Separated shoulder

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A Separated Shoulder XRay modified to easily show bones. Notice the separation between the end of the collarbone and the scapula.

[edit] Overview

A separated shoulder, otherwise known as an acromioclavicular separation or AC separation, is a common injury to the acromioclavicular joint. This is not the same as a "shoulder dislocation" as that involves a dislocation of the Glenohumeral joint This occurs often in sports like football, soccer, horseback riding, hockey, mountain biking, and biking. The dislocation is classified into 6 types, with 1 through 3 increasing in severity, and 4 through 6 being the most severe. The most common mechanism of injury is a fall on the tip of the shoulder or also a fall on an outstretched hand (FOOSH). In falls where the force is transmitted indirectly, often only the acromioclavular ligament is affected, and the coracoclavicular ligaments remain unharmed.^[1] In hockey, the separation is sometimes due to a lateral force, as when you get forcefully checked into the side of the rink. ^[2]

[edit] Types

[edit] Type I

A Type I AC dislocation involves trauma to the ligaments that form the joint, but no severe tearing or fracture. It is commonly referred to as a sprain. Most doctors treat this type of dislocation with anti-inflammatory drugs and the placement of the arm in a sling.

[edit] Type II

A Type II AC dislocation involves complete tearing of the acromioclavicular ligament, as well as a sprain or partial tear of the coracoclavicular ligaments. This often causes a noticeable bump on the shoulder. By pressing on the sternal aspect of the clavical you force the acromial end down, and by releasing, watch it pop back up (eliciting a piano key sign due to the tearing of the AC ligament)^[3]. Severe pain and loss of movement are common. Treatment is typically an arm sling, bedrest, ice and heat therapy, and anti-inflammatory drugs. Most people recover full motion of the shoulder and arm within 6 to 8 weeks, often with the assistance of physical therapy.

[edit] Types III, IV, V and VI

More severe and less treatable are type 3 through 6 separations. These involve the complete tearing of the ligaments at the AC joint and those under the scapula that hold the shoulder in place, leaving the clavicle bone floating. A significant bump appears and movement may be very restricted. Pain can also be very severe. Many doctors will not do surgery on a type 3 separation as it is debatable how effective the surgery is. Types 4 through 6 involve tearing of the surrounding muscle tissue and severe misplacement of the clavicle in various directions. AC separations of type 4 through 6 always result in surgery.

[edit] Current Treatment options

[edit] Non Surgical

Most non-surgical treatment options include physical therapy to build up the muscles around the joint, helping stablize the joint. Literature regarding long-term follow-up after surgical repair of type III injuries is scarce, and those treated nonoperatively generally do quite well. ^[4] Many studies ^[5] ^[6] ^[7] ^[8] ^[9] have come to the conclusion that non-surgical treatment is as good or better than surgical treatment, or that anything attained because of surgery is quite limited.^[9] It appears that after a while, the body "remodels" the joint, either expanding the distal clavicle or causing it to atrophy. ^[10] One study suggests that quarterbacks with type III injuries on their dominant side may possibly do better with surgery. ^[11] There may also be the potential that surgical repair may be less painful in the long run. .^[9] ^{[citation needed]}

[edit] Surgical

Type 2 separations have always been treated non-surgically, initially. However, the risks of arthritis with type 2 separations are greatly increased. If this becomes severe, the Mumford procedure or distal clavicle excision can be performed.

There have been many surgeries described to fix complete acromioclavicular separations, including recently arthroscopic. There is no consensus on which surgery is best. Several surgeries have been described with pins or hooks^{[citation needed]}. Another surgery performs muscle transfer ^{[citation needed]}

A common surgery is some form of Modified Weaver-Dunn, which involves cutting off the end of the clavicle portion, partially sacrificing the coracoacromial ligament and suturing the displaced acromial end to the lateral aspect of the clavicle for stabilization, then often some form of additional support is introduced to replace the coracoclavicular ligament(s). Variations of this support includes grafting of tendons from the leg ^[12] or the use of synthetic sutures or suture anchors^[13] . Other surgeries have used a Rockwood screw that is inserted initially and then removed after 12 weeks. Physical therapy is always recommended after surgery, and most patients get flexibility back, although possibly somewhat limited.