KANOKKORN NAVAMAJ IT I RA5402002

ORTHOPAEDICS CONFERENCE

ผปวยชายไทย อาย 78 ป No underlying diseaseCC : ปวดไหลขวา 5 วนกอนมาโรงพยาบาล

PRIMARY SURVEY

A : can speak, patent airway, c-spine not tenderB : no dyspnea, trachea in midline, no CW wound, equally chest movement, equally breath sound, no subcutaneous emphysema, CCT negativeC : BP 160/80 mmHg, PR 67 bpm, no site of external bleedingD : E4V5M6, pupil 3 mm RTLBE E : deformity Rt. shoulder

SECONDARY SURVEY

A : no drug/food allergyM : no medication usedP : no underlying diseaseL : NPO time 10.30 amE : 5 วนกอนมาโรงพยาบาล ขจกรยาน ลมเอง ไหลขวากระแทกพน เจบไหลขวา ยงขยบได แตยกแขนไดไมสด ไหลขวาบวมมากขน เรมยกแขนลำาบาก กนยาแกปวดทบาน อาการไมดขน จงมาโรงพยาบาล

SECONDARY SURVEYHead-to-toe examinationV/S – T 37c, BP 160/80 mmHg, PR 67 bpm, RR 20/minHEENT – not pale conjunctiva, anicteric sclera, no scalp contusionHeart – normal S1S2, no murmurLungs – equally breath sound, clear, no adventitious soundAbdomen – no contusion, no distension, soft, not tender, BS+Extremities – Rt shoulder deformity+, tender at AC and CC joint limit Abduction due to pain full Adduction, F/E, ER/IR Radial pulse 2+

ORTHOPAEDICS CONFERENCE

ACROMIOCLAVICULAR JOINT INJURY

ANATOMY

o Contains intra-articular disk of variable size.

o Thin capsule stabilized by ligaments on all sides:

Coracoclavicular ligaments Stronger than AC ligaments Provide vertical stability to AC joint

MECHANISM OF INJURY

PHYSICAL FINDINGS

•Pain over lateral clavicle / AC joint•May have prominent distal clavicle•May have skin abrasions•Unwilling to lift arm.•Should have full passive ROM of the shoulder.

PHYSICAL EXAMINATIONInspection

Evaluate deformity and/or displacementBeware of rare inferior/posterior displacement of distal/medial ends of clavicleCompare to opposite side.PalpationEvaluate pain / Look for instability with stress

Neurovascular examinationMust be done thoroughly and documented!

Evaluate upper extremity motor and sensationMeasure shoulder range-of-motion

RADIOGRAPHIC EVALUATION OF THE CLAVICLE

Anteroposterior View

Transcapular Y-View

RADIOGRAPHIC EVALUATION OF THE AC JOINT

Zanca View• AP view centered at AC joint

with 10 degree cephalic tilt• Less voltage than used for AP

shoulder

Axillary lateral View

demonstrate instability and differentiate grade III AC separations from partial Grade I-II injuries.Performed by having patient hold 10# weight with injured arm.Rarely used today, since most Grade I-III AC joint injuries are treated the same anyway, and management of distal clavicle fractures depends on initial displacement and location of fracture.

RADIOGRAPHIC EVALUATION OF THE AC JOINT

Stress Views of the Distal Clavicle & AC Joint

RADIOGRAPHIC EVALUATION OF THE ACROMIOCLAVICULAR JOINT

• Proper exposure of the AC joint requires one-third to one-half the x-ray penetration of routine shoulder views• Initial Views:• Anteroposterior view• Zanca view (15 degree cephalic tilt)

• Other views:• Axillary: demonstrates anterior-posterior displacement• Stress views: not generally relevant for treatment

decisions.

CLASSIFICATIONInitially classified by both Allman and Tossy et al. into three types (I, II, and III).

Rockwood later added types IV, V, and VI, so that now six types are recognized.Classified depending on the degree and direction of displacement of the distal clavicle.

CLASSIFICATION

TREATMENT OPTIONS TYPES I - II ACROMIOCLAVICULAR JOINT INJURIES

Non-operative treatment• Ice and protection until pain subsides (7 to 10 days).• Return to sports as pain allows (1-2 weeks)• No apparent benefit to the use of specialized braces.

(Type II) operative treatment• Generally reserved only for the patient with chronic

pain.• Treatment is resection of the distal clavicle and

reconstruction of the coracoclavicular ligaments.

TREATMENT OPTIONS TYPE III-VI ACROMIOCLAVICULAR

JOINT INJURIES• Nonoperative treatment• Closed reduction and application of a

sling and harness to maintain reduction of the clavicle• Short-term sling and early range of

motion• Operative treatment• Primary AC joint fixation• Primary CC ligament reconstruction

(usually with allograft, often with augmentation)• Excision of the distal clavicle • Dynamic muscle transfers

Type III Injuries **• Need for acute surgical treatment

remains very controversial.• Most surgeons recommend conservative

treatment except in the throwing athlete or overhead worker.• Repair generally avoided in contact

athletes because of the risk of reinjury.

LITERATURE UNABLE TO SUPPORT OPERATIVE OR NONOPERATIVE TREATMENT AS SUPERIOR

• Functional outcomes appear similar.• Cosmesis not different (scar vs bump)• Only 50% of surgical cases reduced at follow-

up.• 10% complications after surgery.

Ceccarelli et al. J Orthopaed Traumatol 2008;9:105-108.

INDICATIONS FOR ACUTE SURGICAL TREATMENT OF ACROMIOCLAVICULAR INJURIES

• Type III injuries in highly active patients• Type IV, V, and VI injuries

SURGICAL OPTIONS FOR AC JOINT INSTABILITY

• Coracoid process transfer to distal transfer (Dynamic muscle transfer)• Primary AC joint fixation• Primary Coracoclavicular Fixation• CC ligament reconstruction +/- distal

clavicle excision.

WEAVER-DUNN PROCEDURE

• The distal clavicle is excised.• The CA ligament is

transferred to the distal clavicle.• The CC ligaments are

repaired and/or augmented with a coracoclavicular screw or suture.• Repair of deltotrapezial

fascia

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997

INDICATIONS FOR LATE SURGICAL TREATMENT OF ACROMIOCLAVICULAR INJURIES

• Pain•Weakness•Deformity

TECHNIQUES• Reduction of AC joint and repair of AC and CC

ligaments• Resection of distal clavicle and reconstruction

of CC ligaments (Weaver-Dunn Procedure)

THIS PATIENT

• Advice คนไข ขอลอง conservative (ปฏเสธการผาตด)• On arm sling• Pain control – Tramadol, Paracetamol• นด follow up 9/1/60 + film