Acromioclavicular disjunctions

The shoulder is a joint: it is composed of 3 bony parts: the clavicle, part of the shoulder blade and part of the humerus. These parts are bound by ligaments and covered by a muscular cap that ensures its stability.
The clavicle is the connecting bone between the sternum (beginning of the rib cage) and the shoulder blade.
The acromioclavicular joint is the joint between the shoulder blade and the clavicle. It is maintained stable by 2 ligaments, the conoid ligament and the trapezoid.
If one of the means of stabilizing the clavicle is affected, it is called acromioclavicular disjunction.
Acromioclavicular disjunction most often occurs during a direct trauma such as a bicycle fall or a violent impact during a sport (rubgy, judo and combat sport, snowboard etc…).
Depending on the severity of the impact, the inclination of the shoulder, the energy, the clinical picture ranges from a simple sprain to a disjunction or complete dislocation of the joint.
When this trauma causes a rupture of one or more ligaments, the humerus head is lowered. The shoulder appears to be lowered and a small bone projection under the skin is then visible at the clavicle.
There are different stages of gravity depending on the damaged structures and the extent of clavicle displacement and mobility.
A distinction is made between low-grade sprains (stage I and II) resulting from incomplete ligament lesions and high-grade sprains (stage III, IV and V) resulting from complete and significant damage to caspulo-ligamentary structures.
**What are the symptoms? **
Symptoms are dominated by painful impotence of the shoulder and upper limb. The skin trace of the impact zone is often found with sometimes dermabrasion in front of it.
There is a deformation of the upper surface of the shoulder with a prominent appearance of the lateral end of the clavicle under the skin. The extent of the deformation varies according to the severity of the lesions. Shoulder mobilization is painful or even impossible.

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X-rays are used to confirm the diagnosis and determine the severity of the condition:
It is necessary to carry out a frontal radiography of the acromioclavicular joint and 3 dynamic images: in external rotation and abduction at 90°, one image which tends to reduce the deformation and one image under load which tends to increase the deformation.
If surgical treatment is proposed, must be performed in addition to the x-rays:
A complete biological check-up with a blood group, an electrocardiogram and an appointment with the anaesthetist.
No medication containing aspirin should be taken within ten days of the operation. You will probably be asked to fast (do not eat or drink anything) six hours before the procedure. Quitting smoking is mandatory.

Treatment depends on the movement of the collarbone. Scores, including the ROCKWOOK score, are used to assess movement and determine treatment.
Medical treatment:
It's a pain management treatment. There is no correction of the deformation.
The doctor prescribes analgesics (pain treatment) and anti-inflammatory drugs. A splint is imperatively prescribed for a minimum period of 15 days.
The splint should be worn as long as possible but can be removed in a sitting or lying position.
Surgical treatment:
The procedure is performed under general anesthesia, which is often combined with local-regional anesthesia. This prevents pain during the procedure and also prevents pain for about 20 hours after the procedure.
The procedure takes place in a semi-seated position as if you were in a deckchair. The duration of the operation varies according to the procedures to be performed. Before going back up to your room, you will pass through the recovery room where a control X-ray will be taken.
The hospitalization lasts 48 hours on average (you enter the day before the operation and leave the next morning).
It is the treatment that restores the anatomy of the shoulder. There are several techniques either by open surgery (conventional technique) or arthroscopy (without opening) which must in both cases be performed after reduction and stabilization of the clavicle.
The acromioclavicular pinning:
This technique is performed in the open air and consists of placing a pin between the clavicle and the acromion to stabilize the joint. A second procedure is required to remove the pins 6 to 8 weeks after the first procedure.
The artificial ligament:
After reduction and stabilization of the collarbone, an artificial ligament is used to permanently stabilize the collarbone. It is performed by arthroscopy.
A small incision is made on the top of the shoulder. The clavicle and coracoid are exposed. An anchor is screwed to the coracoid. The wires mounted on this anchor are passed through the clavicle through small tunnels.
It is then sufficient to reduce the collarbone to its natural position and tie the wires between them to hold the collarbone in place. The ruptured ligaments can then heal in the right position and permanently stabilize the acromioclavicular joint.

The hospitalization is very short: it lasts on average 24/48 hours. If the surgical treatment was performed in the open, hospitalization may require an additional 24 to 48 hours.
During this hospitalization, care and supervision are provided by the medical and paramedical team.
A physiotherapist assists in the transition from lying down to sitting and walking and shows precisely all permitted and prohibited gestures.
An elbow scarf is prescribed for a period of 6 weeks. Gentle rehabilitation is prescribed except for temporarily placed braces.
The removal of the threads takes place between the tenth and fifteenth day.
The post-operative consultation with the surgeon is scheduled 8 days after the operation. This allows him/her to evaluate the postoperative consequences: local (scars, edema), regional (shoulder flexibility, inflammation) and general (pain, fever, asthenia).
Rehabilitation by specialized physiotherapists is then prescribed by the surgeon 3 times a week for a period of about 4 months, which is necessary for a satisfactory functional recovery.
Activities of daily living can be resumed from the 4th week and sports activities from the 6th week.
In the medium and long term, a resumption of normal sporting activities is possible.

About Acromioclavicular disjunctions

Apart from the risks related to anesthesia, there are some risks specific to this type of surgery:
• A risk of capsulitis or algodystrophy of the shoulder (stiffness and pain).
• A low but still present risk of infection (5%)
• A risk of hematoma or post-operative bleeding.
The usual duration of rehabilitation is 3 to 4 months after this type of intervention.
The return to work depends on the type of occupation. For manual force workers, the average time is from 4 months to 6 years. For other professions, work can be resumed earlier.
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