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Acromioclavicular (AC) Joint & Sternoclavicular (SC) Joint Injuries

Mizuho Spangler, DO, Matthew DeLaney, MD, and Rick Pescatore, DO
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Rick, Miz, and Delaney discuss how we can do a better job of looking for injuries to the SC and AC joints that require unique consideration, treatment, or intervention.

Pearls:

  • Lacking any neurovascular compromise, skin tinting, or any other indications for immediate operative intervention, patients with Grade I, II, III AC joint separation can be placed in a sling, provided with NSAID analgesia and appropriate follow up.

 

Acromioclavicular Injuries - Background

  • Consider an AC joint injury whenever there is direct injury to an adducted upper extremity. Classically a bicyclist that lands on an adducted shoulder and then complains of pain or deformity around the acromion.

  • Consider adding a chest x-ray because it allows for direct comparison of  the other normal, uninjured shoulder.

  • Grade I and II AC separations will have minimal displacement of clavicle relative to acromion.

  • In Grade III separations, the clavicle is elevated just above the upper border of the acromion on x-ray.

  • For Grade IV, V, and VI, separations are uncommon and result in severe displacement of the clavicle relative to the acromion.

 

Acromioclavicular Injuries - Management

  • Patients with Grade I or II injuries can be placed in a sling and followed up as an outpatient.

  • Patients with Grade III or above need urgent referral to orthopedic surgery.

  • If patients have severe trauma to the joint that's leading to neurologic ( i.e. axillary nerve damage) or vascular compromise send to the ED

  • For Grade  IV, V, or VI consider calling an orthopedist to help expedite outpatient follow up.

  • Lacking any neurovascular compromise, skin tinting, or any other indications for immediate operative intervention, place in a sling and provided with NSAID analgesia

 

Sternoclavicular Injuries - Background

  • Sternoclavicular joint injuries represent less than 1% of shoulder girdle injuries.

  • Posterior SC injuries are associated with high energy trauma so consider other trauma to the chest.

  • Anterior SC dislocations are much more common that posterior dislocations and are caused by a force being applied to the anterolateral aspect of the shoulder.

  • In an anterior injury, the medial aspect of the clavicle is moving forward and away from the mediastinal vasculature which makes them less dangerous.

  • Posterior injuries, however, can cause life-threatening complications due to mediastinal injury and are commonly due the high velocity car accidents where the chest impacts the steering wheel or a a football player that gets speared in the chest

 

Sternoclavicular Injuries - Management

  • If there's a reasonable suspicion of a posterior dislocation, these patients require transfer to a  higher level of care for CT of the chest.

  • Patients with anterior SC dislocations can follow up with their primary care doctors for orthopedic referrals but don’t necessarily need ER transfer

 

REFERENCES:

  1. Chaudhry S. Pediatric posterior sternoclavicular joint injuries. J Am Acad Orthop Surg. 2015;23(8):468-475. (Review article)

  2. R, Riddervold HO, Shore JL, et al. Dislocations of the sternoclavicular joint: anatomic basis, etiologies, and radiologic diagnosis. J Orthop Trauma. 1991;5(3):379-384. (Case series; 3 patients)

  3. Ponce BA, Kundukulam JA, Pflugner R, et al. Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg. 2013;22(7):993-999. (Prospective cohort; 49 patients)

  4. Saccomanno MF, C DEI, Milano G. Acromioclavicular joint instability: anatomy, biomechanics and evaluation. Joints. 2014;2(2):87-92. (Review article)

  5. Chillemi C, Franceschini V, Dei Giudici L, et al. Epidemiology of isolated acromioclavicular joint dislocation. Emerg Med Int. 2013;2013:171609. (Retrospective review; 108 patients)

  6. Cho CH, Hwang I, Seo JS, et al. Reliability of the classification and treatment of dislocations of the acromioclavicular joint. J Shoulder Elbow Surg. 2014;23(5):665-670. (Observational study; 10 subjects)

  7. Pescatore R, Nyce A. Shoulder Injuries in the Emergency Department. Emergency Medicine Practice, June 2018.

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Head, Shoulders, Knees and Toes Full episode audio for MD edition 190:11 min - 91 MB - M4AUrgent Care RAP December 2018 Written Summary 557 KB - PDF

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