of Orthopaedics. University. Department of Orthopaedic. Surgery,. Glenfield. General. Hospital,. Groby. Road,. Leicester. LE3. 9QP,. England. R. F. Steingold,.
THE
CONSERVATIVE
TREATMENT
OF ACROMIOCLAVICULAR
DISLOCATION REVIEW
J. J. DIAS,
R. F. STEINGOLD,
AFTER
R. A.
From
the
FIVE
YEARS
RICHARDSON,
B. TESFAYOHANNES,
University
P. J. GREGG
of Leicester
The treatment of acromioclavicular injuries is controversial; few studies document the late results. We have reviewed 53 patients about five years after conservative management, in nine for subluxation and 44 for dislocation.
Subjective and objective results were satisfactory in all cases except for one with painful who was the only patient to change her occupation because of the injury. At review, joint demonstrated by improvement in position and by the very small increase in the coracoclavicular radiographs. The treatment controversial. papers
of
acromioclavicular joint injuries 1946 Urist reviewed 101 previous
In
and
reported
between
unsatisfactory results following ment. These unsatisfactory results position of the joint and this led different fixation. some may
methods Internal (Bannister
1983)
Glick
et al.
six
reviewed
five
even
though
(1977)
the results
reported
on
years
after
conservative
1979
to
1981
AND a total
and
at a mean management. reviewed 33 to similar of patients
treatment.
patients
Leicester Royal Infirmary with Grade the acromioclavicular joint (Allman
review
clinic.
Requests
for
reprints
© 1987 British 0301-620X/87/5l6l
VOL.
69-B,
No.
should
presented
at
III dislocation of 1967). In all cases
and
Editorial Society $2.00
5, NOVEMBER
to Mr
of Bone
J. J. Dias. and
Joint
sport
of the
remaining form
patients
in 25 of the
were
reason for were asked about noted.
of General
clavicle
acromion
to
with
an
44 patients
the
basis
were
had
of this
reviewed
no surgical
report.
at
a mean
of
5.26
44 patients,
road
traffic
accidents
in 14
and falls in the remainder. All were treated by broad arm slings for three to five weeks followed by mobilisation of the shoulder. At review, subjective, objective and radiographic recorded.
Any
any change about any
shoulder
discomfort
in the
were
or local
combined
limbs applied
joint
shoulder
stiffness
examined tenderness
relaxed, (Fig. the
weight
for
both
At review
registered
The any
patients remarks
appearance
and
or exact
were
any
clinical
The
range
measured
was measured patient stood
by
by a static with upper
downward force was felt discomfort in the on a spring
balance
was
sides.
standard
acromioclavicular
and
was
while a progressive 1). When the patient
recorded
or
preceding
in occupation and the
recorded.
abduction
Carrying capacity test in which the
shoulder Surgery
were documented. other complaints
weakness,
patients
goniometer. distraction
both 1987
end
of the
years after the injury (range 4.5 to 6.9 years). There were 38 men and six women. Their mean age was 33.3 years (range 19 to 69 years). The cause of injury was contact
deformity
Orthopaedic Surgeon Avenue, Nuneaton, Warwickshire
be sent
The
intervention
The
Consultant Court
lateral
margin
year, difficulty in carrying loads, change sporting activities, the type of occupation
J. J. Dias, FRCS, Lecturer in Orthopaedics R. A. Richardson, FRCS, Consultant Orthopaedic Surgeon B. Tesfayohannes, MB ChB, Senior House Officer P. J. Gregg, MD, FRCS, Professor of Orthopaedics University Department of Orthopaedic Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, England. R. F. Steingold, FRCS, Manor Hospital, Manor CV1 1 5SP, England.
the
superior
increased distance between the clavicle and the coracoid process. In three cases primary internal fixation by acromioclavicular transfixion was used. One patient could not be traced and another refused to attend the
criteria
METHODS
of 49
showed
the
These
treatment. following
35 patients
came group
radiograph
of surgery
of conservative the late results
years after injury and We now report a larger
PATIENTS From
20%
conservative managewere attributed to the to the development of
found no significant functional disability period of three years after conservative Bjerneld, Hovelius and Thorling (1983) patients conclusions.
and
the
be above
of open reduction and internal fixation has been recommended by
be no better than those Very few studies document
injury.
10%
is
subluxation, stability was gap on stress
anteroposterior joints
were
radiographs obtained
with
of a
150
719
J. J. DIAS.
720 Table
R. F. STEINGOLD,
I. Radiographic
R. A. RICHARDSON.
assessment
at review
5 years
B. TESFAYOHANNES,
after
Grade
Position
Coracoclavicular mean increase
Lateral
separation over normal
end
were
orientation clavicle Ossification ligament
studied
to
ossification
document
included spurs discrete ossicles
ossification
bridging
implied
between
The distance
the
the
on
both
sides
and
and
Dislocated
(n=20)
(n23)
2.25
7.84
7.20
Difference
0.50
1.74
1.10
Normal
1
2
1
4
Expanded
0
16
14
30
Atrophied
0
2
8
10
None
I
8
9
18
Minor
0
6
10
16
Major
0
6
4
10
patients, was
and
position. coracoid
after
but
22 reported
some
mild
Ten heavy though related having
about Objective
patients
had
had
discomfort patient
had
and
some
difficulty
the
in
was
only
dislocated, was
in 20 it
it in
is shown in Table change greater than changes
were
normal side coracoclavicular
was
minor
(Table
in 16 (Fig.
with
I). Ossification ligaments was 4) and
major
subluxation.
noted
a normal
I. In no patient
2 mm. in the lateral
end
30 it was atrophy with the
in the region of the present in 26 patients, in
10 (Fig.
During
the
5).
period
1979
to
1981, nine patients had presented with subluxation of the acromioclavicularjoint, that is a Grade II injury (Allman 1967). All nine attended for review and were studied in the same way as the dislocations. Eight had, on clinical
no recent joint,
two had had discomfort
and radiological mioclavicularjoints.
examination, essentially normal acroOne patient, with persistent sublux-
in carrying
loads. Four had stopped playing rugby football, in only one of these was the decision clearly to the shoulder injury alone, the other three also problems at other sites. No patient complained the appearance of the shoulder.
assessment.
Although
36
patients
had
a
clinically obvious deformity, this was gross in only six. All six women had only mild deformity and none expressed concern about the appearance of the shoulder. Eight patients had local tenderness over the acromioclavicular joint. Five patients had lost bined abduction, but only two had a capacity (over 4 kg difference) on the test when compared to the uninjured
Radiographic review
still
one
The change in distance between clavicle and process produced by loading normal, subluxat-
Radiographic
RESULTS
moderate symptoms. In no led to a change of occupation.
and
of the clavicle in all except four patients. In expanded (Fig. 2) and in 10 it had undergone (Fig. 3), appearing to be tapered as compared
loading.
assessment. Twenty patients had had in the region of the acromioclavicular
in 23 the joint
ed and dislocatedjoints at review was this
clavicle.
process
but subluxated
Patients
Subjective discomfort
All (n=44)
Loaded
complete the
and coracoid
before
Subluxated
(n=l)
6.10
position
or almost
process
clavicle
Normal
6.10
the coracoid or clavicle region of the ligaments.
complete
coracoid
between
measured
from in the
at review
1.75
of the joint, the state of the lateral end of the and the presence of degenerative change. in the region of the coracoclavicular was noted to be absent, minor or major. Minor
ossification and small
o f joint
dislocation
At rest
by Zanca ( I 97 1 ) and these were with 10 lb (4.5 kg). The radio-
tilt as described after loading
graphs
Major
ligament
III acromioclavicular
(mm)
of clavicle
Coracoclavicular
cephalad repeated
-
side
P. J. GREGG
had
assessment. improved
The since
Fig. I Static distraction test. The patient stands with upper limbs relaxed. A loop (a) is placed around the wrist on the side to be tested and progressive distraction is applied by the pulley (b) until the patient complains of discomfort at the acromioclavicular joint. The weight at which this occurs is noted from the spring balance (c).
over 20#{176} of corndecreased lifting static distraction side.
position the
b
original
of the joint
on
injury
21
in
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
There is expansion formation on the
ation
but
of the lateral inferior aspect.
no other and
end
pain
patient
in the entire
change
in occupation.
in whom
Bannister that around
conservatively number anatomy
were
clavicle
in lifting.
series
TREATMENT
with
changes,
difficulty
is still considerable of treatment of
clavicularjoint. and found
of the
radiographic
severe
There method
CONSERVATIVE
new
was
the injury
as of
to
have
the
poor
only
led to a
the best acromio-
(1983) reviewed the 15% of the patients to
of
the
had
literature treated results.
of papers report attempts to restore and thereby to prevent disability, but
A
normal none of
these surgical methods have consistently shown an improvement on the outcome of conservative management. Acromioclavicular transfixion was reported to be unsatisfactory lar fixation
in one by either
(Bannister extend the of cases The conservative
third ofcases as was coracoclavicua screw or a loop in 16% of cases
1983). In addition, associated muscular
the few
reduction
was
prospective and surgical
not
VOL.
69-B,
No.
5. NOVEMBER
may third
have compared have failed
Fig. 3 Atrophy clavicle
of the appears
demonstrate Imatani, vatively
lateral tapered
that
end of the clavicle. On the involved side in comparison with the normal side.
early
Hanlon treated
acromioclavicular screw. They
operation
and Cady patients
used
transfixion an exacting
ligament. a discrete
A small spur is ossicle is visible
compared 1 1 who
or a scoring
results. 12 conserhad either
coracoclavicular system to assess any significant Bannister (1983) dislocation 28 of were satisfactory
in 90#{176}c of conservatively in operated patients,
compared treated
returned Reports
sooner on the
while
treated cases the patients
to work long-term
Fig.
and
led to improved
(1975) with
the
results and were unable to establish difference between the two groups. reported 58 cases of acromioclavicular whom had screw fixation. The results
tively to
4
coracoclavicular ofthe clavicle
987
itself in one
maintained.
studies which management
Fig. Minor ossification in the seen on the inferior aspect in the trapezoid ligament.
an operation injuries and
721
DISLOCATION
bone
complained She
controversy dislocation
reported
OF ACROMIOCLAVICULAR
Major ossification in the coracoclavicular bridging in the line of the trapezoid the line of the conoid ligament.
and
sport.
results
are
to 82% conserva-
summarised
in
5
ligament
ligament. with
There partial
is complete bridging
in
J. J. DIAS,
722
R. F. STEINGOLD,
Table
II. Papers
R. A. RICHARDSON,
reporting
long-term
results
Scott & Orr
1973
50
Rosen#{248}rn& Pedersen
1974
13
7 (2 to 10)
1
Glick
1977
35
3 (1 to 10)
It
1983
33
6 (over
2
1987
53
5.3 (4.5 to 6.9)
et al. et al.
Dias et al.
Surgical
Smith
& Stewartl
Vandekerckhoveetal4
*
Pain
t
Needed
wiring clavicle
4
1979
86
4.4
9
1985
41
5.7(1.7to12.2)
leading
the outcome to, if not
sling.
The
wire
than,
only
ACKNOWLEDGEMENTS
that
significant manag-
patient
(1983).
Bannister
radiographs, in the
many
not
that
increase
stability
confidently ment of patients. produce agement
suggests
be expected acromioclavicular
improvement
on
this
injury
suggest
regardless only fails
Bannister
but also exposes Ejesk#{228}r (1974) following coraco-
a satisfactory
outcome
after
the conservative injury, with
managespontaneous
ofthejoint
in about
half
ofcomplete prospective controlled with coracoclat’icular screwfixation. of MCh Orth, The University of
Bjerneld
a specific surgical procedure is shown to results consistently, conservative manremain the treatment of choice.
H,
Scand Ejeskir
A. Coracoclavicular dislocation : a ten year 1974:45:652-61.
JM,
Glick
Milburn
II,
RJ, Hanlon
separation.
wiring follow-up
Haggerty
acromioclavicularjoint clavicular dislocations.
JF,
Nishimoto
D.
Surg
[Am]
complete acromioclavicular 1975:57-A:328-32.
Rosenern M, Pedersen EB. A comparison between operative treatment of acute acromioclavicular Orthop Scand 1974:45:50-9.
conservative dislocation.
and Acta
joint.
Injury
Scott
JC, On MM. 1973 :5 :13-8.
Smith
MJ, study.
Urist
MR. Complete dislocations of the acromioclavicular nature of the traumatic lesion and effective methods with an analysis of forty-one cases. J Bone 1946:28:813-37.
Injuries
Stewart MJ. Am J Sports
Acute Med
to
the
joint Scand
Dislocated acromio-
: follow-up study of 35 unreduced Am J Sports Med 1977:5:264-70. Joint
acromioclavicular
acromioclavicular 1979:7:62-71.
separations
: a 20-year joint : the of treatment Joint Surg
Vandekerckhove B, Van MeirhaegheJ, Van Steenkiste M, De Groote Verbeke R, Vertongen P. Surgical treatment of acromioclavicular dislocations : long-term follow-up study. Ada Orthop 1985:51 :66-79.
Zanca
P. Shoulder (analysis
of
pain
its
separations Acta Orthop
for acromioclavicular study. Acta Orthop
JJ, Cady GW. Acute,
J Bone
and
acromioclavicular dislocation: trial comparing earls’ movement Thesis submitted for the degree Liverpool, 1983.
Hovelius L, Thorling J. Acromio-clavicular conservatively : a 5 year follow-up study. 1983:54:743-5.
treated
can
the
G. The management
a randomised
that
ofthe method to improve on
and ligamentous injuries of the clavicle J Bone Joint Surg [Am] 1967:49-A :774-84.
articulation.
appear
that
in the position Until better should
showed liga-
General to the of the
REFERENCES
significantly
may
the results of conservative management the patients to possible complications, reporting an 18% complication rate clavicular loop fixation in 54 patients.
study
the
Radiology, Glenfield assessment and for the preparation
Aihnan FL Jr. Fractures
Imatani
papers
comparable results are obtained of management. Operation not
Our
addition,
while 59% of the patients region of the coracoclavicular
ments, suggesting spontaneously.
The
did
In
We are grateful to the Department of Hospital for help in the radioraphic Department of Medical Illustration illustrations.
in our
viously on stress ossification
in occupation
of conserva-
better
of the joint improved in with dislocation. Such management was pre-
interval
3
transfixion
The radiographic position nearly half of our patients improvement after conservative coracoclavicular
(1 to 16)
16
to a change
series with functional disability which led to a change of occupation had a painful subluxation. No other patient with subluxation and none with initial dislocation had any significant impairment of function.
by
7
9.6 (6 to 12)
and
after operation. Our study also suggests that disability is uncommon following conservative
reported
1
54
of movement
of the
that
is comparable
arm
2)
operation
§ Resection
a broad
2t
181 or limitation
: Coracoclavicular
with
10
1974
Total
ment
result
treatment
EjeskAr
demonstrate
Poor
185
Total
II and
Follow-up (years)
treatment
Bjerneld
treatment
of
Number patients
Conservative
tive
P. J. GREGG
Date
Authors
Table
B. TESFAYOHANNES,
: involvement of the acromioclavicular AJR 1971:112:493-506.
W, Beig joint
1000 cases).
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
