Acromioclavicular Joint Dislocation Specialist Singapore
Acromioclavicular joint (ACJ) dislocations are injuries often experienced by athletes. They are often mistaken to be glenohumeral joint dislocations (see section on shoulder dislocations).
However this certainly does not mean some who is not an athlete cannot suffer such an injury. Majority of ACJ dislocations occur in males in their thirties. Although many patients with untreated ACJ dislocations do well and eventually suffer few functional deficits, more severe untreated ACJ dislocations can result in chronic pain.
Some knowledge of the anatomy of the shoulder is required to understand ACJ dislocations.
The acromioclavicular (AC) joint is located at the top of the shoulder, where a part of the shoulder blade (acromion) and the collarbone (clavicle) meet.
AC joint dislocation occurs when the clavicle pops out of alignment with the acromion.
What Causes A Acromioclavicular Joint Dislocation?
The common causes of acromioclavicular joint dislocation include:
- Falling directly onto the shoulder
- Violent blow to the shoulder area (e.g. heavy object falling directly onto the shoulder)
- Sports injuries
What Are The Symptoms Of Acromioclavicular Joint Dislocation?
Common symptoms of acromioclavicular joint dislocation include:
- An obvious deformity of the shoulder
- Intense pain in the AC joint
- Inability to move the shoulder joint
- Decreased range of motion
- The end of the collarbone may appear to be sticking up under the skin
How Is A Acromioclavicular Joint Dislocation Diagnosed?
During a physical examination, your doctor may inspect the affected area for pain, tenderness or any deformities. Furthermore, they may test your shoulder’s mobility by asking you to perform specific simple exercises to determine whether or not the AC joint is dislocated.
An X-ray of your shoulder joint may also be performed to reveal the dislocation and other damages to your AC joint. An MRI scan may be required to fully assess the extent of the injury.
It is essential to avoid attempting to put the joint back yourself because of the risk of aggravating the injury. Also, the joint will not stay in place because of the pull of gravity on the arm.
How Is A Acromioclavicular Joint Dislocation Treated?
Common treatment methods include:
- Rest and avoid excessive shoulder movements
- Simple and gentle stretching exercises to slowly regain shoulder mobility and strength
- Physiotherapy
Surgery is generally recommended in the following cases:
- If the patient is highly active, e.g. manual labourer, high level athlete
- If the acromioclavicular joint dislocation is a severe one, with a large gap between the dislocated bones
- If the acromioclavicular joint dislocation is a chronic one which is still painful with shoulder movements
Surgery typically involves resecting the joint and reconstructing the torn ligaments. In chronic cases, an artificial ligament (known as a tendon graft) is used to reconstruct the damaged ones.
Anatomy of the Shoulder Joint
The shoulder joint is made up of 3 bones: the shoulder blade (scapula), the humeral head and the collar-bone (clavicle).
Movements around the shoulder involve 3 separate articulations: the glenohumeral joint, the acromioclavicular joint and the scapulothoracic articulation. When the arm is raised, the majority of movement occur at the glenohumeral joint and the scapulothoracic articulation.
The ACJ is a rather small joint between the clavicle and a part of the scapula known as the acromion. The acromion forms a roof over the glenohumeral joint which is often regarded as the “main” shoulder joint.
When we raise our arms, majority of movement occurs at the glenohumeral joint and scapulothoracic articulation. Only small gliding and rotatory movements occur at this joint. Despite the fact that such little amount of movement occur through this joint, this small joint has to deal with large forces.
The joint is held in place by several structures:
1. The joint capsule (the covering of the joint)
2. Ligaments found within the capsule of the joint (known as the AC ligaments)
3. Ligaments that are attached, on one end to the coracoid process (part of the scapula) and on the other end, to the clavicle. These ligaments are called the coraco-clavicular (CC) ligaments.
Sports injuries are the most common cause of ACJ dislocation. Often times it is the result of direct impact on the point of the shoulder.
The most common scenarios I see are when patients trip while running fast causing them to tumble “head over heels” or when cyclists pitch over the handlebars after having hit a pothole or a branch on the road. In almost all of these scenarios, the patient lands hard directly on their shoulder.
Frequently Asked Questions
When should I visit a doctor for acromioclavicular joint dislocation?
If you suspect you have a dislocated AC joint, you should seek immediate medical attention. This is because treatment is much easier and you have a much better chance of excellent recovery if the injury is treated early.
What will the doctor do?
The first thing is to confirm the diagnosis. This is easily done with a simple x-ray. Often it is prudent to do x-rays of both shoulders to compare both sides. This is because some patients’ clavicles naturally sit slightly high giving the appearance it could be slightly out of place.
Comparing the uninjured side with the injured side allows your doctor to not only confirm the injury, but also allows him to grade its severity. This is important because milder injuries will do fine without any invasive surgery to fix the joint, but more severe injuries may require surgical fixation.
Besides x-rays, some doctors may also recommend doing an MRI scan. This mainly useful for looking for other associated injuries. A number of patients with ACJ dislocations may also suffer concomitant injuries like labral tears. Please refer to the section on Investigations to learn more about MRI scans.
What does surgery for ACJ dislocations entail?
The objective of surgery is to put the ACJ back in place and keep it in place. Many techniques have been developed to achieve this over the years. Many failed and have become historical. Many shoulder surgeons will treat acute injuries differently from chronic injuries. I generally regard injuries less than 2 weeks old as acute.
For acute injuries, I usually use one of 2 methods, depending on patient preference and size of the patient. For large and heavy-set patients, I use a strong hooked plate which levers against the inferior surface of the acromion to push the clavicle down and keep it in place.
This is an excellent and extremely strong method of holding the ACJ stabilized, but a big drawback is the need to remove the plate after a period of about 5 – 6 months. By that time, the ACJ and CC ligaments would have healed.
If the plate is not removed, it may cause irritation and pain when patients lift their arms overhead by impinging on the underlying rotator cuff tendon.
For smaller patients, I use a suspensory type fixation, where a hole is drilled through the clavicle and the base of the coracoid process. The ACJ is then brought back into place and held by passing strong suture tapes through the holes, secured over the clavicle and under the coracoid with small metal buttons.
This surgery is done via keyhole surgery and there is no need for a second surgery to remove the metal buttons. Please see section on keyhole surgery if you would like to know more about keyhole surgery.
Finally for chronic injuries, I use either one of the above techniques, but I loop a tendon graft around the clavicle and the coracoid process so that the body can, over time, convert the tendon graft into a new ligament to help hold the ACJ in place.
A tendon graft is a tendon which is either harvested from the patient’s leg or a commercially prepared tendon procured from deceased donors.
The need to loop a tendon graft increases the complexity of the surgery and there is some evidence that ACJ injuries which are treated early (acute injuries) tend to do better thanchronic ones.
Will I be able to participate in sports after the surgery?
Absolutely. The aim of the surgery is to restore stability to your shoulder, not just during daily activities, but also during sports.
How to prevent acromioclavicular joint dislocation?
Unfortunately acromioclavicular joint dislocations are often accidental injuries and there is not a lot you can do to prevent it from happening.
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