Conservative Treatment of Grade III Acromioclavicular Joint Dislocation

INTRODUCTION

Dislocation of Acromioclavicular (AC) joint is a common injury representing about 9% of all shoulder injuries¹.  Rockwood² classified AC joint dislocation into six types. He reported that classification Tossy et al³ did not provide adequate categorization of all patterns of injury. The ISAKOS (International Society of Arthroscopy, Knee Surgery &Orthopaedic Sports Medicine) modify Rockwood classification by further subdividing the type III AC joint injuries into type IIIA (stable) and type IIIB (unstable).⁴

Radiographic examination includes anteroposterior, axillary views. and zanca views. A cross-body adduction radiograph (so-called Basamania view) was reported to differentiate between a stable and unstable AC joint.⁴ Across body adduction AP view of the AC joint is used to assess the degree to which the clavicle overlaps the acromion because of the anteromedial translation of the scapula. If the clavicle overrides the acromion in this view, it indicates instability of the CC ligaments in addition to the AC joint disruption.⁴

Type1and II dislocations treated conservatively. ^2,4,5,6 The acute types IV-VI dislocation generally require surgical repair.^4,7,8,9 Management of acute type III injuries has been controversial, despite randomized trials that indicate success with nonoperative treatment in most cases.^2,4,5,7,9 A recent operative treatment includes repair of CC ligaments  augmented with metallic buttons or either by arthroscopic or open surgery.^9,10  

PATIENTS AND METHODS

This prospective study was approved by ethical committee of Al-Azhar university included 15 patients with Rockwood type III acute AC joint dislocations. They treated conservatively at the department of orthopedic and traumatology Al-Azhar university hospitals during the period from July 2018 to June 2019.

We included fifteen patients with recent grade lll acromio-clavicular joint dislocation, other grades excluded; also, patients with chronic AC dislocation and dislocation associated with fractures around shoulder excluded.

The study included fourteen men and a woman, with a mean age of 29.7 ±10.2years (17–54 years). In nine cases the dislocation had been caused by an accidental fall during working activities, three cases sustained in road traffic accident, and three cases while practicing sport activities. Ten patients were manual workers with overhead activities and 5 patients had sedentary life.

All the patients underwent complete general and local clinical examination (Fig. 1). We followed the patients for pain, activity level, arm positioning, strength of abduction in pounds, and range of motion according to Constant score.¹¹ Radiographic examinations (Antero-posterior view showing both shoulders (Fig. 2), and Axillary view)(Fig. 3) were done to assess type of dislocation. Coraco-clavicular distance was measured bilaterally in AP view from most superior point of the base of coracoid process to the inferior surface of the clavicle (Fig. 2). Coraco- clavicular distance difference (CCDD) (which represents the absolute difference in displacement between injured and non-injured sides) was measured at time of trauma and after 6 months follow up.

Fig. 1: Acromio-Clavicular (AC) joint dislocation-left shoulder

Fig.2: Antero-posterior view showing both shoulders with red arrows at coraco-clavicular distance.

Fig. 3: Axillary View

Non operative treatment consisted of sling support , ice applied for the first 48 hours, symptomatic treatment with nonsteroidal anti-inflammatory medication, and early mobilization of fingers, elbow and wrist . Patients instructed to avoid overhead use of the arm .After the 2 weeks the arm sling discontinued as symptoms subside and strengthening exercises are instituted. Consideration of range of motion, strength, and pain assisted in determining when the patient may return to unrestricted activity. Rehabilitation involved range of motion and isometric exercises progressing to isotonic exercises. Closed chain exercises performed in order to separate scapular movement into individual motions. Our result was evaluated by Wilcoxon signed ranks test and Paired t-test, P value ≤ 0.05 was considered statistically significant

RESULTS

All the patients were followed for 6 months. Functional outcomes were recorded at the time of trauma and after 6 months from the onset of injury. The mean Constant score improved from39.6 ± 8.2at the time of trauma to 87.3 ± 10 after 6 months follow up with statistically significant difference (p < 0.001) (Table 1).

Clinically, 10patients had no pain, 2 patients had mild pain and 3 patients had moderate pain. Full forward flexion in 12 patient and 3 patients had forward flexion up to 150ْ. 10 patients had full work and 5 patients had moderate limitation of daily activities. The cross-body adduction test was negative in 13patients. The mean of CC distance difference improved from 58 ± 18.8% at time of trauma to 39.7 ± 8% after 6 months of conservative treatment with statistically significant difference (p < 0.006) (Table 2). Eleven out of fifteen patients were satisfied. The main complains of the unsatisfied patients were residual pain, especially at carrying heavy objectives and above head activities and residual deformity. The four patients underwent intraarticular injection with corticosteroids, 2 patients were satisfied with injection and 2 patients were not. One patient underwent operative treatment in the form of open reconstruction of coracoclavicular ligament using autograft and Tight Rope.

We found that the result of conservative treatment in patient involved in sports and works with overhead activities is less good than those had sedentary life with statistically significance (p0.030). There was no statistically correlation between the age and Constant Score (p0.269), however the age inversely proportional to the Constant Score. There is a statistical correlation between the time passed till 1st presentation and the constant score after 6 months (p <0.001) patients early treated give best result. There is statistical correlation between CC distance at time of trauma and Constant Score after 6 months (p 0.002). The more the CC distance the less the Constant score.

Table (1): Data and clinical outcome of fifteen patients with conservative treatment of acute AC joint dislocation grade III.

Table (2) :Coraco-clavicular distance difference (%) at time of trauma trauma and after 6 m. follow up