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Acromioclavicular and Sternoclavicular Injuries and Clavicular, Glenoid, and Scapular Fractures

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Acromioclavicular and Sternoclavicular Injuries and Clavicular, Glenoid, and Scapular Fractures 2491 InstructionalSelected Course Lectures The American Academy of Orthopaedic Surgeons MARY I. O’CONNOR EDITOR,VOL. 59 COMMITTEE MARY I. O’CONNOR CHAIRMAN FREDERICK M. AZAR PAUL J. DUWELIUS KENNETH A. EGOL PAUL TORNETTA III EX-OFFICIO DEMPSEY S. SPRINGFIELD DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY FOR INSTRUCTIONAL COURSE LECTURES JAMES D. HECKMAN EDITOR-IN-CHIEF, THE JOURNAL OF BONE AND JOINT SURGERY Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy’s Annual Meeting, will be available in March 2010 in Instructional Course Lectures, Volume 59. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 A.M.-5 P.M., Central time). 2492 THE J OURNAL OF B ONE &JOINT S URGERY d JBJS. ORG ACROMIOCLAVICULAR AND S TERNOCLAVICULAR I NJURIES VOLUME 91-A d N UMBER 10 d O CTOBER 2009 AND CLAVICULAR,GLENOID, AND S CAPULAR F RACTURES Acromioclavicular and Sternoclavicular Injuries and Clavicular, Glenoid, and Scapular Fractures By Michael S. Bahk, MD, John E. Kuhn, MD, Leesa M. Galatz, MD, Patrick M. Connor, MD, and Gerald R. Williams Jr., MD An Instructional Course Lecture, American Academy of Orthopaedic Surgeons Acromioclavicular joint injuries—or (Table I)1. A Type-I injury is a sprain upward pressure beneath the elbow, separations, as they are commonly (stretching) of the acromioclavicular indicating interposition of soft tissue described—are common sports-related ligament. Type-II injuries tear the (deltotrapezial fascia) between the distal injuries resulting from falls or other di- acromioclavicular ligament, leaving the part of the clavicle and the acromioclavi- rect forces on the superolateral aspect coracoclavicular ligament intact. When cular joint. Type VI is an exceedingly of the shoulder pushing the acromion in the coracoclavicular and acromioclavi- rare, high-energy injury characterized an inferior direction. Acromioclavicular cular ligaments are both torn and the by inferior displacement of the clavicle joint injuries represent a spectrum of acromioclavicular separation is reduc- beneath the coracoid. Most surgeons severity, ranging from a simple sprain ible with gentle upward pressure under never encounter this injury, and it is not of the acromioclavicular ligament with the elbow, the injury is classified as Type discussed in detail in this review. no displacement to widely displaced III. A Type-IV acromioclavicular sepa- Neviaser developed a simpler injuries associated with severe soft- ration occurs when the coracoclavicular classification system, also emphasizing tissue injury to the acromioclavicular and acromioclavicular ligaments are the reducibility of the joint in deter- ligament, the coracoclavicular ligament, torn and the scapula is displaced infe- mining the diagnosis and classification2. and the deltotrapezial fascia. Treatment riorly and anteriorly, resulting in a Type I is a sprain of the acromioclavi- options vary according to the severity relative posterior displacement of the cular ligament, and Type II is a tear of of the injury and logically reflect the distal part of the clavicle through a tear this ligament. Type III is subclassified as associated soft-tissue involvement. This in the deltotrapezial fascia. The distal Type IIIA if the injury is reducible and lecture briefly outlines the types of part of the clavicle lies directly subcu- as Type IIIB (corresponding to Rock- injuries and current recommendations taneously in these injuries. A Type-V wood Types IV and V) if the injury is for treatment. injury is characterized by a wide cora- not reducible. coclavicular separation. The distal part Classification of the clavicle is herniated through a Diagnosis The modified Rockwood classification rent in the deltotrapezial fascia with the Type I system is the most commonly used scapula displaced inferiorly. Type-IV Type-I injuries, according to the Rock- method of categorizing these injuries and V injuries are not reducible with wood system, are sprains of the acro- Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Biomet Sports Medicine). J Bone Joint Surg Am. 2009;91:2492-510 2493 THE J OURNAL OF B ONE &JOINT S URGERY d JBJS. ORG ACROMIOCLAVICULAR AND S TERNOCLAVICULAR I NJURIES VOLUME 91-A d N UMBER 10 d O CTOBER 2009 AND CLAVICULAR,GLENOID, AND S CAPULAR F RACTURES TABLE I Modified Rockwood System for Classification of Acromioclavicular Separations Acromioclavicular Coracoclavicular Deltotrapezial Type Ligament Ligament Fascia I Sprained Intact — II Torn Intact — III Torn Torn Intact IV Torn Torn Torn V Torn Torn Torn mioclavicular ligament with no dis- Complete separation of the acromio- involvement. There is very little con- placement. Radiographic findings are clavicular joint and an increase in the troversy regarding the treatment of usually normal if the injury occurs in coracoclavicular distance are seen on Type-I and II injuries or Type-IV and V isolation. The diagnosis is based on the radiographs. injuries. However, treatment of Type-III history and the findings of the physical injuries is controversial, and there is no examination. There is tenderness di- Type IV general consensus3-6. rectly at the acromioclavicular joint. It is The clavicle is driven in a posterior unusual for an inspection of the shoul- direction in a Type-IV separation. This Type I der to reveal a deformity, with the results in a distinct visible deformity Sling immobilization and symptomatic exception of ecchymosis or abrasion on with extreme prominence of the clavicle treatment of pain are usually all that are the superior aspect of the shoulder in over the scapular spine. The clavicle is necessary for these injuries. Activities the acute phase after the injury. herniated through the trapezius and is are resumed as tolerated. subcutaneous. Although the acromio- Type II clavicular joint is unstable, because it is Type II Type-II injuries are tears of the acro- impaled over the scapula, it does not These injuries are usually successfully mioclavicular ligament with an intact move on physical examination. Poste- managed with the methods used for coracoclavicular ligament. Physical ex- rior displacement of the clavicle is seen Type I. Occasionally, pain persists at amination reveals tenderness to palpa- on the axillary radiograph, whereas the the acromioclavicular joint and addi- tion at the acromioclavicular joint. The dislocated acromioclavicular joint and a tional treatment is indicated. Nonop- acromion may be slightly displaced widened coracoclavicular distance are erative measures such as cortisone inferiorly relative to the distal part of the seen on the anteroposterior radiograph. injections and nonsteroidal anti- clavicle, but it continues to be at least inflammatory medication can be ad- partially in contact with the distal part Type V ministered. An excision of the distal of the clavicle. The joint is unstable in Displacement of the distal part of the part of the clavicle alone is insufficient the anteroposterior plane. The distance clavicle occurs predominantly in the treatment; it results in a short, unstable between the coracoid and clavicle re- vertical plane. The injury results in distal part of the clavicle, continued mains normal, but the acromion is obvious visible deformity of the distal pain, and disability. If surgery is se- subluxated relative to the distal part of part of the clavicle associated with lected because of the persistence of the clavicle. downward and slightly anterior dis- pain after nonoperative treatment, the placement of the scapula. The separa- distal aspect of the clavicle should be Type III tion is not completely reducible because removed and a capsular plication with When the acromioclavicular and cora- the distal part of the clavicle is herniated ligament reconstruction should be coclavicular ligaments are both torn, the through the deltotrapezial fascia. There performed. distal part of the clavicle is prominent is usually substantial tenderness and as an obvious visible deformity. The dis- swelling in the acute phase after the Type III tal part of the clavicle is usually tender injury. An increase in the coracoclavi- Type-III injuries should initially be to palpation, and the joint is reducible cular distance (of up to 300%) and treated without surgery1,3,6.Most with upward pressure under the elbow. superior displacement of the distal part patients recover and regain normal Chronic separations are less reducible of the clavicle are seen on the antero- shoulder function, although the visi- because of scar formation around the posterior radiograph. ble deformity is permanent. Early joint. Nevertheless, the deltotrapezial surgical treatment can be considered aponeurosis is intact. The acromio- Treatment for individuals with high sports or clavicular joint is unstable in both the Treatment varies depending on the vocational demands, although this is vertical and the horizontal plane. severity of the injury and the soft-tissue controversial as many high-demand 2494 THE J OURNAL OF B ONE &JOINT S URGERY d JBJS. ORG ACROMIOCLAVICULAR AND S TERNOCLAVICULAR I NJURIES VOLUME 91-A d N UMBER 10 d O CTOBER 2009 AND CLAVICULAR,GLENOID, AND S CAPULAR F RACTURES TABLE II Injuries Associated with Fracture of the Medial Aspect of the Clavicle* Associated Injury Percent of Patients Pneumothorax and/or hemothorax 42 Pulmonary contusion/respiratory failure 55 Rib fracture 73 Vascular injury 2 Facial fracture 31 Head injury 36 Cervical spine injury 25 Visceral injury 29 Upper-extremity injury 45 Lower-extremity injury 31 *Reproduced, with modification, from: Throckmorton T, Kuhn JE. Fractures of the medial end of the clavicle. J Shoulder Elbow Surg. 2007;16:49-54; with permission from Elsevier. individuals do well with nonoperative surgical repair does not restore normal for whom nonoperative treatment treatment4.
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