A separated shoulder, also known as acromioclavicular joint injury, is a common injury to the acromioclavicular joint. The AC joint is located at the outer end of the clavicle where it attaches to the acromion of the scapula. Symptoms include non-radiating pain which may make it difficult to move the shoulder. The presence of swelling or bruising and a deformity in the shoulder is also common depending on how severe the dislocation is. It is most commonly due to a fall onto the front and upper part of the shoulder when the arm is by the side. They are classified as type I, II, III, IV, V, or VI with the higher the number the more severe the injury. Diagnosis is typically based on physical examination and X-rays. In type I and II injuries there is minimal deformity while in a type III injury the deformity resolves upon lifting the arm upwards. In type IV, V, and VI the deformity does not resolve with lifting the arm. Generally types I and II are treated without surgery, while type III may be treated with or without surgery, and types IV, V, and VI are treated with surgery. For type I and II treatment is usually with a sling and pain medications for a week or two. In type III injuries surgery is generally only done if symptoms remain following treatment without surgery. A separated shoulder is a common injury among those involved in sports, especially contact sports. It makes up about half of shoulder injuries among those who play hockey, football, and rugby. Those affected are typically 20 to 30 years old. Males are more often affected than females. The injury was initially classified in 1967 with the current classification from 1984.
Cause
Separated shoulders often occur in people who participate in sports such as football, soccer, horseback riding, hockey, lacrosse, parkour, combat sports, rowing, rugby, snowboarding, skateboarding, crack the whip, cycling, roller derby and wrestling. The separation is classified into 6 types, with 1 through 3 increasing in severity, and 4 through 6 being the most severe. The most common mechanism of injury is a fall on the tip of the shoulder or also a fall on an outstretched hand. In falls where the force is transmitted indirectly, often only the acromioclavicular ligament is affected, and the coracoclavicular ligaments remain unharmed. In ice hockey, the separation is sometimes due to a lateral force, as when one gets forcefully checked into the side of the rink.
Mechanism
The acromion of the scapula is connected to the clavicle by the superior acromioclavicular ligament. The coracoclavicular ligaments connect the clavicle to the coracoid process. The two ligaments that form the coracoclavicular ligaments are the trapezoid and conoid ligaments. These three ligaments add support to the shoulder joint. There are four types of soft tissue disruptions that may cause acromioclavicular separation:
The conoid and trapezoid ligaments may tear at any location The lateral clavicle may ride upward after being avulsed from its periosteum The acromioclavicular ligaments may be torn The conoid-trapezoid ligament origin may avulse from the coracoid
Diagnosis Diagnosis is based on physical examination and an x-ray. A physical examination can identify point tenderness, pain at the AC joint with cross-arm adduction, and pain relief with an injection of a local anesthetic. The cross-arm adduction will produce pain specifically at the AC joint and will be done by elevating the arm to a 90° angle, flexing the elbow to a 90° angle, and adducting the arm across the chest. The pain in the shoulder is hard to pinpoint due to the shared innervation of the AC joint and the glenohumeral joint. An injury to the AC joint will result in pain over the AC joint, in the anterolateral neck and in the region in the anterolateral deltoid. X-ray indicates a separated shoulder when the acromioclavicular joint space is widened (it is normally 5 to 8 mm). It can be classified into 6 types.
Type I A Type I AC separation involves direct trauma to the shoulder causing the injury to ligaments that form the joint, but no severe tearing or fracture. It is commonly referred to as a sprain. For a type 1 AC separation, the joint does not lose stability.
Type II A Type II AC separation involves complete tearing of the acromioclavicular ligament, as well as a partial tear (but not a full tear) of the coracoclavicular ligaments. This often causes a noticeable bump on the shoulder and partial or incomplete dislocation. This bump is permanent. The clavicle is unstable to direct stress examination. On radiographs, the lateral end of the clavicle may be slightly elevated by pressing on the sternal aspect of the clavicle forcing the acromial end down, and by releasing, it may pop back up eliciting a piano key sign due to the tearing of the AC.
Type III
In a Type III AC separation both acromioclavicular and coracoclavicular ligaments are torn without significant disruption of the deltoid or trapezial fascia. A significant bump, resulting in some shoulder deformity, is formed by the lateral end of the clavicle. This bump, caused by the clavicle's dislocation, is permanent. The clavicle can be moved in and out of place on the shoulder. A radiographic examination will show the results as abnormal.
Type IV This is a type III injury with avulsion of the coracoclavicular ligament from the clavicle, with the distal clavicle displaced posteriorly into or through the trapezius and may tent the posterior skin. A displaced clavicle is easily seen on a radiograph. It is important to evaluate the sternoclavicular joint also, because there can be an anterior dislocation of the sternoclavicular joint and posterior dislocation of the AC joint. This injury is generally acknowledged to require surgery.
Type V This is a more severe form of a type III injury, with the trapezial and deltoid fascia stripped off of the acromion as well as the clavicle. This is type III but with exaggeration of the vertical displacement of the clavicle from the scapula. There is a 2- to 3-fold increase in the coracoclavicular distance, causing such a severe displacement that the clavicle almost pierces the skin. The humerus and scapula drop without having the clavicular strut to lift them, which manifests as a severely drooping shoulder. This injury generally requires surgery. Distinguishing between Type III and Type V separations on imaging can be unreliable.
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