eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Acromioclavicular Injury: Differential Diagnoses & Workup

Author: Moira Davenport, MD, Attending Physician, Departments of Emergency Medicine and Orthopedic Surgery, Allegheny General Hospital
Coauthor(s): Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Contributor Information and Disclosures

Updated: Apr 1, 2008

Differential Diagnoses

Rotator Cuff Injuries

Other Problems to Be Considered

Septic arthritis
Erb-Duchenne injury
Distal clavicle osteolysis

Workup

Imaging Studies

  • Standard radiographs of the shoulder should be obtained. To optimally image the AC joint, a cross body adduction radiograph should be obtained. A radiograph of the entire upper thorax is useful to compare the vertical distance between the clavicle and the coracoid process on both sides. Radiographic results according to severity of injury are as follows:
    • Type I - Normal
    • Type II - Subluxation of AC joint space less than 1 cm; normal CC space
    • Type III - Subluxation of AC joint space more than 1 cm; widening of the CC space more than 50%
    • Types IV-VI - Subluxation of AC joint space more than 1 cm, widening of the CC space more than 50%; associated displacement of the clavicle
  • Stress radiographs (10-lb weight in each hand) may help distinguish type I from type II injuries, but many authorities consider such studies unnecessary. Stress views are of limited value as any involuntary splinting by the patient prevents full visualization of the AC joint and may simply serve to increase the patient's pain.
  • With complete AC/CC ligament rupture, cross body adduction films will show the scapula rotated anteromedially and the acromion will migrate medially.
  • Assess the clavicle and scapula for associated fractures.
  • For pediatric injuries, plain radiographs may reveal fractures at the base of the coracoid.
  • Obtain a chest radiograph if concern exists with regard pulmonary involvement.
  • Research has looked at the additional information provided by ultrasonographic examination of the AC joint in suspected high-grade injuries. Heers and Hedtmann showed that ultrasonographic examination of the AC joint in experienced hands had 100% sensitivity for diagnosis of deltoid muscle detachment and fascial disruption.1 The study also showed 80% sensitivity and 100% specificity for disruption of the trapezius muscle. More studies are necessary to evaluate the potential for ultrasonography in the routine examination of suspected AC injury.
  • MRI should be considered to further delineate the extent of AC joint injury, particularly in highly competitive athletes.

Procedures

  • Reduction of AC injuries is rarely attempted in the emergency department. Such maneuvers should only be performed in cooperation with an orthopedic surgeon.

More on Acromioclavicular Injury

Overview: Acromioclavicular Injury
Differential Diagnoses & Workup: Acromioclavicular Injury
Treatment & Medication: Acromioclavicular Injury
Follow-up: Acromioclavicular Injury
Multimedia: Acromioclavicular Injury
References
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References

  1. Heers G, Hedtmann A. Correlation of ultrasonographic findings to Tossy's and Rockwood's classification of acromioclavicular joint injuries. Ultrasound Med Biol. Jun 2005;31(6):725-32. [Medline].

  2. Nissen CW, Chatterjee A. Type III acromioclavicular separation: results of a recent survey on its management. Am J Orthop. Feb 2007;36(2):89-93. [Medline].

  3. Phillips AM, Smart C, Groom AF. Acromioclavicular dislocation. Conservative or surgical therapy. Clin Orthop Relat Res. Aug 1998;10-7. [Medline].

  4. Basamania CJ, Higgins LD, Witkowski EG. Medial instability of the shoulder: A new concept of the pathomechanics of acromioclavicular separations. Program and Abstracts of the American Shoulder and Elbow Surgeons 18th Annual Meeting. 2001;Abstract 49.

  5. Bradley JP, Elkousy H. Decision making: operative versus nonoperative treatment of acromioclavicular joint injuries. Clin Sports Med. Apr 2003;22(2):277-90. [Medline].

  6. Clarke HD, McCann PD. Acromioclavicular joint injuries. Orthop Clin North Am. Apr 2000;31(2):177-87. [Medline].

  7. Codsi MJ. The painful shoulder: when to inject and when to refer. Cleve Clin J Med. Jul 2007;74(7):473-4, 477-8, 480-2 passim. [Medline].

  8. Crenshaw AH, Daugherty K, Campbell WC. Campbell's Operative Orthopaedics. 8th ed. Mosby-Year Book; 1992:1358.

  9. Donovan PJ. Shoulder injuries. In: Hart RG, Rittenberry TJ, Uehara DT, eds. Handbook of Orthopaedic Emergencies. Lippincott Williams & Wilkins Publishers; 1999:166-168.

  10. Dumonski M, Mazzocca AD, Rios C, et al. Evaluation and management of acromioclavicular joint injuries. Am J Orthop. Oct 2004;33(10):526-32. [Medline].

  11. Gordon BH, Chew FS. Isolated acromioclavicular joint pathology in the symptomatic shoulder on magnetic resonance imaging: a pictorial essay. J Comput Assist Tomogr. Mar-Apr 2004;28(2):215-22. [Medline].

  12. Kaplan LD, Flanigan DC, Norwig J, et al. Prevalence and variance of shoulder injuries in elite collegiate football players. Am J Sports Med. Aug 2005;33(8):1142-6. [Medline].

  13. McMahon P, Skinner H. Acromioclavicular injury. In: Current Diagnosis and Treatment in Orthopedics [online]. 3rd ed. 2005.

  14. Montellese P, Dancy T. The acromioclavicular joint. Prim Care. Dec 2004;31(4):857-66. [Medline].

  15. Mouhsine E, Garofalo R, Crevoisier X, Farron A. Grade I and II acromioclavicular dislocations: results of conservative treatment. J Shoulder Elbow Surg. Nov-Dec 2003;12(6):599-602. [Medline].

  16. Peetrons P, Bédard JP. Acromioclavicular joint injury: enhanced technique of examination with dynamic maneuver. J Clin Ultrasound. Jun 2007;35(5):262-7. [Medline].

  17. Petron DJ, Hanson RW Jr. Acromioclavicular joint disorders. Curr Sports Med Rep. Oct 2007;6(5):300-6. [Medline].

  18. Rockwood CA, Green DP. Fractures in Adults. Lippincott-Raven; 1984:860.

  19. Rockwood CA, Wilkins KE, King RE. Fractures in Children. Vol 3. Lippincott Williams & Wilkins Publishers; 1984:631.

  20. Schlegel TF, Burks RT, Marcus RL, Dunn HK. A prospective evaluation of untreated acute grade III acromioclavicular separations. Am J Sports Med. Nov-Dec 2001;29(6):699-703. [Medline].

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Further Reading

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Keywords

acromioclavicular injury, acromioclavicular joint separation, acromioclavicular joint, AC, ACJ, acromioclavicular joint injuries, AC joint injuries, ACJ injuries, clavicular displacement, pediatric AC joint injury, shoulder injury, shoulder dislocation, clavicle dislocation, clavicular injury 

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Contributor Information and Disclosures

Author

Moira Davenport, MD, Attending Physician, Departments of Emergency Medicine and Orthopedic Surgery, Allegheny General Hospital
Moira Davenport, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Disclosure: Nothing to disclose.

Medical Editor

Roy Alson, MD, PhD, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare
Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Tom Scaletta, MD, Past-President, American Academy of Emergency Medicine; Chairperson, Department of Emergency Medicine, Edward Hospital; Assistant Professor of Emergency Medicine, Rush Medical College and Cook County Hospital
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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