Can an acute high-grade acromioclavicular joint separation be reduced and stabilized without surgery? A surgeon’s experience

Abstract

Introduction While the management of Rockwood type III injuries is still a topic of debate, high-grade Rockwood type V injuries are mostly treated surgically, to anatomically reduce the acromioclavicular (AC) joint and to restore functionality. In this case report, we present a method for non-operative reduction and stabilization of a high-grade AC joint injury. Case A 31-year-old male orthopaedic resident sustained a Rockwood type V injury during a snowboarding accident. His AC joint was reduced and stabilized with an AC joint brace for six weeks. The brace provided active clavicle depression and humeral elevation. After removal of the brace the AC joint showed a nearly anatomic reduction. Six-month follow-up weighted X-ray views showed an AC joint which had healed in a Rockwood type II position and the patient returned to full pre-injury function with a satisfying cosmetic appearance. Conclusion Non-operative reduction and stabilization of high-grade AC joint separations seems to be a valuable treatment option. A “closed reduction and external fixation” approach with the aid of a dedicated AC joint brace can reduce the AC joint and keep it in place until ligamentous consolidation occurs, thus improving AC joint stability and cosmetic appearance without surgical intervention.

Operative vs. conservative treatment of AC-Joint Dislocations Rockwood grade ≥ III -An economical and clinical evaluation-

“…Studies have shown higher grade injuries, type Rockwood grade IV-VI, which are associated with complete rupture of all ligament structures and therefore significant instability of the clavicle should be treated operatively [ 7 , 9 ]. Data on conservative therapy attempts for Rockwood grade IV and V injuries are hardly available [ 10 ]. One factor in favor of operative treatment may be a remaining visible protrusion of the clavicle [ 11 , 12 ].…”

Conservative treatment of Rockwood type III acromioclavicular joint separation: a randomized controlled trial sling vs. brace

“…However, the radiological assessment with measurement of the CC index showed only a slight difference without statistical difference in the AC brace group compared to the group treated with a sling at any time of evaluation until 3 months post injury. Maleitzke et al 15 recently published a case report using the same AC brace in a 31-year-old male for a Rockwood V injury. In contrast to our results, they described a nearly anatomic reduction after 6 weeks of immobilization following the same treatment protocol.…”

“… 19 Even though multiple studies have shown good functional outcomes 14 , 23 , 25 the anatomy of the ACJ is not restored and a prominent, potentially cosmetically disturbing or unstable distal clavicle will remain. 4 Recently, a case report 15 on the conservative treatment of a high-grade Rockwood V injury with a brace eliciting depression on the distal clavicle and humeral elevation showed healing of the injury in a reduced Rockwood II position, suggesting the efficacy of such a brace when worn for 6 weeks in combination with a restrictive physiotherapy protocol. Up to date, there is no study looking at the effect of this modern brace in the treatment of Rockwood III injuries in comparison to the standard sling treatment.…”

Morphology of the acromioclavicular-joint score (MAC)

“…Usually failed conservative therapy over a time period of months is the indication for AC-joint resection or resection of the lateral clavicle [ 14 ]. This procedure can be performed either in an open fashion or arthroscopically [ 21 , 28 , 31 ].…”