0:01

This is my rugby friend.

0:04

I never played rugby 'cause I, I liked my teeth.

0:07

But let's take a look at this, uh, rugby player

0:11

who was injured while being toppled by three other large men

0:16

with the typical mechanism of injury.

0:18

And what is that? When you see an athlete go down,

0:21

whether it's on television

0:23

or you're working as a, as a doctor at your, your daughter

0:26

or son's soccer

0:28

or football game, when they go down like this,

0:31

they usually have a dislocation when they go down like this

0:36

and men and women fall on the other shoulder

0:38

and the arm is abducted,

0:41

they usually have a shoulder separation

0:43

and you can tell right away impressing your family members

0:46

while you're watching television, what the injury is.

0:49

So let's look at this acromioclavicular joint separation,

0:53

which we haven't talked much about,

0:56

and you can see a few things here that are relevant to

1:01

the grading or discussion

1:03

or adjectives that you give to ac joint separation.

1:07

The first thing is, what is the relationship

1:09

of the clavicle, uh, to the acromion?

1:13

In some areas it's a little bit higher,

1:15

and in some areas it's a little bit lower, suggesting

1:18

that there's a twisting element.

1:21

What is the status of the adjacent inserting muscles?

1:24

Frequently and overlooked is delamination of the trapezius,

1:28

sorry, delamination of the deltoid of the lateral head

1:31

of the deltoid, which this patient has.

1:34

Sometimes you'll see an injury to the trapezius,

1:37

which this patient has.

1:39

Clinicians like to know this.

1:41

Then another aspect to grading the character

1:45

of an AC joint separation is the status of the capsule.

1:49

We've got the superior capsular ligament,

1:51

which is most vulnerable,

1:53

and it looks like a little stippled arc right here.

1:57

It should be one straight black line.

1:59

And then when we look at the inferior capsular ligament,

2:02

I'm gonna blow it up a little bit so you can see it.

2:04

It's this very irregular looking, uh, linear structure.

2:09

And then we would look at the anterior posterior capsular

2:11

ligaments in the axial projection.

2:14

And they're, they're a little harder to see and,

2:17

and in fact, we don't even see them.

2:19

Uh, they're ruptured. Here's one in the front,

2:21

the back one I do not see.

2:23

And then in the sagittal projection,

2:25

the all important caracal clavicular, post medial conoid

2:28

and trapezoid ligaments,

2:30

which are best seen in the sagittal projection.

2:33

So these are intact.

2:34

If these are gone, that takes you into the realm

2:37

of a grade three separation.

2:39

If you've got an offset with tear of the capsular ligaments,

2:42

grade two separation.

2:44

And if you've got swelling of the joint,

2:46

but the capsular ligaments remain intact,

2:48

and there's simply edema, grade one separation.

2:51

Don't forget to look at the trapezius.

2:53

Don't forget to look at the deltoid.

2:54

And one more caveat, if you're really a glutton

2:57

for punishment, Charlie

2:59

NIR described somewhere between seven

3:00

and eight types of separation.

3:03

And those rely on the position of the clavicle. Is it down?

3:07

Is it up? What percent? Is it up? Is it anterior?

3:11

Is it posterior?

3:12

If it's anterior, what is its relationship

3:15

to the neurovascular bundle?

3:17

Well, that's my story

3:18

with acromioclavicular joint separation.