Acromio-clavicular joint (ACJ) dislocation (separation)

WHAT IS AN ACJ DISLOCATION ?

An ACJ injury, otherwise known as a shoulder separation, is a traumatic injury to the acromioclavicular (AC) joint with disruption of the surrounding ligaments. It typically occurs due to a fall on the corner of the shoulder, for example, falling from a bike. The shoulder blade is forcibly pushed down and therefore pushed away from the clavicle and the separation occurs at the ACJ. There are different grades of injury and treatment ranges from immobilisation in a sling for a short period or surgical reconstruction depending on the degree of separation and ligament injury.


 

This is a photograph showing how the shoulder may look with an ACJ injury. You can see the step-off at the edge of the shoulder.


This image shows how the ligaments tear, leading to the separation.

How do surgeons grade these injuries ?

Grading system (Rockwood Classification)

Type 1 ACJ sprain only, the X-ray looks normal

Type 2 ACJ is slightly disrupted; the X-ray shows increased ACJ gap (< 25% change)

Type 3 ACJ is moderately disrupted; increased ACJ gap; distance 25-100% of contralateral

Type 4 ACJ is disrupted; end of clavicle sits behind where it should, seen on the axial X ray

Type 5 ACJ is severely disrupted; increased ACJ gap (> 100% change)

Type 6 ACJ is disrupted; end of clavicle displaced inferior (under) where it should.

This is a chronic grade 3 ACJ separation. You can see the end of the clavicle is lifted up away from the acromion.

This is a grade 3 ACJ injury.
 

This is a grade 5 ACJ injury.

This is a grade 6 ACJ injury. The clavicle has come to lie underneath the coracoid process.
 

WHAT IS THE TREATMENT?

Non-surgical Treatment:
In most people, a separated shoulder doesn't usually require surgery, but treatment is based on the grade of your injury. For types I, 2 and type 3 in most people, a brief period in a sling 2-4 weeks, ice, NSAIDs, physiotherapy and a gradual return to normal activity is usually all that is required. One can expect a return to full function by 2-3 months after the injury.

This image shows a patient wearing a polysling to rest the shoulder and ease the pain.

Surgical treatment:
 

For type 3 injuries in laborers or elite athletes, for example, surgery can be performed. Also for types 4, 5 and 6. Historically it was thought acute injuries were treated with ORIF (fixation) and chronic injuries were treated with ligament reconstruction however, recent studies have shown no difference in outcomes in types III injuries treated surgically after 6 weeks non-op treatment versus immediate surgery. A period of nonoperative treatment with a view to surgery if symptoms don’t settle seems reasonable for type 3 injuries. I would recommend acute surgical stabilisation for types 4-6.

A traditional technique has been the Weaver-Dunn procedure which involves distal clavicle excision with transfer of coracoacromial ligament to the distal clavicle to recreate a new ligament. However, with the advent of easily available synthetic ligaments, such intricate surgery is now rarely performed.

The technique I use is open (not key-hole) and passes a synthetic graft (Lockdown tape) under the coracoid process and then over the top of the clavicle and then is secured to the clavicle with a single screw. The tape doesn’t dissolve with time but rather acts as a scaffold for your new natural ligament to grow along. In time, perhaps 2 or 3 years, if one were to re-explore the area surgically, the tape would be indistinct from your own tissue. You can watch the surgical technique here https://lockdownmedical.com/

The surgery takes about an hour and it’s often feasible for you to go home the same day. You will have a sling on which is usually recommended for a period of 4 weeks. This should be worn day and night but can be safely removed for short periods for washing and dressing. You should also do some gentle exercises every day for the hand, wrist and elbow. In the shower, you must keep your wound dry for 2 weeks to help prevent infection. So, remove your sling and keep your arm in the position as if it were still in the sling and then hold the shower head in the other hand. Shower low down but do not get your dressing wet. You can use a wet flannel around the shoulder and under the arm. At 2 weeks you will see a member of the team who will check your wound and trim or remove your stitches.

At 4 weeks you can start to move your shoulder out of the sling for light daily activity and progress more with the physiotherapists. At this point, restricting movement to below the level of the shoulder is preferred. At 6 weeks most people are comfortable enough to drive and start to lift the arm above the shoulder level. By 8-12 weeks strength will be building in the shoulder and by 12 weeks most people are fully recovered. Contact sport and heavy manual labour is usually feasible at 12 weeks post-op.

This image shows the white Lockdown tape in position. it is wrapped around the coracoid process and over the top of the clavicle and a single screw secures it in place.

This post-operative X-ray shows the ACJ has been re-aligned and there is a screw in the clavicle.

Spire Elland Hospital

Elland Lane
Elland
HX5 9EB

For an appointment, telephone:
Outpatient Bookings on 01422 324 069
Self pay enquiries on 01422 229 597
Main Hospital on 01422 229 632

BMI The Huddersfield Hospital

Birkby Hall Road
Huddersfield
West Yorkshire
HD2 2BL

Reception: 01484 533 131

Department of Orthopaedics & Trauma

Calderdale and Huddersfield NHS Foundation Trust
Huddersfield Royal Infirmary
Acre Street
Lindley
Huddersfield
HD3 3EA

NHS Secretary:
Mrs Margaret Thomas
Tel 01484 342 343

NHS Clinics

Trauma:
Calderdale Royal Hospital (Halifax) and
Huddersfield Royal Infirmary

Elective Shoulder and Elbow problems:
Friday morning at Calderdale Royal Hospital, Halifax

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