ACJ Dislocation

Type 3 ACJ Dislocation



Synovial joint with hyaline cartilage


Has fibrocartilage intra-articular disc

- complete or incomplete

- usually degeneration by 4th decade


Clavicle may lie superior to acromion in normal population


Acromioclavicular Ligaments


ACJ capsule

- strongest superiorly

- horizontal / AP stability


Coracoclavicular Ligaments / CCL


Primary restraint to superior translation

- primary suspensory ligament of upper limb


Trapezoid Ligament (anterolateral)

- anterolateral on coracoid

- inserts trapezoid ridge also anterolateral to conoid

- almost horizontal in sagittal plane

- primary restraint to axial compression


Conoid Ligament (posteromedial)

- arises postero-medial to trapezoid

- inverted cone

- inserts conoid tubercle

- apex of posterior clavicular curve

- junction lateral & medial 2/3

- lies vertically

- primary restraint to superior and anterior translation


Delto-trapezial fascia

- dynamic stabiliser


Motion at ACJ


Only small 5-8o

- 40o at SC joint

- motion is at scapulo-thoracic joint rather than ACJ




Usually direct force onto adducted shoulder joint

- clavicle remains in normal position

- arm falls down




Usually clinically obvious


Grade 3 ACJGrade 3 ACJ


Allman grades I-III 1967 / Rockwood modified 1989 Classification


I     ACJ sprain


II    ACJ Disrupted & CCL intact / sprained


ACJ Dislocation Grade 2


III  Rupture ACJ & CCL 

- displaced > 100% of clavicular width


Grade 3 ACJ Dislocation


IV   Into trapezius

- can be easily missed

- need axillary lateral


Type IV ACJ APType IV ACJ Axillary LateralType IV ACJ


V     High dislocation > 1 x clavicle width

- disrupted trapezius & deltoid

- end of clavicle subcutaneous


ACJ Dislocation Type 5


VI    Subcoracoid dislocation




Zanca view

- specific for ACJ

- 10ocephalad, 50% voltage


Stress views

- occasionally used

- hold weights in each arm

- bilateral xray



- 50% overriding clavicle

- 2% under riding

- 29% incongruent

- joint width 0.5-7 mm




Type I


Symptoms 7-10 days


- Avoid heavy stress & contact sport till FROM & no pain to palpation

- 2/52


Type II


Sling 2/52

- avoid heavy lifting, contact sports 8-10/52 to allow ligament healing

- OT if Persistent pain


Chronic Symptomatic I & II

- trapped capsular ligament / loose articular cartilage / detached meniscus

- excision outer end clavicle if continued symptoma


Acute Type III


RCT Operative vs Non-Operative


Tamaoki et al Cochrane Database 2010

- meta-analysis of 3 RCT

- operative v non operative

- multiple fixation techniques

- no obvious advantage in operative group

- RCT insufficient to decide merit of operative management


Surgical Indications



- heavy labourer

- < 25 years undecided on career

- not in athlete (will just destroy repair when next falls)




1.  Hook plate

- reduction of ACJ

- hook under posterior acromion

- allows CC ligaments to heal

- must be removed

- but can mobilise the shoulder at 4-6 weeks with implant in situ


Clavicle Hook Plate


Gstettner et al J Should Elbow Surg 2008 

- acute injuries

- hook plate or non operatively, patient choice

- 57 v 30

- hook plate removed after 3 months

- 1 hook plate cut up through acromion (still good result)

- 3 superficial infections

- slightly improved constant scores in surgical group

- similar ROM

- improved pain and power scores



- acromial cut out

- clavicle fracture


Clavicle Hook Plate Fracture


2.  Reconstruction


Chronic Symptomatic Grade III


Excision distal clavicle


Poor results

- convert long high riding clavicle to short high riding clavicle


Reconstruction Options

- Phemister technique

- Weaver Dunn

- CCL augmentation (anchors / tightrope)

- CCL Reconstruction

- combinations


1.  Phemister technique



- open reduction of ACJ

- 2 x K wires across ACJ

- suture repair AC and CC ligaments


Calvo J Should Elbow Surg 2006

- Phemister v Non operative

- similar rates of deformity (i.e. non anatomic reduction) 

- less radiographic OA in non surgically treated cases

- may be that K wires further damage joint

- similar functional results in each

- recommend non operative treatment


2.  Weaver Dunn Reconstruction



- reconstruction of CC ligament with coraco-acromial ligament (CAL)

- CA ligament left attached to coracoid

- excise 1.5 (2.5cm original recommendation) lateral clavicle

- CAL taken off anterior acromion with bone fragment

- transferred from acromion to clavicle end / intra-osseous suture repair


Supplement with

- hook plate

- Bosworth Screw

- anchor / sutures

- Lars Ligament / Hamstring / allograft


3.  CCL Augmentation



- 5 mm anchor with sutures about clavicle

- tightrope constructs

- Bosworth screw


Weaver Dunn with Twinfix AnchorACJ Reconstruction TightropeACJ Reconstruction Tightrope


4.  CCL Reconstruction



- pass allograft / autograft / LARS around coracoid

- pass around clavicle and suture or

- can pass through drill holes and secure with screws

- second technique risks clavicle fracture




Tauber et al J Should Elbow Surg 2007

- 12 revision cases of failed Weaver Dunn

- autogenous ST in figure 8 configuration

- through drill holes in clavicle, around coracoid, then over clavicle

- augmented with Bosworth / TBW removed at 3/12

- 4 weeks immobilised, then ROM to 90o for another 8 weeks

- good results, one clavicle fracture from wire



- intra-operative fracture coracoid

- failure repair (10 - 20%)

- recurrent deformity common in surgical groups

- clavicle fracture (due to sutures or metal work)


- continued pain

- posterior dislocation (due to non intact AC ligament)

- NV damage


Type IV, V, VI


Most recommend surgery

- hook plate / reconstruction acutely

- reconstruction late


Technique Weaver Dunn + Augmentation / Reconstruction



- 45o beach chair

- sabre incision over ACJ

- split fascia transversely along the clavicle and onto acromion

- must skeletalise distal end of clavicle to beyond former insertion of conoid and trapezoid

- expose anterior aspect of acromion

- resect 1 cm of distal clavicle with microsagittal saw

- find the CA ligament which will run from anterior acromion down to coracoid

- often a great deal of scar tissue in this area from injury

- expose the coracoid laterally and carefully medially

- take off anterior 5mm of acromion and carefully peel CAL off the underlying SSC

- will need to release some of CAL from coracoid to get sufficient length


Reduction / Reconstruction

- reduce clavicle down with preferred technique

- 5mm anchor / tightrope / allograft / autograft / Lars ligament through drill holes

- cross graft at clavicle so gives front to back stability as well as superior / inferior

- place drill holes through distal clavicle

- use 2 fibre wire to weave through CAL under bony fragment

- secure with intra-osseous sutures


Post op

- sling for 6/52

- no contact sports for 6/12


Post Weaver Dunn with Lars Ligament