Acromioclaviclar joint dislocation / Clavicle fracture
Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association
Acromioclavicular dislocation and fracture tend to occur in contact sports such as Judo, wrestling and so on.
Acromioclabicular dislocation and clavicle fracture may result from contact sports, such as rugby, American Football, football (soccer), Judo, wrestling, as well as bicycle races, skiing, snowboarding and motorcycle falls. This section focuses on acromioclavicular dislocation.
Causes and mechanism of onset
The cause may be a direct fall on the shoulder or a fall on the elbow, where the impact acts as an external force to the shoulder, causing the acromioclavicular joint capsule to break down and dislocate.
The acromioclavicular joint is a planar joint that connects the distal clavicle to the acromion of the scapula. Other than the joint capsule, stability of the acromioclavicular joint is protected by the acromioclavicular ligament which connects the acromion with the clavicle, and the coracoclavicular ligament between the coracoid process and the clavicle. Menisus discs are present within the joint. Injuries (dislocations) of the acromioclavicular joint are divided into three types.
Grade 1: There are only minor injuries of the ligament, as well as sprains, with no apparent displacement of the joint on the X-ray (Photo 1). Palpation shows no prominent acromioclavicular joint but mild tenderness.
Photo 1: Acromioclavicular dislocation (Grade 1)
Grade 2: There is an injury to the acromioclavicular ligament, shows sublixation on the X-ray. Palpation shows acromioclavicular joint tenderness and mild laxity.
Grade 3: Injury to the coracoclavicular ligament is added to the acromioclavicular ligament injury, which is seen as a complete dislocation on the X-ray (Photo 2). Palpation reveals a protrusion consistent with the acromioclavicular joint. Pressing this part reveals a floating and sinking appearance like a piano key.
Photo 2: Acromioclavicular dislocation shown with a circle (Grade 3)
Symptoms include pain in the acromioclavicular joint, pain during exercise, protrusion of the upper end of the distal clavicle, and pressure may cause laxity. In obsolete, the patient may complain of pain, a feeling of weakness or discomfort when elevating the shoulder, but some with subluxation may be able to perform activities without much pain or limitation of movement.
Dislocations are evident on a simple X-ray, but are more obvious on a stress X-ray with weight.
Treatment and rehabilitation
In Grade 1 and 2, conservative treatment is fundamental and triangular bandage or pressure immobilization downward would be performed for 2 to 3 weeks. In addition to lower extremity exercises, upper extremity exercises (especially except for athletes who perform overhand movements) may be performed at an early stage. Movement of the shoulder joint is reduced to flexion of 90 degrees to reduce the burden on the acromioclavicular joint. Running and exercise bike are then allowed.
In Grade 3, conservative therapy or surgery may be applied. Surgery is indicated for complete dislocations in athletes who plan to be active in the future. The dislocations are reduced, the ligaments are reconstructed, and the ligaments are stabilized with a steel wire. Return to sports takes 2 to 3 months.
Clavicular fracture is a common sports injury, and its cause is similar to that of the acromioclavicular dislocation. Tenderness, swelling, and deformity (Photo 3) of the center or the clavicle on the front of the shoulder and severe pain occur during shoulder elevation.
As a general rule, conservative treatment with bandage in a figure of eight (about 6 to 8 weeks) is done. Professional cyclists and contact sports players who are willing to return to competition immediately are treated surgically with reduction and fixation.
Rehabilitation after removing fixation conforms to acromioclavicular dislocation. Return to sports takes 3 to 4 months.
Photo 3: Right clavicular (diaphyseal) fracture
Photo 4: Porosis after a right clavicular fracture
Associate Professor, the Department of Regional Medicine, Teikyo Heisei University
A certified athletic trainer from the Japan Sport Association, a practitioner of acupuncture and a massage practitioner
On-site evaluation and first aid
Ask the patient about the mechanism of injury (the movement that caused the injury), the ability to move the shoulder joint (the athlete should be careful not to actually move), and the presence of pain during exercise. Next, let the patient expose the area around the shoulder joint to check deformity and the area of tenderness. Tenderness, protrusion, and exercise pain at the joint are seen in dislocation of the acromioclavicular joint. Clavicular fractures may cause deformity (poorly defined clavicle contours compared with the unaffected side), inability to move the shoulder joint, and severe pain during exercise. First aid involves fixation with a sling or holder, and the patient should seek medical attention.
Start with improvement of a limitation in range of motion of the shoulder joint due to long-term fixation. In this time, I would like to introduce “building scapula motion”, which is an introduction of range of motion. Once scapular movements are improved, the shoulder joint (scapula and humerus) movements will be smoothly. Movement building proceeds progressively from simple to complex movements in a step-by-step manner. Complex movement must be improved, when making throwing movement and swing movement in racket sports.
Pattern of active movement
1. Abduction (open scapula)
Adduction (pull scapula)
2. Lift up
3. Upward rotation (abduction of the shoulder joint)
Downward rotation (adduction of the shoulder joint)
4. Shoulder rotation
Rotate the shoulder as much as possible by applying the hand to the shoulder and making move from the scapula.
Perform the movements from backward to forward, and then forward to backward.
* The parentheses indicate movement of scapula, and the arrows indicate the direction of motion.
1. Anterior elevation (elevation, abduction, and upward rotation)
2. Posterior depressor (depressor, adduction, and downward rotation)
3. Posterior elevation (upward elevation, adduction, and upward rotation)
4. Anterior depressor (depressor, abduction, and downward rotation)