Wednesday Image Review

What’s the Diagnosis? By Dr. Shivani Talwar

A 34 year old male presenting to the emergency department for left shoulder pain. The pain is constant and worse with movement. He frequently has been feeling similar pain but was in a motor vehicle accident yesterday that exacerbated the pain. He was noted to have a left shoulder deformity with intact range of motion at the shoulder. What’s the diagnosis and treatment?

Answer: Grade III acromioclavicular joint separation; immobilize with a sling for 6-12 weeks and follow up with orthopedic surgery.

Grade Ligament involvementX-ray Findings and ExamTreatment
I– AC ligament sprain
– No instability of clavicle
Exam: Tenderness over AC joint    

X-ray: Normal imaging
Ice, rest, analgesics, immobilization

Early range of motion 1-2 weeks
II– AC ligament rupture
– Sprain of coracoclavicular ligament
Exam: Tenderness and mild step off of AC joint

X-ray: Clavicle elevated 25-50% above acromion, widening of the AC joint
Ice, rest, analgesics, immobilization

Early range of motion 1-2 weeks
III– AC ligament rupture
– Coracoclavicular ligaments partially ruptured
– Deltoid and trapezius muscles detached
Exam: Shoulder droops, prominent distal clavicle

X-ray: Clavicle elevated 100% above acromion, widening of coracoclavicular space
Conservative with sling immobilization

Some cases may be operative
IV– AC joint dislocation with AC ligament rupture
– Complete or partial rupture of coracoclavicular ligament
– Clavicle displaced posteriorly
Exam: Posterior displacement of clavicle

X-ray: Axillary radiograph required to see posterior dislocation
Surgical repair
V– AC joint dislocation with AC ligament rupture
– Complete rupture of coracoclavicular ligament
Exam: Gross clavicular deformity

X-ray: AC joint dislocated, coracoclavicular interspace with 200-300% disparity
Surgical repair
VI– AC joint dislocation with AC ligament rupture
– Intact coracoclavicular ligament
– Clavicle displaced inferiorly
– Intact, partial or complete deltoid and trapezius detachment
Exam: Severe swelling  

X-ray: AC joint dislocated, clavicle displaced inferiorly
Surgical repair
Rockwood Classification of AC Joint Separation


Gorbaty JD, Hsu JE, Gee AO. Classifications in Brief: Rockwood Classification of Acromioclavicular Joint Separations. Clin Orthop Relat Res. 2017 Jan;475(1):283-287. doi: 10.1007/s11999-016-5079-6. Epub 2016 Sep 16. PMID: 27637619; PMCID: PMC5174051.

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th Edition. Bjoerson, L. Ebinger, A. Chapter 271. Page 1824-1826. McGraw Hill Professional, 22 Oct. 2019.

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