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Sport FRCS > AC pathology > Flashcards

AC pathology Flashcards

Acromium-clavicular injuries- separation distal clavicle osteolysis ac arthritis

1
Q

What is the epidemioogy of AC separation ?

A
  • Common Injury making up 9% shoulder girdle
  • More common in males
  • mechansim
    • direct blow to the shoulder
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2
Q

What is the presentation of ac separation?

A
  • Pain
  • palpable lateral clavicle and ACJ tenderness
  • ap stability assess ac ligament
  • vertical stability assess Coracoclavicular ligament
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3
Q

What is seen on radiographs of AC separation?

A
  • Bilateral AP
    • measure from top of coracoid to bottom of clavicle
  • axillary lateral
    • to dx type iv
  • zanca view
    • tilt beam 10-15o towards cephalic direction adn use only 50% of standard shoulder ap penetration strength
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4
Q

Describe the classification of AC joint separation?

A
  • Rockwood

Type1- sprain AC normal CC no displacment = sling

Type 2- Torn AC/sprain CC-slight increase in CC = sling

Type 3- Torn AC/CC- cc distance 25-100%= contraversial tx

Type 4- torn AC/CC- lateral end clav displ post= surgery

Type 5- torn AC/CC- CC distance >100%= surgery

Type 6- torn AC/CC- displaced inferior= surgery

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5
Q

What is the tx for ac separation injury?

A
  • Type 1-2 , 3 most individuals
    • ice, rest , sling 3/52
    • early rom
    • regain functional motion 6/52
    • return to normal activity 12 weeks
    • complx
      • ​acj arthritis
      • chronic subluxation & instability
  • ​Type 3 labourers/elite athletes types 4-6
    • ORIF or ligament reconstruction
    • sling immobilisation without abduction 6/52
    • no shoulder rom 6/52
    • general return to full activity 6/12
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6
Q

Describe the types of surgical orif fixation?

A
  • ORIF w CC screw fixation
    • prox aspect of anterolateral approach to shoulder
    • superior to inferior screw from distal clavicle to coracoid
    • rigid internal fixation, danger of screw being too long & damage critical structure below
    • Complx: hardware irriation or failure
  • ORIF w CC suture fixation- endobutton
    • suture thru clavicle or around adn arounn base of coracoid
    • no risk of hardware failure or migration
    • suture not as strong as screw fixation
    • complx suture erosion
  • ORIF w hook plate
    • exposure of distal & middle clavicle
    • use of standard hook plate over superior distal clavicle
    • rigid fixation, usually requires 2nd surgery for plate removal
    • high rate of acromial erosion
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7
Q

describe the types of ligament reconstruction for acj separation?

A
  • CC ligament reconstruction= modified Weaver -Dunn
  • http://www.shoulderdoc.co.uk/article.asp?article=666
    • proximal aspect of anterolateral approach to the shoulder
    • arthroscopic also
    • distal clavicle excised
    • transfer of coracoacromial ligament to distal clavicle to recreate CC ligament
    • combined with internal fixation
    • coracoacromial lig only 20% as strong as normal CC ligament
    • lack of internal fixation risks failure of soft tissue repair
  • CC ligament reconstruction w free tendon graft- semitendinosus
  • http://www.orthobullets.com/video/view?id=484
  • figure of 8 passage of graft from distal clavicle to coracoid
  • graft reconstruction more closely recreates the strength of native cc ligament
  • standard risks of allograft use or autograft harvest
  • lack of internal fixation risks failure of soft tissue repair
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8
Q

What approach would you use to gain access to acj ?

A
  • anterolateral Incision- from ACJ /lateral edge of clavicle towards coracoid- see pic
  • No internervous plane
  • Thru deltoid superifical fascia
  • acromial branch of thoracromial artery must be ligated when encountered deep to deltoid, ne ACJ
  • Split thru deltoid, prox to axillary nerve- no internervous plane
  • detach coracoacromial ligament close off acromium
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9
Q

Describe distal clavicle osteolysis?

A
  • Commonly seen in weight lifters
  • hx of traumatic injuries
  • caused by repetitive micro-fx in distal clavicle which leads osteopenia
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10
Q

Describe the ostetology of clavicle?

A
  • S shpaed clavicle
  • last bone to ossify
  • medial growth plate fuses early 20s
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11
Q

Describe the symptoms of clavicle osteolysis?

A
  • Pain at distal clavicle

O/E

  • tenderness at distal end of clavicle
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12
Q

What is seen on imaging of distal clavicle osteolysis?

A
  • Ap clavicle
    • cysts at distal end of clavicle
    • osteopenia
    • tapering of distal clavicle
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13
Q

What is the tx of distal clavicle osteolysis?

A
  • Nonoperative
    • Activity modification, corticosteriod injections, NSAIDS
      • first line
      • quit weight lifitng or move arms further apart
  • Operative
    • Open or arthroscopic distal clavicle excision
    • failed non op tx
    • only resect 0.5-1cm distal clavicle- preserve ligaments
    • leave space that fills with scar tissue
    • arthroscopic adv allowing evaluation of GH joint
    • gd result w arthroscopic
    • open proceedure require meticulous repair of deltoid-trapezial fascia
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14
Q

Can you describe AC arthritis?

A
  • Caused by transmission of large loads through a small contact area
  • more common with age but seen in 20 yrs
  • risk factors
    • Prior AC separation
    • weightlifters/ overhead throwing athletes
  • Assoc conditions
    • distal clavicle osteolysis
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15
Q

Dsecribe the role of AC joint?

A
  • articulates scapula to clavicle
  • contains fibrocartilaginous disc
  • Ac ligaments
    • provide ant-post stability
    • posterior and superior AC igaments most important for stability
  • Coracoclavicular ligaments
    • provide superior-inferior stability
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16
Q

What is the presentation of AC arthritis?

A
  • Activity related pain
    • overhead activity
    • arm adducted

O/E

  • Pain with direct palpation of ACJ
  • pain with cross body adduction
17
Q

What is seen on imaging for AC arthritis?

A
  • Xray
    • Zanca view best- 15o cephalic tilt
    • osteophytes and jointspace narrowing
    • distal clavicle osteolysis
    • imaging findings don’t always correlate with symptoms
  • MRI
    • Increae signal and oedema of ACJ
18
Q

What is the tx for AC arthritis?

A

Non operative

  • activity modification and physio
    • 1st line
    • strengthening and stretching shoulder girdle
  • ACJ injection with corticosteriods
    • can be diagnostic and therapeutic

Operative

  • Arthroscopic vs open distal clavicle resection ( Mumford proceedure)
19
Q

What are the complications of surgery for ACj arthritis?

A
  • AC joint Instability
    • anterior-posterior instability
      • due to too aggressive surgical distal clavicle resection >1-1.5cm
      • due to sacrificing posterior and superior AC ligaments
    • superior- posterior instability
      • usually itraogenic due to too aggressive resection compromising coracoclavicular ligaments
  • Continued pain post surgery
    • failure of post-superior resection of distal clavicle
  • Heterotrophic ossification
  • deltoid dehiscence
    • in open surgery when poor deltoid-trapezoid repair

Sport FRCS (26 decks)

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