Acromio-clavicular joint injuries

Anatomy

  • The average dimension of Acromioclavicular joint is 9mm superoinferiorly and 19mm anteroposteriorly. Joint is straight and vertical in 30% of population and in 70% the joint is oblique downwards and medially.
  • Articular cartilage of clavicle end becomes fibrocartilaginous after 17 years of age and the acromial end becomes fibrocartilaginous at 23 years.
  • A fibrocartilaginous disk of variable size and shape attached to the superior capsule is present between the articular surfaces. The fibrocartilaginous disk is partial and meniscus like in 50%, remnant like in 30%, absent in 20% and complete in less than 2%.

Biomechanics

  • Anteroposterior stability of ACJ is provided by the ACJ capsule and ligaments. The superior and anterior capsule and ligaments are the strongest.
  • Superoinferior stability is provided by the coracoclavicular ligaments. Coracoclavicular ligaments have trapezoid and conoid parts. They are confluent at the coracoid and separate at the clavicle side. They form the primary suspensory complex of the upper limb.
  • Conoid ligament is conical and is attached to the posterior-medial aspect of coracoid process. Trapezoid ligament is quadrangular and attaches to coracoid shaft. Trapezoid ligament is attached 2.5cm from the lateral end of clavicle to the trapezoid ridge and the conoid portion is attached 4.5 cm from the lateral end of clavicle to the conoid tubercle. This is important for anatomical reconstruction of coracoclavicular ligaments.
  • Conoid footprint is posterior and measures 25-30mm. Conoid portion provides 60% of the superoinferior stability.
  • Deltoid inserts to the superior capsule and anterior surface of lateral 1/3rd of clavicle. Trapezius inserts to the superior capsule and dorsal surface of lateral end of clavicle. Their attachments are also detached in higher grades of ACJ injury.
  • Joint allows axial rotation of clavicle and anteroposterior and superoinferior sliding of acromion.

Mechanism of injury

  • Acromioclavicular joint injuries occur due to direct trauma over the acromion with the arm in the adducted position.
  • Once the ligaments are ruptured, the acromion is pulled down by the weight of the upper limb and the lateral end of clavicle is pulled up by the sternocleidomastoid and the trapezius.

Investigations

  • Zanca view showing both Acromioclavicular joints is the best view for diagnosis. Measure and compare the coracoclavicular distance on either side.
  • Zanca view taken in the standing position. Should show both ACJ. It is a true AP view with 10-150 cephalic tilt.
  • Axillary view is needed for diagnosis of posterior displacement in type IV injury. Axillary view taken in 70-900 abduction with the beam directed cranially.
  • Normal distance from superior border of coracoid to inferior border of clavicle ranges 1.1cm to 1.3 cm. Side to side difference of > 25% diagnostic of injury.
  • Stress x-rays taken with 10-15 pounds hanging from the forearm with the shoulder muscles relaxed. But it is impractical in acute cases due to pain.
  • Associated injuries to the glenohumeral joint especially SLAP lesions are common. Hence MRI scans may be necessary in higher grades of injury.

Rockwood & Young classification

  1. Acromioclavicular sprain.
  2. Acromioclavicular ligaments ruptured and coracoclavicular ligaments intact. Joint displaced to a third of the width of clavicle.
  3. Acromioclavicular and coracoclavicular ligaments ruptured with 25-100% displacement.
  4. Acromion displaced posteriorly into the trapezius.
  5. >100-300% dislocated.
  6. Acromion displaced below the coracoid.

Pathology of different grades of ACJ injury

Type Acromioclavicular Ligaments Coracoclavicular Ligaments Delto-trapezial fascia Coracoclavicular gap Acromioclavicular joint congruity
I Partial injury Intact Intact Normal Normal
II Complete rupture Partial injury Intact <25% Up to 1/3rd dislocation
III Complete rupture Complete rupture Ruptured 25-100% 25-100% dislocation
IV Complete rupture Complete rupture Ruptured Increased Displaced posteriorly
V Complete rupture Complete rupture Ruptured >100% 100-300% displaced
VI Complete rupture Complete rupture Ruptured Decreased Displaced inferiorly

 

Management

  • Grade I & II are treated conservatively by short period of immobilization followed by early mobilization.
  • Grade III injuries may be treated operatively or nonoperatively.
  • Nonoperative treatment is by a rehabilitation protocol with 4 phases.

I.          Pain control, protected mobilization, isometric exercises

II.          Isotonic exercises

III.          Restricted sports participation

IV.          Return to sports with specific functional drills

  • Grade IV and above are treated by anatomical reduction, repair of coracoclavicular ligaments and deltopectoral fascia and fixation.

Fixation options

  • Open reduction and fixation by hook plate. Hook plate removed after 8 weeks.
  • K WIRE FIXATION SHOULD NOT BE DONE AS THERE IS SERIOUS RISK OF BREAKAGE AND MIGRATION INTO HEART, LUNG OR GREAT VESSELS.
  • Transfer of coracoid with short head of biceps into the clavicle.
  • Weaver and Dunn procedure- Excision of clavicle lateral end and transfer of coracoacromial ligament to the medullary canal of resected end of clavicle.
  • Bosworth screw- Screw from clavicle into the coracoid. Removed at 8 weeks.
  • Cerclage techniques with augmentation devices fixing clavicle to the coracoid. Should be combined with ACJ reduction and fixation to prevent anterior subluxation of clavicle.
  • Mumford procedure- Excision of 5mm of lateral end of clavicle. If >10mm is excised there may be instability of clavicle.

Chronic Acromioclavicular instability

  • Indication for surgery is persistent pain and functional disability in an active and compliant patient.
  • In grade I and II ACJ injuries, excision of 5-8mm of lateral end of clavicle gives good results. If the length of excision is more there may be instability of the clavicle remnant.
  • Excision of lateral end of clavicle is contraindicated in ACJ injuries of grade III and above severity.
  • Weaver Dunn procedure is the gold standard in such patients.
  • Weaver Dunn procedure is transfer of insertion of coracoacromial ligament from the acromion to the lateral end of clavicle.
  • Coracoacromial ligament has only 25% strength of coracoclavicular ligament and 30-50% failure rates have been reported with Weaver Dunn technique.
  • Current recommendation is anatomic reconstruction of coracoclavicular ligaments by autograft or allograft with or without instrumentation.

Anatomic reconstruction technique

  • Reconstruction or repair may be open or arthroscopy assisted.
  • Autograft or allograft tendon either weaved through a coracoid tunnel or looped around the coracoid and then passed through 2 tunnels in the clavicle to recreate the conoid and trapezoid bundles. Augmentation by sutures or cables is the preferred technique.
  • 2 guide pins in the proximal-distal direction from posterior to anterior with at 20mm gap in between are used for making tunnels.
  • Trapezoid tunnel is made 20mm from the lateral edge of clavicle.
  • Conoid tunnel is 45mm from the lateral end of clavicle. Starting point is at the junction of posterior 1/3rd and anterior 2/3rd. Directed 450 anteriorly
  • There should be 20mm bone between the tunnels.
  • Fixation may be suturing of tendon on to itself or by tightrope.

One thought on “Acromio-clavicular joint injuries”

  1. Your topics are very informative. I don’t hv to search many books for the basic and advance knowledge. Keep posting with more topics.i like all your topics sir. Thanks sir

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.