AC separationMANAGEMENT

SHOULDER & CLAVICLE · 12 SECTIONS

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453 items

☷ Legend

01Approach to the Critical Patient/attcp31

Triage and immediate priorities

›Immediate priorities

›Abnormal vital signs

›Hypotension or shock

›Hypoxia

›Severe uncontrolled pain

›Concomitant trauma triggers

›Head or cervical spine injury concern

›Chest wall injury

›Polytrauma activation criteria

›Limb threat screen

›Distal pulses and capillary refill

›Motor and sensation in axillary nerve distribution

›Rapidly progressive swelling

›Escalate for expanding hematoma or progressive neurologic deficit

Open injury and infection risk

›Open injury pathway

›Skin breach over clavicle or AC region

›Gross contamination

›Farm or soil contamination

›If open injury suspected, antibiotics and tetanus first when feasible

›Urgent orthopedics notification

›Transfer if no operative capability

Key decision points

›Critical decisions

›Rockwood type estimate from exam and radiographs

›Type I and II likely outpatient

›Type III shared decision based on function and demands

›Type IV, V, VI urgent orthopedic evaluation

›Associated injuries screen

›Clavicle fracture

›Glenohumeral dislocation

›Rotator cuff tear in older adult

›Brachial plexus traction injury

02History/hx29

Mechanism and functional context

›Mechanism and context

›Direct blow to lateral shoulder

›Contact sports collision

›Bicycle or skateboard fall

›Fall onto outstretched hand

›Lower suspicion than direct impact

›High energy mechanism

›Motor vehicle collision

›Ejection or high speed cycling crash

›Time course

›Time since injury

›Progressive deformity or swelling

›Functional impact

›Inability to lift arm

›Occupational demands overhead work

›Athlete level and season timing

Symptoms and red flags

›Symptoms and risks

›Pain location at AC joint

›Pain with cross body movement

›Pain with overhead reach

›Neurologic symptoms

›Lateral deltoid numbness

›Hand paresthesia

›Vascular symptoms

›Cool hand

›Arm fatigue with use

›Medication and bleeding risk

›Anticoagulants

›Antiplatelet therapy

03Physical Exam/exam46

Inspection and palpation

›Local exam

›Deformity

›Distal clavicle prominence

›Loss of normal shoulder contour

›Skin status

›Tenting or blanching

›Abrasion over AC joint

›Fracture blisters

›Point tenderness

›AC joint line tenderness

›Coracoid tenderness suggesting coracoclavicular injury

›Swelling and ecchymosis

›Deltoid and trapezius bruising

Range of motion and provocative maneuvers

›Function tests

›Active range of motion tolerance

›Pain limited abduction

›Pain limited forward flexion

›Cross body adduction pain

›AC joint provocation

›AC shear test pain

›Compression of clavicle and scapular spine

›Rotator cuff screen

›External rotation strength

›Abduction strength

›Drop arm concern in older adult

Neurovascular exam

›Neurovascular status

›Axillary nerve

›Deltoid sensation lateral shoulder

›Deltoid contraction

›Distal motor screen

›Wrist extension

›Finger abduction

›Distal sensation

›Median nerve distribution

›Ulnar nerve distribution

›Radial nerve distribution

›Perfusion

›Radial pulse

›Capillary refill

›Doppler if pulse asymmetry

PITFALLS

›Pitfalls

›Clavicle fracture mimicking AC separation

›Posterior clavicle displacement missed without axillary view

›Concomitant glenohumeral dislocation

›Rotator cuff tear in older adult with normal radiographs

›Pain at AC joint from distal clavicle fracture

04Differential Diagnosis/ddx20

Traumatic shoulder girdle conditions

›Traumatic differentials

›Distal clavicle fracture

›ICD 10 S42.03

›Midshaft clavicle fracture

›ICD 10 S42.02

›Sternoclavicular joint dislocation

›ICD 10 S43.2

›Glenohumeral dislocation

›ICD 10 S43.0

›Scapular fracture

›ICD 10 S42.1

›Proximal humerus fracture

›ICD 10 S42.2

Soft tissue and overuse mimics

›Non fracture differentials

›Rotator cuff tear

›AC joint sprain without displacement

›ICD 10 S43.5

›Labral injury

›Cervical radiculopathy

›Brachial plexus neuropraxia

05Laboratory Tests/lt14

Routine labs and selective indications

›Laboratory strategy

›No routine labs for isolated closed low energy injury

›Normal vitals

›No planned procedure

›Procedural sedation pathway labs by local protocol

›Glucose in diabetes or altered mental status

›Pregnancy test in reproductive age when imaging or sedation planned

›Trauma labs for high energy mechanism

›Complete blood count for suspected major injury

›Electrolytes and creatinine for trauma imaging planning

›Coagulation profile for anticoagulant use or bleeding concern

›Infection labs if open injury or systemic signs

›White blood cell count trend

›C reactive protein trend

06Diagnostic Tests/dt57

Scoring Systems

›Classification systems

›Rockwood classification

›Type I

›AC ligament sprain

›Coracoclavicular ligaments intact

›Normal coracoclavicular distance

›Type II

›AC ligament rupture

›Coracoclavicular ligament sprain or partial tear

›Mild clavicle elevation

›Type III

›AC ligament rupture

›Coracoclavicular ligament rupture

›Increased coracoclavicular distance

›Type IV

›Posterior displacement of distal clavicle into trapezius

›Often missed without axillary view

›Type V

›Marked superior displacement

›Deltotrapezial fascia disruption

›Type VI

›Inferior displacement under acromion or coracoid

›High energy association

›Management implications summary

›Type I and II nonoperative standard

›Type III initial nonoperative in many patients

›Type IV, V, VI operative consultation standard

Radiographs

›Plain radiographs

›Initial views

›AP shoulder

›Zanca view

›Axillary lateral view

›Bilateral comparison

›Coracoclavicular distance comparison

›AC joint alignment comparison

›Stress views

›Consider if diagnosis unclear

›Avoid if significant pain and obvious displacement

›Post reduction imaging

›If any reduction attempt performed

MRI

›MRI indications

›Persistent pain with normal radiographs

›Suspected occult distal clavicle fracture

›Suspected rotator cuff tear

›High level athlete with type III management uncertainty

›Coracoclavicular ligament integrity assessment

›Chronic symptoms

›Post traumatic osteolysis of distal clavicle

›Symptomatic AC joint arthritis unmasked by injury

›CT indications

›Suspected type IV injury

›Posterior displacement confirmation

›Complex fracture suspicion

›Distal clavicle fracture extension

›Scapular fracture evaluation

›Polytrauma imaging

›Concurrent chest injury evaluation

07Disposition/dispo31

Outpatient versus urgent orthopedic evaluation

›Disposition planning

›Discharge suitable

›Rockwood type I or II

›Pain controlled on oral medications

›Intact neurovascular exam

›No skin tenting or threatened skin

›Expedited orthopedic follow up

›Rockwood type III

›High demand athlete

›Cosmetic concern affecting function

›Persistent functional limitation after short trial of conservative care

›Urgent orthopedic evaluation

›Rockwood type IV, V, VI

›Skin tenting with blanching

›Neurovascular deficit

›Open injury

›Admission considerations

›Polytrauma requiring monitoring

›Uncontrolled pain despite ED measures

Follow up timing and activity restrictions

›Follow up plan

›Type I

›Primary care or sports medicine in 1 to 2 weeks

›Type II

›Orthopedics or sports medicine in 1 to 2 weeks

›Type III

›Orthopedics in 3 to 7 days

›Type IV to VI

›Orthopedics same day or within 24 hours

›Work and sport restrictions

›No overhead lifting until pain free and strength recovered

›No contact sports until cleared

08Treatment/t113

Immediate life-saving interventions

›Life threats and limb threats

›Hemodynamic instability management per trauma protocols

›Hemorrhage source search in high energy trauma

›Chest injury evaluation

›If neurovascular compromise, immediate escalation

›Urgent orthopedics

›Vascular surgery if pulse deficit

Immobilization and Splinting

›Immobilization plan

›Sling immobilization

›Comfort based duration

›Early gentle range of motion when pain improves

›Figure of eight brace

›Not routine for isolated AC separation

›Consider only per specialist preference

›Ice and elevation

›Short intervals multiple times daily for swelling

›Post immobilization reassessment

›Neurovascular exam after sling placement

›Pain trajectory documentation

Reduction

›Reduction considerations

›Closed reduction in ED rarely definitive

›Temporary symptom relief possible

›High recurrence without stabilization

›If attempted for severe deformity with threatened skin, specialist involvement

›Type V tenting with blanching

›Suspected type IV posterior displacement

›Analgesia and anesthesia options

›Non opioid analgesia

›Acetaminophen

›Adult maximum daily dose per local protocol

›NSAID if no contraindication

›Avoid if high bleeding risk

›Opioid options for severe pain

›Titrated IV opioid

›Reassessment intervals

›Respiratory monitoring

›Regional anesthesia options

›Supraclavicular block by trained clinician

›Local anesthetic dosing per institutional protocol

›LAST monitoring readiness

›Procedural sedation if needed for reduction

›Airway equipment readiness

›Continuous pulse oximetry

›Capnography when available

›Resuscitation drugs available

›Post reduction requirements

›Repeat neurovascular exam

›Post reduction radiographs

›Immobilization in sling

›Failed reduction pathway

›Persistent deformity with threatened skin triggers urgent orthopedics

›Persistent neurologic deficit triggers urgent escalation

Open fracture medications and timing

›Open injury medication pathway

›If open wound present, antibiotic timing as soon as feasible

›First generation cephalosporin for low contamination

›Add gram negative coverage for severe contamination per protocol

›Add anaerobe coverage for farm contamination per protocol

›Tetanus prophylaxis per immunization status

›Tetanus toxoid booster when indicated

›Tetanus immune globulin when indicated

›Irrigation and dressing

›Saline irrigation volume as tolerated

›Moist sterile dressing

›Urgent operative management planning

›Orthopedics notification

›Transfer if no operative capability

DVT prophylaxis when relevant

›Thrombosis prevention

›Not routine for isolated upper extremity sling immobilization

›Ambulatory patient

›Short duration immobilization

›Consider prophylaxis only with additional risk factors

›Major trauma

›Prolonged immobilization

›Prior venous thromboembolism history

›Active malignancy

›Local protocol alignment documentation

›Indication and contraindications documented

Injury grade specific management

›Rockwood type I management

›Sling for comfort

›Typically days to 1 week

›Early range of motion

›Pendulum exercises as tolerated

›Return to sport guidance

›Pain free full range of motion

›Near normal strength

›Rockwood type II management

›Sling for comfort

›Typically 1 to 2 weeks

›Progressive range of motion

›Gentle active assisted motion when pain improves

›Strengthening progression

›Scapular stabilizers

›Rotator cuff

›Rockwood type III management

›Initial nonoperative management common

›Sling 1 to 3 weeks as tolerated

›Early functional rehab

›Consider early orthopedic discussion for high demand patients

›Elite overhead athlete

›Heavy laborer

›Persistent pain and dysfunction after rehab trial

›Rockwood type IV management

›Operative consultation standard

›Posterior displacement risk

›Trapezius penetration risk

›Rockwood type V management

›Operative consultation standard

›Marked displacement

›Skin tenting risk

›Rockwood type VI management

›Emergent orthopedic evaluation

›High energy association

›Concomitant injuries common

09Special Populations/sp35

Pregnancy

›Pregnancy considerations

›Imaging considerations

›Radiographs acceptable when clinically indicated

›Abdominal shielding per institutional practice

›Analgesia considerations

›Acetaminophen preferred first line

›NSAID avoidance in later pregnancy per obstetric guidance

›Opioid short course only when necessary

›Disposition considerations

›Lower threshold for obstetric consultation in major trauma

›Fetal monitoring when indicated by gestational age and trauma severity

Geriatric

›Older adult considerations

›Fragility mechanism

›Lower energy fall still concerning for concomitant fracture

›Rotator cuff tear risk

›Weakness disproportionate to pain

›Early MRI or ultrasound consideration per follow up

›Medication safety

›NSAID renal and GI risk

›Opioid delirium and fall risk

›Follow up threshold

›Earlier reassessment if persistent functional limitation

Pediatrics

›Pediatric considerations

›Skeletal immaturity

›Distal clavicle physeal injury mimics AC separation

›Consider comparison views and specialist review

›Non accidental trauma consideration

›Inconsistent history

›Multiple injuries

›Management pattern

›Higher remodeling and healing potential

›Nonoperative management favored in most cases

›Return to sport guidance

›Full painless range of motion

›Normal strength compared to baseline

10Background/b37

Epidemiology

›Epidemiology facts

›AC joint injuries constitute 11 percent of shoulder injuries in a population study

›287 of 2650 shoulder injuries

›Incidence 45 per 100000 person years in a population study

›95 percent confidence interval 40 to 51

›Male predominance 82 percent in a population study

›Median age 32 years

›Contact athlete burden

›Up to 50 percent of shoulder injuries in contact athletes reported

Pathophysiology

›Mechanism and anatomy

›AC joint stabilizers

›Acromioclavicular ligaments for horizontal stability

›Coracoclavicular ligaments for vertical stability

›Typical mechanism

›Direct fall or blow to lateral shoulder with arm adducted

›Deformity mechanism

›Scapula drops with arm weight

›Clavicle appears elevated due to relative displacement

›High grade injury features

›Deltoid and trapezius fascia disruption in type V

›Posterior displacement in type IV

Therapeutic Considerations

›Treatment rationale

›Nonoperative success in low grade injuries

›Pain control

›Early motion to prevent stiffness

›Type III controversy

›Nonoperative first line strategy commonly recommended

›Surgery consideration for unstable variants or persistent dysfunction

›Operative indications in high grade injuries

›Mechanical instability

›Soft tissue interposition

›Functional loss despite rehab

›Complications to counsel

›Cosmetic prominence

›Chronic pain at AC joint

›Post traumatic AC arthritis

›Distal clavicle osteolysis in chronic cases

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge instructions

›Sling use

›Wear for comfort

›Remove for gentle elbow and wrist motion several times daily

›Ice and elevation

›Ice 10 to 15 minutes at a time

›Keep arm supported and elevated when resting

›Pain control plan

›Acetaminophen as directed on label or as prescribed

›NSAID if safe for you and not contraindicated

›Avoid alcohol or driving if sedating medications used

›Activity restrictions

›No lifting with the injured arm until cleared

›Avoid overhead reaching until pain improves

›Avoid contact sports until cleared

›Return to ED now

›New numbness or weakness

›Hand becomes cold or pale

›Rapidly increasing swelling or pain out of proportion

›Skin tenting with blanching

›Fever or drainage from any wound

›Follow up plan

›Type I or II follow up in 1 to 2 weeks

›Type III follow up in 3 to 7 days

›Type IV to VI urgent orthopedic evaluation

12References/r15

Guidelines and evidence sources

›Evidence sources

›AAOS OrthoInfo Shoulder Separation patient education

›Grade based ligament injury descriptions

›Skjaker 2020 population study on AC joint injury incidence and demographics

›AC joint injuries 11 percent of shoulder injuries

›Incidence 45 per 100000 person years

›Kim 2018 review on Rockwood type III management

›Nonoperative first line recommendation for type III unless unstable variant

›Smith 2011 meta analysis on AC joint dislocation management consensus

›Conservative management consensus for types I and II

›Operative management consensus for types V and VI

›Orthobullets AC joint injury reference

›Radiograph approach and treatment overview

›Moyal 2025 review on AC and SC joint injuries in athletes

›Contact athlete burden up to 50 percent of shoulder injuries reported

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.