Acromioclavicular Joint Injury Workup

  • Author: L. Edward Seade, MD; Chief Editor: Craig C Young, MD   more...
 
Updated: Dec 5, 2011
 

Imaging Studies

Radiographs

As with all skeletal injuries, a minimum of 2 radiographic views is necessary to evaluate the individual injury in cases of suspected acromioclavicular joint injury.[5]

AP and lateral views are the minimum needed to evaluate an acromioclavicular joint injury. The AP view should be taken with the arms at the side, and both acromioclavicular joints should be imaged for comparison. If a true AP view is obtained, the acromioclavicular joint can be seen superimposed on the spine of the scapula; hence, some authorities have recommended the Zanca view, in which 10-15° of cephalic tilt of the radiographic beam provides a clearer image of the acromioclavicular joint. (See below.)

Type III acromioclavicular joint separation. Type III acromioclavicular joint separation. Type III acromioclavicular joint separation. Type III acromioclavicular joint separation.

An axillary lateral view is also needed in suspected acromioclavicular joint injuries to account for any anterior or posterior displacement of the distal clavicle.

If an unstable acromioclavicular joint injury is suspected, yet not confirmed on routine AP and lateral views, stress views may be indicated.

Ten to 15 lb of weight should be attached to the wrist of the affected side, and an AP view can be taken. This stress tests the integrity of the coracoclavicular ligament, and, if the ligament has been disrupted completely, the test will demonstrate the complete dislocation.

Routine use of stress radiographs is not recommended in the emergency department setting because of the painful nature of the test. Weighted stress tests may be valuable in follow-up care if the clinician has any doubt about the instability of the acromioclavicular joint. Even with conservative care of types III-VI acromioclavicular disruptions, this test may be helpful for determining a timetable for return to conditioning and sporting activities.

Athletes with a previous history of acromioclavicular injury or a history of heavy weight lifting may present with relatively acute shoulder pain over the distal clavicle, and they may have classic radiographic findings of distal clavicle osteolysis or acromioclavicular osteoarthritis (ie, joint narrowing, distal clavicle or acromial spurring). When these radiographic findings are present, the clinician may expect that seemingly little trauma may result in significant pain.

Magnetic resonance imaging (MRI)

MRI is not routinely ordered in the management of straightforward acromioclavicular disruptions. Detailed knowledge of acromioclavicular and coracoclavicular ligamentous injury is not needed for conservative or, in rare cases, surgical care.[5]

In middle-aged and older patients who continue to have disabling shoulder pain after the acute pain of an acromioclavicular disruption abates, one may consider an MRI to evaluate for a possible rotator cuff tear.

Very rarely, athletes with persistent pain over the acromioclavicular joint merit an MRI to determine whether or not the cartilaginous disk has been damaged irreversibly and to determine whether or not the process of distal clavicle osteolysis or early osteoarthritis has begun.

Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

L. Edward Seade, MD  Chief of Shoulder Service, Orthopaedic Specialists of Austin

Disclosure: Nothing to disclose.

Coauthor(s)

Reed L Bartz, MD  Consulting Staff, Division of Sports Medicine, Nebraska Orthopaedic and Sports Medicine PC

Disclosure: Nothing to disclose.

Robert Josey, MD  Consulting Staff, Department of Orthopedic Surgery, Orthopaedic Specialists of Austin

Robert Josey, MD is a member of the following medical societies: American Medical Association, Phi Beta Kappa, and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David T Bernhardt, MD  Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD  Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

References

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  2. Hudson VJ. Evaluation, diagnosis, and treatment of shoulder injuries in athletes. Clin Sports Med. Jan 2010;29(1):19-32, table of contents. [Medline].

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  5. Nemec U, Oberleitner G, Nemec SF, Gruber M, Weber M, Czerny C, et al. MRI versus radiography of acromioclavicular joint dislocation. AJR Am J Roentgenol. Oct 2011;197(4):968-73. [Medline].

  6. Lizaur A, Sanz-Reig J, Gonzalez-Parreño S. Long-term results of the surgical treatment of type III acromioclavicular dislocations: an update of a previous report. J Bone Joint Surg Br. Aug 2011;93(8):1088-92. [Medline].

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  8. Slawski DP, Cahill BR. Atraumatic osteolysis of the distal clavicle. Results of open surgical excision. Am J Sports Med. Mar-Apr 1994;22(2):267-71. [Medline].

  9. Cahill BR. Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg Am. Sep 1982;64(7):1053-8. [Medline]. [Full Text].

  10. Flatow EL, Duralde XA, Nicholson GP, Pollock RG, Bigliani LU. Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg. Jan-Feb 1995;4(1 pt 1):41-50. [Medline].

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  14. Lee SJ, Keefer EP, McHugh MP, Kremenic IJ, et al. Cyclical loading of coracoclavicular ligament reconstructions: a comparative biomechanical study. Am J Sports Med. Oct 2008;36(10):1990-7. [Medline].

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  17. Seade LE. Coracoclavicular ligament reconstruction with semitendinosus allograft for AC joint separations, 2-5 year follow-up. Presented at: Annual Meeting of Texas Orthopaedic Association; May 14, 2004; Austin, Texas.

  18. Seade LE. Coracoclavicular ligament reconstruction with semitendinosus allograft for AC joint separations, 2-5 year follow-up. Presented at: Western Orthopaedic Association; October 13, 2006; Santa Fe, New Mexico.

  19. Urist MR. Complete dislocation of the acromioclavicular joint: the nature of the traumatic lesion and effective methods of treatment with analysis of 41 cases. J Bone Joint Surg Am. 1946;28A:813-37. [Full Text].

  20. Zanca P. Shoulder pain: involvement of the acromioclavicular joint. (Analysis of 1,000 cases). Am J Roentgenol Radium Ther Nucl Med. Jul 1971;112(3):493-506. [Medline].

 
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Classification of acromioclavicular joint injuries.
Type III acromioclavicular joint separation.
Type III acromioclavicular joint separation.
Postoperative coracoclavicular ligament reconstruction. The clavicle is back to its normal position. The anchor in the clavicle keeps the allograft tendon from coming off of the clavicle. Also note the distal clavicle has been excised, because it had traumatic arthritis from the injury.
Postoperative rehabilitation.
 
 
 
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