Sports Medicine: Just the Facts

• Late treatment of lateral third nonunions usually com-
  prises excision of the distal fragment. The medial
  fragment must be stabilized with a ligament transfer
  caused by the earlier injury to the CC ligaments.
  Failure to do so will result in significant instability of
  the clavicle.
  •Intra-articular distal clavicle fractures are treated with
  rest until there is evidence of radiographic and clini-
  cal healing. If the patient has later symptoms, they can
  be treated with a simple distal clavicle resection.
  Stability of the remaining clavicle should be assessed
  at the time of surgery.

RETURN TO PLAY CRITERIA

• Nonoperative treatment: The involved extremity
  should be held immobilized in a sling or figure of
  eight harness with no forward elevation of the arm
  more than 45°for 4–6 weeks or until there is evidence
  of radiographic and clinical healing (fracture site non-
  tender). The immobilization can then be discontinued
  and range of motion increased as tolerated. For adults,
  return to full activities, particularly contact sports,
  cannot occur till there is evidence of complete radi-
  ographic healing and no tenderness at the fracture site.
  This may take 3–6 months.


• Operative treatment:A sling is not necessary and
  simple midline activities of daily living can be
  resumed as tolerated with the exception that the
  patient should avoid elevation of the involved hand
  higher than should level for 4–6 weeks to avoid
  excessive torque on the fracture site. Once radi-
  ographic and clinical healing is obtained, usually 4–6
  weeks, activities including full shoulder range of
  motion, can be started. Return to full activity should
  not take place until the patient has full, pain-free
  range of motion and radiographic union of the frac-
  ture.
  
  
  • In the case of intramedullary fixation, the device can
    be removed at about 12 weeks post-op if there is
    clinical and radiographic healing. Full range of
    motion and noncontact sports can be resumed as
    soon as the sutures are removed and contact sports
    can be resumed 6 weeks after removal of the device.
  
  
  
  

ACROMIOCLAVICULAR JOINT FACTS

• The acromioclavicular joint, or AC joint, and the SC
  joint represent the only true joints that link the entire
  upper extremity to the rest of the axial skeleton.


• There is approximately 5–10°of differential motion
  between the clavicle and the acromion as compared to

40 °of differential motion between the clavicle and the

sternum.

• The acromioclavicular joint is stabilized by a very
  strong ligamentous complex consisting of the conoid,
  trapezoid, and acromioclavicular ligaments. The
  acromioclavicular ligaments, particularly the poste-
  rior band, are the primary restraints to superior and
  posterior translation of the clavicle relative to the
  acromion. The trapezoid ligament is the primary con-
  straint to axial translation of the acromion in a com-
  pression mode while the conoid ligament acts as a
  restraint to superior translation and rotation of the
  clavicle. The load to failure strength of this complex
  is about 1000 N (Fukuda et al, 1986; Harris et al,
  2000).

INJURIES TO THE

ACROMIOCLAVICULAR JOINT

• In addition to wear and tear due to strenuous activity,
  the AC joint is commonly injured though falls on to
  the lateral aspect of the shoulder. In fact, the AC joint
  is second most commonly dislocated major joint, with
  the glenohumeral joint being first.


• It is the most commonly injured joint in martial arts
  and hockey.
  •With a fall on to the lateral aspect of the shoulder, a
  load is placed on the AC joint ligament complex. If
  the tensile strength of the ligaments is exceeded, the
  ligaments can then rupture, probably in a sequential
  pattern, with the acromioclavicular ligaments failing
  first, followed by the trapezoid and conoid ligaments
  (Basamania, 2000).


• If the entire ligament complex is damaged, the patient
  can be left with significant inability of the AC joint
  and disability, particularly with overhead work and
  lifting.

CLINICAL EVALUATION

• Most patients present with the complaint of pain and
  actively splint the injured shoulder with the uninjured
  arm. There may be ecchymosis or abrasions over the
  later aspect of the shoulder, particularly the postero-
  lateral aspect of the acromion.


• Due to swelling about the AC joint and splinting of
  the injured side, there may or may not be obvious
  deformity of the AC joint itself.


• There is typically exquisite tenderness on palpation of
  the AC joint.
  •Patients should be reexamined after a few days because
  once the initial pain has subsided, many patients who

278 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE