Clavicle Elevation or Shoulder Girdle Depression in Acromioclavicular Joint Dislocation: A Radiological Investigation

Abstract

Background: The side-comparative coracoclavicular (CC) distance is used to describe the vertical instability component of acute acromioclavicular (AC) joint dislocations. Elevation of the clavicle or a depression of the shoulder girdle can lead to an increased CC distance. The dislocation direction has not yet been investigated and is not included in common classification systems.

Hypothesis: Clavicle elevation is primarily responsible for vertical dislocation in AC joint separation.

Study design: Cross-sectional study; Level of evidence, 3.

Methods: Weighted and nonweighted bilateral plain anteroposterior views of the shoulder girdles of patients with AC joint dislocations (Rockwood [RW] types III and V), diagnosed in our trauma department between 2001 and 2018, were included in this study. After determining the CC distance, a side-comparative determination of the positions of both the clavicle and shoulder girdle, with reference to the spinal column, was conducted.

Results: In total, 245 bilateral plain anteroposterior views were evaluated (RW III, n = 116; RW V, n = 129). All patients showed a side-comparative clavicle elevation (mean ± SD: RW III, 5 ± 14 mm; RW V, 11 ± 17 mm) in weighted and nonweighted views. While no depression of the shoulder girdle was measured in RW III injuries (weighted and nonweighted views, 0 ± 11 mm), dropping of the shoulder girdle in RW V lesions on nonweighted views was observed (-5 ± 11 mm).

Conclusion: Vertical dislocation is mostly associated with clavicle elevation in RW III injures, while in high-grade AC joint dislocations (RW V), a combination of clavicle elevation and shoulder girdle depression is present. A significantly greater superior displacement of the clavicle in RW V injuries was seen in weighted views, while a depression of the shoulder girdle could be detected in nonweighted views. For the first time, these results include the dislocation direction in the classification of an AC joint injury. Further studies are needed to investigate the extent to which dislocation types differ in optimal therapy and outcome.

Keywords: AC joint dislocation; Rockwood classification; acromioclavicular joint; shoulder girdle; vertical instability.

Figure 1.

Standardized radiological measurement (mm) in a patient with a Rockwood type V injury of the left acromioclavicular joint. Bilateral plain views of the shoulder girdles with a 15-kg axial load on both sides (weighted). (A) Measurement of the coracoclavicular distance on the nonaffected side (*) and the affected side (**). (B) Position determination of the clavicle (***). In this case, a superior displacement of the affected clavicle is measured. (C) Position determination of the shoulder girdle (****). In this case, a slightly higher shoulder girdle of the affected side as compared with the nonaffected side is measured.

Figure 2.

Standardized radiological measurement (mm) in a patient with a Rockwood type V injury of the left acromioclavicular joint. Bilateral plain views of the shoulder girdles without axial load (nonweighted). (A) Measurement of the coracoclavicular distance on the nonaffected side (*) and the affected side (**). (B) Position determination of the clavicle (***). In this case, a slightly inferior displacement of the affected clavicle is measured. (C) Position determination of the shoulder girdle (****). In this case, dropping of the affected shoulder girdle as compared with the nonaffected side is measured.

Figure 3.

Mean vertical dislocation of the clavicle and shoulder girdle in relation to the Rockwood classification and imaging study modality (weightbearing vs nonweightbearing). Error bars indicate 95% CI.

Figure 4.

Analysis of nonweightbearing views: Mean vertical dislocation of the clavicle and shoulder girdle in relation to the relative coracoclavicular distance, ΔCC (coracoclavicular distance of the affected vs nonaffected side). With increasing ΔCC, a side-comparative elevation of the clavicle and depression of the shoulder girdle could be detected.

Figure 5.

Analysis of weightbearing views: Mean vertical dislocation of the clavicle and shoulder girdle in relation to the relative coracoclavicular distance, ΔCC (coracoclavicular distance of the affected vs nonaffected side). With increasing ΔCC, a side-comparative elevation of the clavicle could be detected. The side-comparative shoulder girdle position remained unchanged.