- Separated shoulder
Name = Separated shoulder
Caption = A Separated Shoulder XRay modified to easily show bones. Notice the separation between the end of the collarbone and the scapula.
ICD10 = ICD10|S|43|1|s|40
ICD9 = ICD9|831.04, ICD9|831.14
eMedicineSubj = orthoped
eMedicineTopic = 462
MeshID = A separated shoulder, otherwise known as an acromioclavicular separation or AC separation, is a common injury to the
acromioclavicular joint. This is not the same as a shoulder dislocation as that involves a dislocation of the Glenohumeral joint
Separated shoulders often occur in people who participate in sports such as football, soccer,
horseback riding, hockey, mountain biking, biking, roller derby, rowing,rugby, snowboarding, and wrestling. The separation is classified into 6 types, with 1 through 3 increasing in severity, and 4 through 6 being the most severe. The most common mechanism of injury is a fall on the tip of the shoulder or also a fall on an outstretched hand (FOOSH). In falls where the force is transmitted indirectly, often only the acromioclavular ligament is affected, and the coracoclavicular ligaments remain unharmed. [cite journal|url = http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1323387&pageindex=3#page |title = Acromioclavicular Joint Injuries |author = Gloria M. Beim, MD|accessdate = 2006-11-24 | journal = J Athl Train | date = 2000 Jul–Sep| volume = 35 | issue = 3| pages= 261–267 |pmid = 16558638 ] In hockey, the separation is sometimes due to a lateral force, as when one gets forcefully checked into the side of the rink. [cite web |url = http://www.theacc.com/genrel/120905aad.html |title = Acromioclavicular Separation in Ice Hockey, Typical injury...different mechanism! |author = Stephen Bushee, ATC |accessdate = 2006-11-01 ]
A Type I AC separation involves trauma to the ligaments that form the joint, but no severe tearing or fracture. It is commonly referred to as a
sprain. Most doctors treat this type of dislocation with anti-inflammatory drugs, pain medication and the placement of the arm in a slingor an immobilizer.
A Type II AC separation involves complete tearing of the
acromioclavicular ligament, as well as a sprain or partial tear of the coracoclavicular ligaments. This often causes a noticeable bump on the shoulder. By pressing on the sternal aspect of the clavicle you force the acromial end down, and by releasing, watch it pop back up (eliciting a piano key signdue to the tearing of the AC ligament) [http://www.hope.edu/academic/kinesiology/athtrain/program/studentprojects/Ldornbos2/shoulder/sld060.htm] . Severe pain and loss of movement are common. Treatment is typically an arm sling, bedrest, ice and heat therapy, and anti-inflammatory drugs. Most people recover full motion of the shoulder and arm within 6 to 8 weeks, often with the assistance of physical therapy.
In a Type III AC separation both acromioclavicular and coracoclavicular ligaments are torn. A significant bump is formed by the lateral end of the clavicle. This bump is permanent. The clavicle can be moved in and out of place on the shoulder. It may take 12 weeks to heal, and physical therapy can be beneficial. It may take even longer for the shoulder strength to approach feeling normal. The injured shoulder may not be able to take the abuse that it could previously, but for most purposes it will be quite usable and sufficient. However, there still is controversy as to whether or not surgery may be necessary for optimal shoulder use in sport.
This is a type III injury with avulsion of the coracoclavicular ligament from the clavicle, with the distal clavicle displaced posteriorly into or through the trapezius. This injury is generally acknowledged to require surgery.
This is type III but with exaggeration of the vertical displacement of the clavicle from the scapula. This injury generally requires surgery.
This is type III with inferior dislocation of the lateral end of the clavicle below the coracoid. It is extremely rare and generally only involved with motor vehicle collisions. This requires surgery.
Current treatment options
Most non-surgical treatment options include physical therapy to build up the muscles around the joint, helping stabilize the joint. Literature regarding long-term follow-up after surgical repair of type III injuries is scarce, and those treated nonoperatively generally do quite well. [cite website
author = David Prybyla, MD, Brett D Owens, MD
url = http://www.emedicine.com/orthoped/topic462.htm
title = Acromioclavicular Joint Separations
publisher = eMedicine.com
date = 2005-03-15
accessdate = 2006-11-01] Many studies [cite journal
journal= Acta Orthopaedica Scandinavica.
title = Acromio-clavicular separations treated conservatively. A 5-year follow-up study.
volume = 54
issue = 5
pages = 743–745
date = October 1983
url = http://www.worldortho.com/database/abstracts/u_limb/bjerneld.html
author = Bjerneld H. Hovelius L. Thorling J.
format = Dead link|date=June 2008 – [http://scholar.google.co.uk/scholar?hl=en&lr=&q=author%3A+intitle%3AAcromio-clavicular+separations+treated+conservatively.+A+5-year+follow-up+study.&as_publication=Acta+Orthopaedica+Scandinavica.&as_ylo=&as_yhi=&btnG=Search Scholar search] ] [cite journal
journal= Journal of Bone & Joint Surgery - American Volume.
title = Dislocation of the acromioclavicular joint. An end-result study.
volume = 69
issue = 7
pages = 1045–51
date = September 1987
url = http://www.worldortho.com/database/abstracts/u_limb/taft.html
author = Taft TN. Wilson FC. Oglesby JW.
format = Dead link|date=June 2008 – [http://scholar.google.co.uk/scholar?hl=en&lr=&q=author%3A+intitle%3ADislocation+of+the+acromioclavicular+joint.+An+end-result+study.&as_publication=Journal+of+Bone+%26+Joint+Surgery+-+American+Volume.&as_ylo=&as_yhi=&btnG=Search Scholar search] ] [cite paper
title = A Prospective Evaluation of Untreated Acute Grade III Acromioclavicular Separations
authors = Theodore F. Schlegel, MD*, Robert T. Burks, MD*, Robin L. Marcus, MS, PT and Harold K. Dunn, MD*
url = http://ajsm.highwire.org/cgi/content/abstract/29/6/699] [cite journal
journal= Journal of Bone & Joint Surgery - American Volume.
title = Conservative or surgical treatment of acromioclavicular dislocation. Aprospective, controlled, randomized study.
volume = 68
issue = 4
pages = 552–5
date = 1986 Apr.
url = http://www.worldortho.com/database/abstracts/u_limb/larsen.html
author = Larsen E. Bjerg-Nielsen A. Christensen P.
format = Dead link|date=June 2008 – [http://scholar.google.co.uk/scholar?hl=en&lr=&q=author%3A+intitle%3AConservative+or+surgical+treatment+of+acromioclavicular+dislocation.+Aprospective%2C+controlled%2C+randomized+study.&as_publication=Journal+of+Bone+%26+Joint+Surgery+-+American+Volume.&as_ylo=&as_yhi=&btnG=Search Scholar search] ] cite journal
journal= Bull Hosp Jt Dis.
title = Treatment of grade III acromioclavicular separations. Operative versus nonoperative management.
volume = 56
issue = 2
pages = 77–83
date = 1997
url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=97363803
author = Press J, Zuckerman JD, Gallagher M, Cuomo F.] have come to the conclusion that non-surgical treatment is as good or better than surgical treatment, or that anything attained because of surgery is quite limited. It appears that after a while, the body "remodels" the joint, either expanding the distal clavicle or causing it to atrophy. [cite journal
journal= J Bone Joint Surg (Br)
title = LONG-TERM RESULTS OF CONSERVATIVE TREATMENT FOR ACROMIOCLAVICULAR DISLOCATION
volume = 78
issue = B
pages = 410–2
date = 1996
url = http://www.jbjs.org.uk/cgi/reprint/78-B/3/410.pdf
author = M. L. RAWES, J. J. DIAS] One study suggests that quarterbacks with type III injuries on their dominant side may possibly do better with surgery. [Schlegel TF, Boublik M, Hawkins RJ. Grade III acromioclavicular separations in NFL quarterbacks. Program and abstracts of the American Orthopaedic Society of Sports Medicine Annual Meeting; July 14-17, 2005; Keystone, Colorado.] There may also be the potential that surgical repair may be less painful in the long run. Fact|date=February 2007
Type 2 separations have always been treated non-surgically, initially. However, the risks of arthritis with type 2 separations are greatly increased. If this becomes severe, the
Mumford procedureor distal clavicle excision can be performed.
There have been many surgeries described to fix complete acromioclavicular separations, including recently arthroscopic. There is no consensus on which surgery is best. Several surgeries have been described with pins or hooksFact|date=February 2007. Another surgery performs muscle transferFact|date=February 2007.
A common surgery is some form of Modified
Weaver-Dunn procedure, which involves cutting off the end of the clavicle portion, partially sacrificing the coracoacromial ligamentand suturing the displaced acromial end to the lateral aspect of the clavicle for stabilization, then often some form of additional support is introduced to replace the coracoclavicular ligament(s). Variations of this support includes grafting of tendons from the leg [cite website
url = http://japan.medscape.com/viewarticle/515092
title = Acromioclavicular Injuries: New Management Options Emerge
authors = Raffy Mirzayan, MD Keck School of Medicine
publisher = eMedicine.com
date = 2005
accessdate = 2006-11-11] or the use of synthetic sutures or suture anchors [cite journal
journal= J Shoulder Elbow Surg.
title = Treatment of acromioclavicular joint separation: suture or suture anchors?
volume = 11
issue = 3Unicode|
pages = 225–9
date = 2002
url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Display&DB=pubmed
author = Breslow MJ, Jazrawi LM, Bernstein AD, Kummer FJ, Rokito AS.
doi = 10.1067/mse.2002.123904] . Other surgeries have used a Rockwood screw that is inserted initially and then removed after 12 weeks. Physical therapy is always recommended after surgery, and most patients get flexibility back, although possibly somewhat limited.
* Other shoulder problems
* [http://shoulderpaininfo.com/shoulderACSeparation.html Overview and diagram]
* [http://www.wheelessonline.com/ortho/acromioclavicular_joint Wheelessonline (very Confusing) online orthopedic resource]
* [http://www.stoneclinic.com/acromioclavicularjointreconstruction Stone Clinic: Acromioclavicular Joint Reconstruction Using Gore-Tex Tape (Now using allograft tendon)]
* [http://www.shoulderdoc.co.uk/education/article.asp?article=524 Arthroscopic Weaver-Dunn]
* [http://tra.sagepub.com/cgi/content/refs/7/4/217 Injuries of the acromioclavicular joint and current treatment options (Free full text pdf available)]
* [http://www.medscape.com/viewarticle/515092 Acromioclavicular Injuries: New Management Options Emerge (free with registration)]
* [http://history.amedd.army.mil/booksdocs/wwii/orthoeuropn/chapter17.htm Complete Dislocations of the Acromioclavicular Joint] Chapter 17 of a Military book on orthopedic treatment during World War II.
* [http://www.shoulder1.com/forum/categories.cfm?catid=58&entercat=y Shoulder1.com forum for dealing with a separated shoulder or surgeries to correct the problem.]
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