Jacob S. Levine, MD
Resident Physician
Mount Sinai Hospital
NYC, New York, United States
Mena R. Hasaballa, MS
Medical Student
Touro College of Osteopathic Medicine-New York
Bayonne, New Jersey, United States
Parag Sheth, MD
Chief of Spinal Intervention
Mount Sinai Medical Center
NY, New York, United States
A 34 year-old male presented to MSK clinic with one week of left shoulder pain following a cycling-accident-induced mechanical fall. Patient was evaluated in the ED with XR ruling out fracture and CT revealing acromioclavicular joint (ACJ) separation with posterior subluxation. There was no further clarification of impression. Patient was discharged with instructions to take over-the-counter medications and follow up with sports medicine. Physical examination revealed notable deformity of left ACJ with posterior and superior displacement, limited left shoulder abduction to 90 degrees, and tenderness to palpation of left ACJ. Prior CT scan was carefully reviewed, with knowledge of the Rockwood Classification incorporated, to determine that this scan revealed a Grade IV ACJ separation, as there was noted posterior involvement. Patient was referred to orthopedic surgery and underwent an open reduction and repair. Patient functionally improved with progressive physical therapy and followed up as needed with continued conservative management.
Discussions: This report highlights a noteworthy case of posteriorly involved ACJ separation. Knowledge of the Rockwood Classification can identify that either a posterior directionality of subluxation and/or a disruption of the deltopectoral fascia indicates at least a Grade IV injury. Low grade or anterior ACJ separations are recommended to be managed conservatively. While a Grade III injury provides controversy in the literature for management, once an injury is evaluated as Grade IV, surgical consultation is preferred. We believe that sharing this information for grading and interventions can help improve outcomes, especially in young athletes, by expediting the process for surgical consultation and recovery.
Conclusions: For patients with suspected ACJ injuries, it is imperative to perform imaging and carefully review it while utilizing the Rockwood classification. Diagnosing a posteriorly involved ACJ separation should be followed by surgical consultation in order to improve outcomes.
