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Shoulder Separation

• Shoulder separation is not truly an injury to the shoulder joint.

• The injury actually involves the acromioclavicular joint (also called the AC joint).

What type of Injury?

AC Separation

• The most common cause for a separation of the AC joint is from a fall directly onto the shoulder.

• The fall injures the ligaments that surround and stabilize the AC joint.

Injury

If the force is severe enough, the ligaments attaching to the underside of the clavicle are torn. • This causes the

"separation" of the collarbone and wingbone.

• The wingbone actually moves downward from the weight of the arm.

• This creates a "bump" or bulge above the shoulder.

Injury• injury can range from a little

change in configuration with mild pain, to quite deforming and very painful.

• Good pain-free function often returns even with a lot of deformity.

• The greater the deformity, the longer it takes for pain-free function to return

Types of Separation• .

• A mild shoulder separation involves a sprain of the AC ligament that does not move the collarbone and looks normal on X-rays.

• A more serious injury tears the AC ligament and sprains or slightly tears the coracoclavicular (CC) ligament, putting the collarbone out of alignment to some extent.

Severe Separation

• The most severe shoulder separation completely tears both the AC and CC ligaments and puts the AC joint noticeably out of position.

Injury

• Injury is easy to identify when it causes deformity.

• When there is less deformity, the location of pain and X-rays help the doctor make the diagnosis.

• Sometimes having the patient hold a weight in the hand can increase the deformity, which makes the injury more obvious on X-rays.

Timeout

Symptoms

• Pain at the end of the collar bone

• Pain may feel widespread throughout the shoulder until the initial pain resolves, following this it is more likely to be a very specific site of pain over the joint itself

• Swelling often occurs

Symptoms

• Depending on the extent of the injury a step-deformity may be visible. This is an obvious lump where the joint has been disrupted and is visible on more severe injuries

• Pain on moving the shoulder, especially when trying to raise the arms above shoulder height

Cross Body Adduction Test

What is Paxinos Sign?

Paxinos Sign

• Pushes the acromium into the clavicle with the thumb

• Positive if there is pain increases

• AC joint injuries are graded from 1-6 using the Rockwood scale which classifies injuries in relation to the extent of ligament damage and the space between the acromion and clavicle

What is Rockwood Scale?

Rockwood Scale

• Separated shoulders are graded according to the severity of the injury and the position of the displaced bones.

• Shoulder separations are graded from type I to VI:

Grades• Grade 1 is a simple sprain to

the AC joint, grade 2 involves rupture of the AC ligament and grade 3 rupture of both AC and CC ligaments which often results in a superior displacement.

• From this point onwards the scale and grade of injury depends on the degree of displacement of the clavicle.

Type I Shoulder Separation

• Injury to the capsule that surrounds the AC joint.

• The bones are not out of position and the primary symptom is pain.

• • Sprain of

acromioclavicular ligament only

Type II Shoulder Separation

• Involves an injury to the AC joint capsule as well as one of the important ligaments that stabilizes the clavicle.

• This ligament, the coracoclavicular ligament, is partially torn.

• Patients with a type II separated shoulder may have a small bump over the injury.

• Acromioclavicular ligaments and joint capsule disrupted. Coracoclavicular ligaments intact. 50% vertical subluxation of clavicle.

Type III Shoulder Separation

• Involves the same type of injury as a type II separated shoulder, but the injury is more significant.

• These patients usually have a large bump over the injured AC joint.

• Acromioclavicular ligaments and capsule disrupted.Coracoclavicular ligaments disrupted. Acromioclavicular joint dislocation with clavicle displaced superiorly and complete loss of contact between clavicle and acromion.

• Grade 4, 5, and 6 separations are severe injuries with high degree of displacement of the clavicle with respect to the acromion and usually require surgery.

Type IV Shoulder Separation

• A type IV shoulder separation is an unusual injury where the clavicle is pushed behind the AC joint.

• Type V Shoulder Separation:

• A type V shoulder separation is an exaggerated type III injury. In this type of separated shoulder, the muscle above the AC joint is punctured by the end of the clavicle causing a significant bump over the injury.

Type VI Shoulder Separation

• Rare.

• In this type of injury the clavicle is pushed downwards, and becomes lodged below the corocoid (part of the scapula

• Acromioclavicular ligaments and capsule disrupted. Coracoclavicular ligaments disrupted.

• Acromioclavicular joint dislocation and clavicle displaced posteriorly into or through trapezius muscle (posterior displacement confirmed on axillary radiograph)

• Grade 4 involves posterior displacement and grade 5 superior displacement, to a greater degree than grade 3, with an increase in coracoclavicular space by 3-5 times the norm.

• • A step deformity may be

apparent with grade 3, 4 & 5 injuries.

Grade 6

• involves full rupture of both AC and CC ligaments with the clavicle being displaced inferiorly.

Treatment

• Whether treated conservatively or with surgery, the shoulder will require rehabilitation to restore and rebuild motion, strength, and flexibility.

Treatment – depend on the type of injury

• The initial treatment of a separated shoulder consists of controlling the inflammation, and resting the joint.

Icing the Injury

• The inflammation from a separated shoulder can be controlled with ice placed on the joint every four hours for a period of 15 minutes.

• Icing can be done for the first several days until the swelling around the joint has subsided.

Rest the AC joint

• A sling to rest the joint can be worn until the pain has subsided and you can begin some simple exercises. Resting the joint will help minimize painful symptoms and allow healing to begin.

Anti-inflammatory Medication

• Anti-inflammatory medication such as Advil or Motrin will also help to minimize the pain and inflammation--check with your doctor before using these medications.

Grade I and II Injuries

• underestimated and may lead to more chronic disability than previously recognised

• especially in athletes and heavy labourers who stress their shoulder daily.

• • Some late surgery as AC joint resection arthroplasty may be

needed.

• However, more than 50% of the patients having a good or excellent shoulder 6 years after injury.

Surgery• not in most cases.

• Type I and type II shoulder separations are by far the most common types of separated shoulders, and these types of injuries rarely need surgery--and only if there are problems with non-operative treatment.

• Type IV, V, and VI shoulder separations almost always require surgery, but these are very uncommon injuries.

• The difficult decisions arise with patients with a type III shoulder separation. There is controversy among orthopedic surgeons as to how to best manage patients with a type III shoulder separation.

• there is no 'right answer,'

Surgical Treatment

• Surgery can be considered if pain persists or the deformity is severe.

• A surgeon might recommend trimming back the end of the collarbone so that it does not rub against the acromion.

• Where there is significant deformity, reconstructing the ligaments that attach to the underside of the collarbone is helpful.

• This type of surgery works well even if it is done long after the problem started.

Non-Surgical Treatment for type III Shoulder Separations...

• Most evidence suggests that patients with type III shoulder separations do just as well without surgery, and avoid the potential risks of surgical treatment.

• These patients return to sports and work faster than patients who have surgery for this type of injury.

Type III and IV• Furthermore, AC joint instability symptoms may persist, with

impingement symptoms secondary to the drop down of the shoulder and the abnormal biomechanics.

• Patient may complain of severe deformity in the AC joint and traction symptoms with neck pain and neural brachial plexus symptoms.

• There is significant decrease (24%) in horizontal abduction strength at fast speeds.

• However, overall 87% with type III dislocation showed satisfactory outcome with conservative treatment of ‘Skilful neglect’.

•

Surgery for type III Shoulder Separations...

• Recent studies have suggested that some athletes and heavy laborers may benefit from early surgical treatment of type III shoulder separations.

• These include athletes who participate in sports that require overhead throwing such as baseball.

• The potential benefit of early surgical treatment for type III shoulder separations remains unproven.

Physiatric Prescription?