eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Acromioclavicular Injury: Treatment & Medication
Updated: Apr 1, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Distinguishing AC injuries from other shoulder injuries (ie, clavicular fractures, shoulder dislocations, proximal humeral fractures) is difficult.
- Prehospital providers should splint suspected AC injuries in a position of comfort. Neurovascular status of the injured extremity should always be checked after application of a splint.
- Assess and immobilize the spine, if indicated.
Emergency Department Care
- Type I
- These injuries involve minimal disruption of the AC joint and are intrinsically stable. Treatment involves application of a sling for comfort, ice, and analgesic agents.
- Athletes can usually return to sports in 1-2 weeks. For patients whose symptoms do not improve within this time frame, intra-articular steroid injections may be indicated. Patients with persistent pain for extended amounts of time may be candidates for a distal clavicle excision.
- Type II
- In these patients, the AC ligament is completely torn. For the most part, these patients receive the same treatment as those with type I injuries. However, patients with type II injuries take longer to improve. With significant instability, strap immobilization for 2-4 weeks and no heavy lifting for 6-8 weeks are appropriate.
- A Kenny-Howard shoulder harness may be used for strap immobilization, although this device frequently is uncomfortable for the patient and may not change the outcome.
- Late management of these injuries may require intra-articular steroids or surgery. Distal clavicle excision has been noted to produce inferior results compared with the same surgery in patients with type I injury due to increased instability of the AC joint.
- Type III
- Patients with type III AC injuries have complete tearing of the coracoclavicular ligament in addition to a complete tear of the AC ligament. This injury results in superior displacement and greater instability of the clavicle.
- Controversy exists regarding the optimal management of this injury. Most studies suggest that conservative therapy produces better functional results than operative repair. Comparison trials between operative and nonoperative management have suffered from insufficient numbers of patients, a retrospective design in most cases, heterogenous patient groups, or a lack of objective evaluation in the follow-up period. Furthermore, a variety of different surgical techniques have been developed making comparison between conservative management and general operative management difficult.
- Nissen and Chatterjee recently published a survey of members of the American Orthopaedic Society for Sports Medicine and ACGME accredited residency directors; they found that conservative therapy is still the recommended first line of care (>90%).2
- In 1998, Philips et al performed a meta-analysis of all studies looking at outcomes of AC separations.3 This study looked at 24 papers, 5 of which directly compared surgical and nonsurgical management of type III AC injury. They concluded that nonsurgical intervention yielded improved strength, range of motion, and fewer complications than operative intervention.
- Other authorities point out that individuals in certain active occupations, such as baseball pitchers, manual laborers, and soldiers, may disproportionately benefit from an operative intervention.
- Type IV
- In patients with type IV injury, the deltotrapezial fascia is disrupted in addition to complete tears of the AC and CC ligaments. This injury complex allows posterior displacement of the clavicle into the trapezius and requires reduction, usually operative.
- In theory, a closed reduction could be possible to convert the injury into a type III AC injury, which could then be managed conservatively. Barring this possibility, surgery with an open reduction and internal fixation is necessary.
- Type V and VI: These forms of AC injury are the most severe and will universally require open reduction and internal fixation (ORIF).
- AC joint injection may be considered in the patient with recurrent ED visits for AC pain. However, this is not recommended in the acute setting as any fluid injected may complicate MRI evaluation of the joint.
- Pediatric injuries
- For types I-III, closed reduction can be effective, although surgical intervention for selected cases may be indicated to achieve better functional results.
- Types IV and V commonly require ORIF.
Consultations
- Orthopedic surgery
- Pediatric cases
- Types III-VI in adults
Medication
The goals of therapy are to reduce pain and inflammation.
Nonsteroidal anti-inflammatory agents (NSAIDs)
These agents are used for both anti-inflammatory and analgesic effects. Acetaminophen (with or without an opiate) is the most commonly used analgesic.
Ibuprofen (Motrin, Nuprin, Midol, Advil)
In the absence of contraindications, usually DOC for treatment of mild to moderate pain.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Nonopioid analgesics
These agents are used for mild-to-moderate analgesic effects.
Acetaminophen (Tylenol, Aspirin Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, in those diagnosed with upper GI disease, or in those taking PO anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg PO q6-8h; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Opioid analgesics
These agents are used for moderate-to-strong analgesic effects.
Propoxyphene and acetaminophen (Darvocet N-100)
Indicated for the treatment of mild to moderate pain.
Adult
1-2 tab PO q4h prn; not to exceed 600 mg/d
Pediatric
Not established
May increase serum concentrations of MAOIs, TCAs, carbamazepine, phenobarbital, and warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates (substitution may result in acute opiate withdrawal symptoms); caution in severe renal or hepatic dysfunction
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn for pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg of hydrocodone bitartrate per dose; not to exceed 5 doses/d
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or TCAs
Documented hypersensitivity; HACE; elevated ICP
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tabs contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates, since this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction
Acetaminophen and codeine (Tylenol with Codeine)
Indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab PO q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Toxicity increases with CNS depressants or TCAs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Corticosteroids
These agents have both anti-inflammatory and salt retaining properties. Glucocorticoids have profound and varied metabolic effects. In addition these agents modify the body's immune response to diverse stimuli.
Triamcinolone hexacetonide (Aristospan, Kenalog)
For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
20-40 mg injected into AC joint
Pediatric
Not established
None reported
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Most common side effect is postinjection flare, which manifests as pain at injection site and can be relieved with oral NSAIDs; this pain is due to crystal deposition of the steroid preparation in the joint space and usually lasts <24 h
Other side effects related to poor technique and include skin atrophy, hypopigmentation, and tendon rupture; rare side effects include infection of joint space and anaphylaxis; side effects such as Cushing syndrome, osteoporosis, and menstrual irregularities are rare and only occur when multiple injections are given over a relatively short time period
A percentage of injected drug might be absorbed systemically; if application is repeated, some systemic effects of the corticosteroids may occur; most common side effect is postinjection flare due to crystal deposition of steroid preparation in joint space (lasts <24 h; can be relieved with oral NSAIDs); other side effects are related to poor technique and include skin atrophy, hypopigmentation, and tendon rupture
May cause transient hyperglycemia in diabetics
Methylprednisolone (Depo-Medrol, Solu-Medrol)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
30-40 mg intra-articular injection
Pediatric
Not established
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics; grapefruit juice increases prednisolone concentrations; methylprednisolone and cyclosporine mutually inhibit one another resulting in increased plasma levels of each drug
Documented hypersensitivity; viral, fungal or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Most common side effect is postinjection flare, which manifests as pain at injection site and can be relieved with oral NSAIDs; this pain is due to crystal deposition of the steroid preparation in joint space and usually lasts <24 h
Other side effects are related to poor technique and include skin atrophy, hypopigmentation, and tendon rupture rare side effects include infection of joint space and anaphylaxis; side effects such as Cushing syndrome, osteoporosis, and menstrual irregularities are rare and only occur when multiple injections are given over a relatively short time period
A percentage of injected drug might be absorbed systemically; if application is repeated, some systemic effects of the corticosteroids may occur; most common side effect is postinjection flare due to crystal deposition of steroid preparation in joint space (lasts <24 h; can be relieved with oral NSAIDs); other side effects are related to poor technique and include skin atrophy, hypopigmentation, and tendon rupture
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
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Further Reading
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
