White KL, Hinton RY (2010) TightRope versus fiber mesh tape augmentation of acromioclavicular joint reconstruction: a biomechanical study. Am J Sports Med 38(6):1204–1208PubMedCrossRefGoogle Scholar
  66. 66.
    Klimkiewicz JJ, Williams GR, Sher JS, Karduna A, Des Jardins J, Iannotti JP (1999) The acromioclavicular capsule as a restraint to posterior translation of the clavicle: a biomechanical analysis. J Shoulder Elbow Surg 8(2):119–124PubMedCrossRefGoogle Scholar
  67. 67.
    Scheibel M, Droschel S, Gerhardt C, Kraus N (2011) Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations. Am J Sports Med 39(7):1507–1516PubMedCrossRefGoogle Scholar
  68. 68.
    Pauly S, Gerhardt C, Haas NP, Scheibel M (2009) Prevalence of concomitant intraarticular lesions in patients treated operatively for high-grade acromioclavicular joint separations. Knee Surg Sports Traumatol Arthrosc 17(5):513–517PubMedCrossRefGoogle Scholar
  69. 69.
    Tischer T, Salzmann GM, El-Azab H, Vogt S, Imhoff AB (2009) Incidence of associated injuries with acute acromioclavicular joint dislocations types III through V. Am J Sports Med 37(1):136–139PubMedCrossRefGoogle Scholar
  70. 70.
    Petersen W, Wellmann M, Rosslenbroich S, Zantop T (2010) Minimally Invasive Acromioclavicular Joint Reconstruction (MINAR). Oper Orthop Traumatol 22(1):52–61PubMedCrossRefGoogle Scholar
  71. 71.
    Allman FL Jr (1967) Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 49(4):774–784PubMedGoogle Scholar
  72. 72.
    Mouhsine E, Garofalo R, Crevoisier X, Farron A (2003) Grade I and II acromioclavicular dislocations: results of conservative treatment. J Shoulder Elbow Surg 12(6):599–602PubMedCrossRefGoogle Scholar
  73. 73.
    Bjerneld H, Hovelius L, Thorling J (1983) Acromio-clavicular separations treated conservatively. A 5-year follow-up study. Acta Orthop Scand 54(5):743–745PubMedCrossRefGoogle Scholar
  74. 74.
    Bannister GC, Wallace WA, Stableforth PG, Hutson MA (1989) The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. J Bone Joint Surg Br 71(5):848–850PubMedGoogle Scholar
  75. 75.
    Collins DN (2009) Disorders of the acromioclavicular joint. In: Rockwood CA MF, Wirth MA, Lippitt SA (eds) The shoulder. 4th edn. Saunders, PhiladelphiaGoogle Scholar
  76. 76.
    Bergfeld JA, Andrish JT, Clancy WG (1978) Evaluation of the acromioclavicular joint following first- and second-degree sprains. Am J Sports Med 6(4):153–159PubMedCrossRefGoogle Scholar
  77. 77.
    Shaw MB, McInerney JJ, Dias JJ, Evans PA (2003) Acromioclavicular joint sprains: the post-injury recovery interval. Injury 34(6):438–442PubMedCrossRefGoogle Scholar
  78. 78.
    Bakalim G, Wilppula E (1975) Surgical or conservative treatment of total dislocation of the acromioclavicular joint. Acta Chir Scand 141(1):43–47PubMedGoogle Scholar
  79. 79.
    Phillips AM, Smart C, Groom AF (1998) Acromioclavicular dislocation. Conservative or surgical therapy. Clin Orthop Relat Res 353:10–17PubMedCrossRefGoogle Scholar
  80. 80.
    Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU (1995) Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med 23(3):324–331PubMedCrossRefGoogle Scholar
  81. 81.
    Cox JS (1981) The fate of the acromioclavicular joint in athletic injuries. Am J Sports Med 9(1):50–53PubMedCrossRefGoogle Scholar
  82. 82.
    Hedtmann A, Fett H, Ludwig J (1998) Management of old neglected posttraumatic acromioclavicular joint instability and arthrosis. Orthopade 27(8):556–566PubMedGoogle Scholar
  83. 83.
    Madsen B (1963) Osteolysis of the acromial end of the clavicle following trauma. Br J Radiol 36:822–828PubMedCrossRefGoogle Scholar
  84. 84.
    Stohr H, Geyer M, Volle E (1996) Osteolysis of the lateral clavicle after Tossy II injury in ice hockey players. Sportverletz Sportschaden 10(3):70–73PubMedCrossRefGoogle Scholar
  85. 85.
    Walsh WM, Peterson DA, Shelton G, Neumann RD (1985) Shoulder strength following acromioclavicular injury. Am J Sports Med 13(3):153–158PubMedCrossRefGoogle Scholar
  86. 86.
    Smith TO, Chester R, Pearse EO, Hing CB (2011) Operative versus non-operative management following Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base. J Orthop Traumatol 12(1):19–27PubMedCrossRefGoogle Scholar
  87. 87.
    Beckmann T (1924) A case of simultaneous luxation of both ends of the clavicle. Acta Chir Scand 56:156–163Google Scholar
  88. 88.
    Cook F, Horowitz M (1987) Bipolar clavicular dislocation. Report of a case. J Bone Joint Surg Am 69(1):145–147PubMedGoogle Scholar
  89. 89.
    Echo BS, Donati RB, Powell CE (1988) Bipolar clavicular dislocation treated surgically. A case report. J Bone Joint Surg Am 70(8):1251–1253PubMedGoogle Scholar
  90. 90.
    Gearen PF, Petty W (1982) Panclavicular dislocation. Report of a case. J Bone Joint Surg Am 64(3):454–455PubMedGoogle Scholar
  91. 91.
    Hastings DE, Horne JG (1979) Anterior dislocation of the acromioclavicular joint. Injury 10(4):285–288PubMedCrossRefGoogle Scholar
  92. 92.
    Malcapi C, Grassi G, Oretti D (1978) Posterior dislocation of the acromio-clavicular joint: a rare or an easily overlooked lesion? Ital J Orthop Traumatol 4(1):79–83PubMedGoogle Scholar
  93. 93.
    Nieminen S, Aho AJ (1984) Anterior dislocation of the acromioclavicular joint. Ann Chir Gynaecol 73(1):21–24PubMedGoogle Scholar
  94. 94.
    Sondergard-Petersen P, Mikkelsen P (1982) Posterior acromioclavicular dislocation. J Bone Joint Surg Br 64(1):52–53PubMedGoogle Scholar
  95. 95.
    Koka SR, D’Arcy JC (1993) Inferior (subacromial) dislocation of the outer end of the clavicle. Injury 24(3):210–211PubMedCrossRefGoogle Scholar
  96. 96.
    McPhee IB (1980) Inferior dislocation of the outer end of the clavicle. J Trauma 20(8):709–710PubMedCrossRefGoogle Scholar
  97. 97.
    Patterson WR (1967) Inferior dislocation of the distal end of the clavicle. A case report. J Bone Joint Surg Am 49(6):1184–1186PubMedGoogle Scholar
  98. 98.
    Gerber C, Rockwood CA Jr (1987) Subcoracoid dislocation of the lateral end of the clavicle. A report of three cases. J Bone Joint Surg Am 69(6):924–927PubMedGoogle Scholar
  99. 99.
    Schwarz N, Kuderna H (1988) Inferior acromioclavicular separation. Report of an unusual case. Clin Orthop Relat Res 234:28–30PubMedGoogle Scholar
  100. 100.
    Torrens C, Mestre C, Perez P, Marin M (1998) Subcoracoid dislocation of the distal end of the clavicle. A case report. Clin Orthop Relat Res 348:121–123PubMedCrossRefGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Shoulder and Elbow ServiceATOS Clinic MunichMunichGermany
  2. 2.Paracelsus Medical UniversitySalzburgAustria

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