Download Acromioclavicular Joint Injuries

Acromioclavicular Joint Disorders
BY
EMAD ZAYED (M.D)
LECTURER OF ORTHOPAEDIC SURGERY
FACULTY OF MEDICINE
AL AZHAR UNIVERSITY
2016
• AC joint is a common source of shoulder pain.
SPECTRUM OF DISORDERS
• TRAUMATIC DISORDERS
• NONTRAUMATIC DISORDERS
• Injuries
• Post-traumatic degeneration
• Osteolysis
• Arthritis
• Part of Impingement Syndrome
ANATOMY
•
Diarthrodial Joint.
•
Thin capsule
Stability
The orientation of the sagittal plane of the joint is
variable, ranging from nearly vertical to angulations
approaching 50 degrees, results in greater overriding of
the lateral clavicle on the medial acromion
• Ligaments:
Main stabilizer
C.C. Lig
A.C. Lig
• Horizontal Stability is accomplished by the AC lig
• Vertical stability is obtained through C.C. Lig.
EVALUATION
• History
Pain is the most common symptom of an AC joint disorder
Physical Examination
Patient preparation for physical examination requires unimpeded
access to both shoulders.
Surface landmarks helping to identify ACJ, which lies directly anterior
to the soft spot at the apex of the triangle formed by the scapular spine,
the clavicle, and the base of the neck.
The cross-body adduction stress test
Pain localized to the AC joint is the hallmark examination findings
The AC resisted-extension test
The Paxinos test
The thumb and finger are squeezed together
AC joint injections are easier said than done.
Plain Radiographs
The Zanca view is taken with the x-ray directed 10 to 15 degrees cephalad.
Enables assessment for anterior or posterior displacement of the clavicle with respect to the acromion.
Stress Views
Magnetic Resonance Imaging
• Displays the pathologic changes that result
from injuries and nontraumatic disorders.
Osteolysis of lat end clavicle
NONTRAUMATIC DISORDERS
AC Osteolysis
•
Radiographic findings
•
Irregular or absent subchondral bone
•
Alteration of the distal clavicle morphology such as
tapering, cysts, calcification, and osteophytes.
• MRI,
reveal edema within the marrow elements of the
distal clavicle, cortical erosions, and cysts.
Traumatic
Atraumatic
(limited)
specially with bilateral involvement.
• Systemic diseases such as
•
Hyperparathyroidism
•
Rheumatoid arthritis
•
Scleroderma
• Local processes that can resemble classic osteolysis are
•
Infections
•
Metastatic malignancy
•
Primary bone tumors such as multiple myeloma
•
Crystal arthropathy, especially gout
Acromioclavicular Arthritis
• Primary (not commonly symptomatic)
• Secondary (especially trauma-related osteoarthritis, is more prevalent).
Eccentric joint space narrowing, osteophytes, and subchondral cysts.
Rheumatoid Arthritis
• The AC joint is affected in at least 50% of patients with rheumatoid
arthritis; even more commonly than the glenohumeral joint.
• Only rarely is operative treatment performed.
Crystal Arthritis
•
Gout and pseudogout of the AC joint have been reported
Conservative Treatment
• Rest
• Activity Modification.
• Nonsteroidal anti-inflammatory medication
• Corticosteroid Injection
• Excision of the lateral end clavicle will definitively terminate
the process and, in nearly all cases, result in an excellent or
good outcome
Excision of the lateral end clavicle
TRAUMATIC DISORDERS
• AC joint injuries represent nearly half of all
athletic shoulder injuries.
Classification
ACL sprained •
Type I:
ACJ intact •
C.C. lig intact •
C.C. distance intact •
Muscles intact •
No displacement •
Type II:
• AC lig disrupted
• C.C. lig sprained
• C.C. Distance
slightly increased
< 25%
Type III
• AC lig and CC lig disrupted
• ACJ
dislocated
• C.C. Distance increased (25 to
100%) of normal
Rockwood
added three types caused by 3 different
mechanism
TREATMENT
• Nonsurgical treatment is indicated for type I and II
injuries.
• Surgery is almost always recommended for type IV, V,
and VI injuries.
• Management of type III injuries remains controversial.
TREATMENT
Type I & II
• Sling ( 1wk for type I and 2 wks. for type II)
• Once the shoulder pain has subsided, an early
and gradual rehabilitation program is instituted,
with the focus on passive- and active-assisted
ROM.
Taping the AC joint
Taping of the AC joint has been used for first or second degree sprains,
because it can provide some external support while not limiting the athlete’s
range of motion.
Protection of the AC Joint
• Adequate protection should be provided to the AC joint to
prevent further injury specially in athletes (football and ice
hockey).
Impact AC prefabricated pad
Spider pad
Type III Controversial
• Numerous studies have failed to demonstrate
superior outcomes after surgical treatment as
compared to non operative treatment.
Operative treatment reserved for:
1. Young athletes
2. Concern of cosmesis
3. Associated injuries
4. Failure of conservative treatment
Operative Treatment
1- Primary ACJ fixation
2- Primary CC fixation
3- C C Ligament reconstruction
4- Dynamic muscle transfer
Primary AC Joint Fixation
• Pinning
- risk of:
- loss of fixation
- pin breakage
- pin migration
- Injury to meniscus and articular
cartilage  Degen arthritis
- Second surgery for removal
• HOOKED PLATE
Primary CoracoClavicular Fixation
• Rigid construct:
Screws
wires
• Non Rigid construct:
Sutures (absorbable or nonabsorbable)
Grafts
CoracoClavicular ligament
Reconstruction
Modification of Weaver-Dunn
• Resection of the distal end of clavicle
• Coracoacromial lig detached from the
acromion with a piece of bone and
transferred to the hollowed canal of the
calvicle.
• Augmentation by non absorbable sling
between the clavicle & coracoid.
BIOLOGICAL ANATOMICAL RECONSTRUCTION
Thank You