Does a patient with a low-grade acromioclavicular (AC) joint separation and smooth bony fragments near the distal clavicle require referral to an orthopedic (ortho) specialist?

From the Guidelines

A patient with a low-grade acromioclavicular (AC) joint separation and smooth bony fragments near the distal clavicle generally does not require immediate referral to an orthopedic specialist. The current evidence, as outlined in the American Academy of Orthopaedic Surgeons clinical practice guideline summary on the treatment of clavicle fractures 1, suggests that many clavicle fractures, including those with minimal displacement, can be managed successfully without surgery. This is particularly relevant for low-grade AC joint separations, where the risk of nonunion or symptomatic malunion is lower.

Key considerations in managing these patients include:

• The grade of the AC joint separation, with lower grades (Type I or II) typically being more amenable to conservative management
• The presence of smooth bony fragments, which may represent small avulsions that can heal with rest and gradual return to activity
• The absence of degenerative changes in the glenohumeral joint, which suggests that the injury is isolated to the AC joint
• The patient's overall clinical presentation, including pain level, functional limitations, and ability to perform daily activities

Conservative management for these patients typically involves:

• Rest and ice to reduce pain and inflammation
• Use of a sling for comfort, usually for 1-2 weeks
• Over-the-counter pain medications such as ibuprofen (400-600mg three times daily) or acetaminophen (500-1000mg every 6 hours as needed)
• Gradual progression to range of motion exercises and then strengthening exercises over 4-6 weeks

Referral to an orthopedic specialist is warranted if the patient shows no improvement after 2-3 weeks of conservative treatment, has persistent pain beyond 4-6 weeks, demonstrates significant functional limitations, or if imaging reveals a higher-grade separation or concerning bony fragments that might represent unstable fractures rather than smooth avulsions, as suggested by the guideline summary 1.

From the Research

Patient Condition

• The patient has a low-grade acromioclavicular (AC) joint separation.
• Smooth bony fragments are seen near the distal clavicle.
• The glenohumeral joint is without degenerative changes.
• The condition is diagnosed as an AC joint separation with an old fracture.

Treatment Considerations

• According to 2, grade I-III ACJ separations are typically managed conservatively.
• The study 3 found that non-operative treatment for grade III or higher AC joint injuries resulted in similar functional outcomes and patient satisfaction as surgical treatment, but with fewer complications.
• 4 suggests that grade I and II separations respond favorably to conservative management, while grades IV, V, and VI often require surgical reconstruction.
• 5 states that low-grade injuries are frequently managed successfully using non-surgical measures, while high-grade injuries frequently warrant surgical intervention.

Referral to Ortho

• Based on the evidence, a low-grade AC joint separation may not necessarily require referral to an orthopedic (ortho) specialist for surgical treatment.
• However, the presence of smooth bony fragments near the distal clavicle and the old fracture may need to be evaluated further by an orthopedic specialist to determine the best course of treatment.
• The patient's overall condition, activity level, and other factors should be taken into account when deciding on a treatment plan, as suggested by 5 and 6.