normal acromioclavicular joint morphology in sudanese...
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The National Ribat University
Faculty of Graduate Studies & Scientific Research
Normal Acromioclavicular Joint Morphology In
Sudanese People
(A Radiographic Study)
A Thesis Submitted in Partial Fulfillment Required for M.Sc in
Human Clinical Anatomy
By: Khalid Mohamed Abdelhafiz
Supervisor: Dr. Kamal Eldin Elbadawi
1439- 2017
I
: تعالى قال
(114)ةيلاهـــطةروس
II
ACKNOWLEDGEMENTS
First and before all, my great thanks and prayers to ALLAH for giving me the
ability to do and complete this work.
Wondering around looking for proper words to thank the main supervisor of
this research, Professor Kamal Eldin Elbadawi Babiker, who paved the way not
only for me but also for many students in this university to complete their post
graduatestudiesinaproperway.Wordsarepowerlesstoexpressmyendlessgratitude and
appreciation for the great support and kind advices given by thehim.
Finally,itisnoneedtosaythatthisworkcouldnothavebeenpossiblewithout the
continuous and generous support and encouragement of my lovely family, and their
nice patience andcooperation.
I say thank you all very much…
III
DEDICATION
To
my lovely family,
who
keepsupportingmeallthroughmyway
withtheirloveandkindcare..
Great thanks
and
best wishes ..
IV
مستخلصالدراسة
تهدف هذه الدراسة التحليلية الوصفية بأثر رجعي إلى التحقق في التشكل التشريحي الطبيعي للمفصل األخرمي
نية. هذهاألشعة السيتم فحصهمببين السودانيين. شملت الدراسة مائتي مفصل أخرمي ترقوي ا للترقوة إشعاعي
تراوحت بين عاما ) 54عمارهم أمن اإلناث، متوسط 55منهم ذكور و 55، شخصمائة لحواليالمفاصل تنتمي
الدانية، )بعاد . تم تصنيف المفصل من خالل مالحظة النهاية األخرمية والترقوية للمفصل وقياس األ( عاما 07و 81
فت نوالمسافات الطولية للمفصل، كما تم حساب المسافة المشتركة المتكاملة للمفصل. وقد ص (ةقاصيالمتوسطة، ال
إلى تسعة أنواع: مسطح/ مسطح، مسطح/ منحني، السطوح المفصليةشكال أهذه الدراسة المفصل معتمدة على
ح مسطح/ منحرف، منحرف/ منحرف، منحرف/ مسطح، منحرف/ منحني، منحني/ منحني، منحني / مسط
بين كل من الذكور واإلناث هو النوع المسطح/ المنحني. ال النوع األكثر شيوعا وإتضح أن ومنحني/ منحرف.
لمسافة ن اأصت الدراسة إلى ل ة بالجانبين األيمن واأليسر. كما خ تعلقتوجد فروقات في األنواع والمسافات الم
(، بينما كانت نقطة المسافة 7..0-8مم ) 5.71ة قاصيال(، المسافة 1.77 - 8.5مم ) 5.75ة الطبيعية للمفصل دانيال
وتم إستخدام هذه المسافات الثالثة المذكورة في تحديد محصلة المسافة (. 7..0 - 8.87مم ) 1..4المتوسطة
ن جميع أوحظ (. كما ل 0.50 - 8.44مم ) 1..5كانت و التي المشتركة المتكاملة للمفصل األخرمي الترقوي
يزداد لذياخفض مع تقدم السن باستثناءطول مسافة المفصل أنها تنفي الذكور منها في اإلناث والمساحات أوسع
مع تقدم السن.
V
Abstract
Acromioclavicularjoint(ACJ)isaplanesynovialjoint,withafibrocartilaginousdisc
initsintraarticularspace.Itisoneofthejointsthatconnecttheaxialandappendicular
skeletons. This study was aimed to evaluate radiologically the normal ACJ
morphological anatomy among the Sudanese population. It has been designed as a
descriptive retrospective analytic study. Two hundred normal ACJs X-rays belongto
one hundred subjects, 55 were male and 45 were female, with an average age of 43
ranged from (18 to 70) yrs were studied. The joint type was classified by observing
the acromial and clavicular ends of the joints. The proximal/middle/distal and
longitudinal distances were measured, moreover the integral joint space was
calculated. The present study had classified the morphology of ACJs into nine types
depending on their articular surfaces shape (acromial/ clavicular), which are flat/flat,
flat/ curved, flat/ oblique, oblique/ oblique, oblique/ flat, oblique/ curved, curved/
curved,curved/flatandcurved/obliquetype.ThemostcommontypeofACJinboth
maleandfemalewastheflat/curvedtype.Therewasnosignificantdifferenceintypes and
distances related to right and left sides. The average of the normal proximal distance
was 5.09 mm ranging from (1.9 – 8.00), the distal distance was 4.08 mm ranging from
(1- 7.20), whereas the average of the middle point distance was 3.68 mm ranging from
(1.10 – 7.20). The integral ACJ space was 4.28 mm ranging from (1.33 – 7.47), which
was calculated by using the average of these three mentioned
distances.Comparativelyallspaceswerewiderinmalethanfemale,furthermore,the
reduction in ACJ space was associated with age advance. However, the longitudinal
length was distance increasing with ageadvanced.
VI
List of abbreviations
AC Acromioclavicular
ACJ Acromioclavicular joint
CC Coracoclavicular
DD Distal distance
Fig Figure
ISD Integral space distance
ISD-LM Integral ACJ space – literature method
LL longitudinal length
MPD Middle point distance
mm Millimeter
yrs Years
VII
List of figures
Fig Title Page
2.1 Shows ACJ Types 10
4.1 Shows gender distribution of study group 14
4.2 Shows the age groups distribution of study
Participants 15
4.3 Shows the distribution of ACJ type 17
4.4 Shoulder X-ray, shows flat/ curved type of the
right ACJ 18
4.5 Shoulder X-ray, shows curved/ flat type of the
left ACJ 18
4.6 Shoulder X-ray, shows flat/ flat type of theright
ACJ 18
4.7 Shoulder X-ray, shows oblique/ curved type of
the left ACJ 18
4.8 Shows the distribution of ACJ type among right
& left sides 20
4.9 Shows distribution of right ACJ articularend
shape type among gender 21
4.10 ShowsdistributionofleftACJarticularendshape
type among gender 22
4.11 Shoulder X- ray, shows left ACJ measurements
(PD, MPD, DD) 23
4.12 Shows the means of ACJ (PD, DD and MPD)
measurements among study age groups. 24
4.13 Shows means of ACJ (LL) measures among
study age groups 25
4.13 Shows the means of ISD- LM & ISD comparison
using unpaired t test. 25
VIII
List of tables
Table Title Page
4.1 Shows gender distribution of study group 14
4.2 Shows the age groups distribution of study
Participants 15
4.3 Shows the distribution of ACJ type 16
4.4 Shows distribution of ACJ type among right &
left sides 19
4.5 Shows the distribution of ACJ articular end shape
according to the gender and side 21
4.6 Shows ACJ distances measurements in (mm) 23
4.7 Shows the means of ACJ measurement among
study age groups (mm) 24
4.8 Shows the means of ISD measurements among
study age groups according to gender and side 26
IX
The Contents
Title Page
Alaya I
Acknowledgements II
Dedication III
Abstract in Arabic IV
Abstract in English V
List of Abbreviations VI
List of Figures VII
List of Tables VIII
The Contents IX
Chapter One: Introduction
1.1. Introduction 1
1.2. Justification 2
1.3. Objectives 2
1.3.1.General Objective 2
1.3.2.Specific Objectives 2
Chapter Two: Literature Review
2.1. Anatomy 3
2.2. Acromioclavicular joint pathology 8
2.3. Previousstudies 9
Chapter Three: Material and Methods
3.1. StudyDesign 12
3.2. StudyArea 12
3.3. StudyDuration 12
3.4. StudyPopulation 12
3.4.1. Inclusion criteria 12
3.4.2. Exclusion criteria 12
3.5. Studyvariables 12
3.6. Sampling 13
3.6.1. Sample type 13
X
3.6.2. Sample size 13
3.7. DataCollection 13
3.7.1. Data Collection tools 13
3.7.2. Data management 13
3.8. Ethical Considerations 13
Chapter Four: Results
4.1. Results 14
Chapter Five: Discussion
5.1. Discussion 27
Chapter Six: Conclusion and Recommendations
6.1.Conclusions 30
6.2.Recommendations 31
Chapter Seven: References
References 32
Appendix
Data collection sheet 34
Chapter One
Introduction & Objectives
1
1. Introduction & Objectives
1.1. Introduction:
The shoulder joint complex is composed of four articulations: the
sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic that
connects the upper limb to the axial skeleton, they work collectively to allow
smooth shoulder function. Together, they allow the shoulder joint to have a wide
rangeofmotionmorethananyjointinthebody,andallthesearticulationsmustbe
respected when managing shoulder dysfunction. The normal function of the
shoulder is a balance between mobility and stability of all these joints. These
studies focus mainly on acromioclavicular joint (ACJ), which one of understudied
joints in literature in comparison with shoulder and sternoclavicular joints in spite
of its varying disorders(1).
AnunderstandingoftheACJanatomyisfundamentaltounderstandinjuriesand
surgical treatments. The ACJ joint is a plane diarthrodial variety of synovial joint,
situated between the lateral end of the clavicle and acromion end of the scapula. It
helps to link the shoulder to the axial skeleton. The articulation surfaces between
thesetwobonescanformathighlyvariableangles(2).Articulationsidesofthisjoint
arecoveredwitharticularcartilage,withafibrocartilaginousdiskinbetween.This
fibrocartilaginous disc is referred to as a meniscal homologue. The degree of disk
completeness varies, with only 10% of individuals having a complete disk(2,3).
The ACJ movements affected by its shape and the repetitiveness of the
movement. The variations of the joint morphology assumed to contribute to
different degrees of attritional damage. Knowledge of ACJ varying morphologies
helps to better understanding of its biomechanics. The purpose of this study is to
describe the normal ACJ morphology on radiograph, to find the prevalence of
particular type (flat, oblique or curved), compare ACJ space diameters (in the
superiorandinferiorendsofthejoints)amonggenderandagegroupsinSudanese
2
subjects, and to assess the similarity of ACJ shape and space diameters on each
side.
1.2. Justification:
ACJ injures & disorders are common and may lead to instability or
degenerative changes requiring surgical intervention. Normal anatomy of the joint
spaceinx-rayisessentialknowledgetodiagnosedislocationsandtodetectarthritic
changes in AC joints. Knowing normal morphometric measurement of joint space
will support decision-making in choosing management modality, emphasize
practicing surgeries and arthroscopes in the shoulder region. Due to lack of
sufficientliteratureonthenormalACJmorphologiesinSundanesepopulation,this
study isinitiated.
1.3. Objectives:
1.3.1. Generalobjective:
To study the radiological morphology of normal ACJ anatomy among the
Sudanese.
1.3.2. Specificobjectives:
1. TofindouttheprevalenceoftheACJtypes(flat,oval,curved)amongstudy
groups.
2. To measure the normal measurement of ACJ space in Sudanesepopulation.
3. To determine the ACJ space differences among different agegroups.
4. To compare the space measurements and shape of ACJ in bothsides.
5. To make a comparison between the measures of ACJ space among males
and females.
6. To provide a data and some literature about the ACJ space in Sudanese
population to be used for furtherstudies.
Chapter Two
Literature Review
2. Literature review:
2.1. Anatomy
2.1.1. Definition ofjoint:
Joints are the areas of the skeleton in which two or more bones meet and
articulate.Thesejointsaresupportedbyavarietyofsofttissuestructures,andtheir
mainfunctionsareeithertofacilitategrowthortoallowmovementbetweenbones
(4).
2.1.2. Classification ofjoints:
Therearemanyclassificationstothejoints;thesimplestclassificationsofjoints relate
to either the range of movement or structural component of the intervening soft
tissues; the most commonly used classification is according to their range of
movement in which they classify to synovial joints with free range of movement,
whereas restricted movement occurs at synarthroses varieties, which can be
subdivided into fibrous and cartilaginous joints(4).
2.1.2.1. Fibrous joints:
Inthefibrousjointsthearticularsurfacesarejoinedbyfibrousconnectivetissue that
allows little movement. Three definable subtypes are sutures, gomphoses and
syndesmoses(4).
2.1.2.2. Cartilaginousjoints:
Inthecartilaginousjointsthearticularsurfacesareunitedbyahyalinecartilage or
fibrocartilage. They are sub divided to: primary cartilaginous joints, or
synchondroses , in which the bones are united by a hyaline cartilage. Primary
cartilaginousjoints,usuallyprovidetemporaryunions,suchasthosepresentduring the
development of a long bone, they permit growth in the length of a bone.
Secondarycartilaginousjointsorsymphysesarelargelydefinedbythepresenceof
aninterveningpadordiscoffibrocartilageinterposedbetweenthearticularhyaline
cartilagethatcoverstheendsoftwobones.Thepadordiscvariesfromafew
millimetres to over a centimeter in width, and the whole region is generally bound
by strong, tightly adherent, dense connective tissues; symphysis pubis joint is a
good example for this type of joints (5).
2.1.2.3. Synovial joints:
These are freely moving joints in which the bony articular surfaces arecovered
withsmooth(hyaline)articularcartilageandseparatedbyafilmofviscoussynovial fluid
that serves as a lubricant. Stability of joint is provided by a fibrous capsule (which
usually has intrinsic ligamentous thickenings) and often by internal or external
accessory ligaments(4).
The articular surfaces are covered by articular cartilage comprises a specialized
type of hyaline cartilage, reflecting its embryological base as part of the
cartilaginous ‘model’ of bone in embryonic life. Exceptions include the ACJ,
sternoclavicular and temporomandibular joints, where articulating surfaces are
covered by dense fibrous tissue containing isolated groups of chondrocytes with
little proteoglycan in their surrounding matrix, presumably reflecting their
formation by intramembranous ossification (4).
A fibrous capsule completely encloses each synovial joint, except where it is
interrupted by synovial protrusions. It is composed of interlacing bundles of
parallelfibersofcollagentypeI,andisattachedcontinuouslyroundtheendsofthe
articulating bones. It is usually exhibits local thickenings of parallel bundles of
collagen fibers, called capsular (intrinsic) ligaments, and named by their
attachments. They do little to resist normal movements but become taut at the end
of each normal range of movement(4).
Synovial membrane lines and cover the fibrous joint capsule and exposed
osseous surfaces, intracapsular ligaments, bursae and tendon sheaths. It does not
coverintra-articulardiscsormenisci,andstopsatthemarginsofarticularcartilages
inatransitionalzonethatoccupiestheperipheralfew millimetersofcartilage.The
synovialmembraneconsistsoftwolayers;ahighlycellularintimallayerrestingon a
fibrous and vascular subintimal layer (subsynovial tissue). The function of synovial
membrane is to secrete and absorb a fluid that lubricates the movement between
the articulating surfaces(4).
Synovial fluid occupies synovial joints, bursae and tendon sheaths. In synovial
joints it is clear or pale yellow, viscous and slightly alkaline at rest (the pH lowers
during activity). Fluid volume is low: usually less than 0.5 ml (4).
An articular disc or meniscus can occur between articular surfaces where
congruity (conformity of opposing articular surfaces) is low. The term meniscus
should be reserved for incomplete discs, like those in the knee joint and,
occasionally, in the acromioclavicular joint. Complete discs, such as those in the
sternoclavicular and inferior radio-ulnar joints, extend across a synovial joint,
thereby dividing it structurally into two synovial cavities; they often have small
perforations. The disc in the temporomandibular joint may be complete or
incomplete (4).
Synovial joints are subclassified according to the arrangement of the articular
surfaces and the types of movement in to seven varieties; plane, hinge, pivot,
ellipsoid, saddle and ball & socket joints. In the plane joints, the apposed articular
surfaces are flat or almost flat, and this permits the bones to slide on one another ,
examples of these joints are the sternoclavicular and ACJ. Hinge joints resemble
the hinge on a door, so that flexion and extension movements are possible,
examples of these joints are the elbow, knee, and ankle joints. In pivot joints, a
central bony pivot is surrounded by a bony–ligamentous ring, and rotation is the
only movement possible, the atlantoaxial and superior radioulnar joints are good
examples. Condyloid joints have two distinct convex surfaces that articulate with
two concave surfaces, the movements of flexion, extension, abduction, and
adduction are possible together with a small amount of rotation movement, the
metacarpophalangealjointsorknucklejointsareexamples.Ellipsoidjoints,posses
elliptical convex articular surface fits into an elliptical concave articular surface,
the movements of flexion, extension, abduction, and adduction can take place, but
rotation is impossible, the wrist joint is a good example. In saddle joints, the
articular surfaces are reciprocally concavoconvex and resemble a saddle on a
horse’s back, these joints permit flexion, extension, abduction, adduction, and
rotation. The best example of this type of joint is the carpometacarpal joint of the
thumb. The Ball-and-socket joints, have a ball shaped head of one bone fits into a
socket like concavity of another, this arrangement permits free movements,
includingflexion,extension,abduction,adduction,medialrotation,lateralrotation, and
circumduction, shoulder and hip joints are good examples of this type ofjoint
(6).
2.1.3. Acromioclavicular joint:
ACJ joint is a plane synovial joint and with fibrocartilaginous disc in its
intraarticular space. It is one the joints that connect axial and appendicular
skeletons. The lateral end of the clavicle articulates with the acromion process of
thescapula.Thearticularsurfaces,coveredwithfibrocartilage,areseparatedbyan
incomplete wedge-shaped articular disc, the clavicular surface is a narrow, oval in
shape that faces laterally or inferolaterally and overlaps a corresponding join facet
on the medial acromion border. The long axis is anteroposterior(4,7,8).
ACJfibrouscapsulecompletelysurroundsthearticularmargins.Itislinedbya
synovial membrane and is strengthened superiorly by the acromioclavicular
ligament and the fibres of the attachment of trapezius, posteriorly by the fibres of
attachment of trapezius, and anteriorly by the fibres of attachment of deltoid
muscles. The inferior capsule is often incomplete in later life (4). Its arterial supply
come from the branches of the suprascapular and thoraco-acromial arteries.Is
innervated by branches from the suprascapular and lateral pectoral nerves, which
are branches of brachial plexus (7).
The ACJ is supported by a set of ligaments; superiorly assets by
acromioclavicular ligament (AC), that is a fibrous band extending from the
acromion to the clavicle, which provide the greatest resistance to anteroposterior
displacement of the joint (7).
However,theintegrityofACJismaintainedbyextrinsicligaments,distantfrom
thejointitself.Thekeystoneligamentiscoracoclavicularligament(CC)thatform by a
strong pair of bands extending between coracoid process of the scapula and the
clavicle, anchoring the clavicle to the coracoid process. It resists rotation and
vertical translation of the joint. The CC ligament consists of two ligaments, the
conoid and trapezoid ligaments; the trapezoid part is anterolateral and broad part,
which extend from the upper part of coracoid to the trapezoid line on the inferior
surface of the clavicle. It is almost horizontal, its anterior border is free, and its
posterior border is joined to the conoid part, forming an angle which projects
backwards. The conoid part is posteromedial and is a dense, almost vertical
triangular band. Its base is attached to the conoid tubercle of the clavicle and its
inferiorapexisattachedposteromediallytotherootofthecoracoidprocessinfront of the
scapular notch. which are often separated by a bursa. In addition to augmenting the
AC ligment, the CC ligament provides the means by which the scapula and free
limb are (passively) suspended from the clavicular strut(4,7).
Regarding the movement of ACJ, the acromion of the scapula rotates on the
acromial end of the clavicle. These movements are associated with motion at the
physiological scapulothoracic joint. No muscles connect the articulating bones to
movetheACjoint;theaxio-appendicularmuscles;(deltoidandtrapeziusmuscles),
which attach to and move the scapula cause the acromion to move on theclavicle
(7).
2.2. Acromioclavicular JointPathology:
2.2.1. Acromioclavicularseparation:
Theseinjuriesaretypicallycausedbyadirectblowtotheshoulder,arecommon
athletic injuries, and can be classified into six types according to the radiological
classification originally described by Rockwood et al, represents a continuum of
increasedsofttissueinjury;intypeItheACligamentsaresprained,butthejointis intact.
In addition there is no palpable displacement of the joint itself. Patients present
only by mild pain associated with movement, the radiograph may show mild soft
tissue swelling, but there is no widening, separation, or deformity at the
ACJ.IntypeIIinjuries,theACligamentsaretorn,buttheCCligamentsareintact. In this
type the patient complain of moderate to severe pain at the AC joint. On
examination the distal part of the clavicle will be slightly superior to the acromion
andshouldermotionincreasesthepainsignificantlyatACJ.AbilateralZancaview may
demonstrate that the distal clavicle is slightly elevated, but the CC ligaments
interspace is the same in both the injured and uninjured shoulders(9).
In type III injuries both ligaments AC and CC are torn, but the deltoid and
trapezial fascia are intact. On examination The distal clavicle may be prominent
enough to camp the skin and is unstable in both planes vertical and horizontal.
Patientspresentwithsupportingtheiraffectedupperlimbinadductedandelevated
positiontohelprelievingpain.IntypeIVinjuries,thesamestructuresaredisrupted
asintypeIIIinjuries.Thedistalclavicleisdisplacedposteriorlyintoorthroughthe
trapezius muscle. In type V injuries, the distal attachments of the deltoid and
trapezius to the clavicle are detached from the distal half of the clavicle. The ACJ
is displaced 100% to 300% and a gross separation between the clavicle and the
acromionispresent.TypeVIinjuriesarerareandarecausedbyextremeabduction that
tears the AC and CC ligaments. The distal clavicle is displaced under the coracoid
and behind the conjoined tendons(9).
2.2.2. Acromioclavicular degenerative jointdisease:
As effect of large loads which transmitted through ACJ with its small surface
area, ACJ one of earliest joints start to degenerates; it may start as the second
decade of life. This condition presents pain especially in crossed-chest adduction
movementanddiagnosedbydirectpalpation,radiographicevidenceofosteophytes and
joint-space narrowing, and pain relief with selective acromioclavicular joint
injection(10).
2.3. Previousstudies:
Several methods are used for evaluating ACJ include patient history, physical
examination,selectiveinjections,plainradiography,ultrasonographyandmagnetic
resonance imaging (MRI). Plane radiographs are often the first imaging modality
of examination performed on a person with a suspected shoulder abnormality and
the complex anatomy of the shoulder has led to the development of numerous
radiographic views and techniques, each designed to optimize the evaluation of
specific parts of the shoulder girdle (2, 8,11).
In a study done by Zanc, analyzing 1000 cases of shoulder pain investigated
involvementofACJ.HedevelopedatechniquepreferredinimagingACJbyusing
anAPviewwitha50%decreaseinpenetrancewiththeX-raybeamtiltedcephalad by 10
to 15°. The decrease in penetrance prevents overexposure and the 15° cephalic tilt
helps to remove the scapula from being superimposed onto the acromioclavicular
joint(11).
In study done by Colegate-Stone et al in (2010) studied the morphology of the
ACJ using cadaveric and radiological analysis. They classified ACJ by describing
articular surfaces of the joint to flat, oblique and curved types. Flat and oblique
varieties were more common (39.2 %) and (38.1 %) respectively. The oblique
joints was sub grouped into:oblique anterior, with the most distal end of the
clavicle inclined anteromedially; and oblique posterior, where the most distal end
was inclined posteromedially (8). Fig (2.1).
Fig (1): Shows the three ACJ subgroups
In another study done by De Palma in (1983) upon morphologicalvariation of
the ACJ by studying, 66 cadavers, with main concern on varying anglesoftorsion
of the joint. It suggested to classify ACJ into three groups with respecttothe
inferomedially angulated plane of the joint; type 1 with average angulationof16°;
type 2 with average angulation of 26° and type 3 average angulation of36°.Also
hedescribedanassociationbetweenACJpathologyandtype1jointwhichwas
thoughttobesecondarytoanincreasedshearingforceonthearticularsurface(2,12).
InstudiesdonebyOppenheimerin(1943)andZancain1971theysuggested
thatthelimitsoftheACJspaceinahealthyshouldervarybetween1and3mm
(13,11).
In study done by Petersson & Redlund-Johnell (1983) in Sweden, they
measured ACJ space in standard antero-posterior images of 151 normal subjects,
theyfoundthatthejointspacewassignificantlywiderinmen,noticedalsoahighly
significant reduction of the joint space with age in both men and women. They
reported that in a person’s past 60 a joint space of 0.5 mm or less can consider as
normalfinding,theyfoundalsothatjointspacewiderthan7mminmenand6mm in
women was abnormal(13,14).
Also in a study done by De Palma (1957) he found that the narrowing of the
ACJ space in increasing frequency with age but did not examine the normal limits
of the normal joint space in different ages (12).
InstudydonebyManaster(1997)hereportedthatthenormalACJspacevaries
between(3–8)mm,andthenormaldifferencebetweenrightandleftsidesshould be not
more than 2 – 3 mm(15).
Chapter Three
Materials & Methods
3.1. Studydesign
3. Materials and Methods
This is a descriptive cross-sectional study.
3.2. Study area:
The study was conducted at Ribat Teaching Hospital - Khartoum state –
Sudan.
3.3. Study duration:
The study was held during the period between (April 2017 – June 2017).
3.4. Studypopulation:
All individuals underwent radiological study in Khartoum state (Ribat
Teaching Hospital).
3.4.1. Inclusioncriteria:
Individualsunderwentchestorshoulderx-rays,inagegroupbetween(18–70) years
old. Asymptomatic patient not complaining from shoulder pain or trauma in last 6
months, with no deformity or previous surgery in shoulder region and X-ray with
good quality (ACJ with adequate appearance, not superimposed bilateral joints
involvement ispreferable).
3.4.2. Exclusioncriteria:
Age groups less than 18 yrs, more than 70 yrs old. Patient’s with shoulder
disorder (dislocations, fracture, rheumatoid arthritis, osteoarthritis). Previous
surgeries in shoulder region and bad quality X-rays (not fulfill the above criteria).
3.5. Study variables:
Participant gender (male - female), participant age, acromial and clavicular
surfacesshape(flat,curved,oblique),ACJmeasurements(Proximaldistance,distal
distance, midpoint distance, longitudinallength).
3.6. Sampling:
3.6.1. Sample type:
The sample group of this study was selected randomly among Sudanese
population.
3.6.2. Sample size:
100 individual computerized x-ray for shoulder joint showing 200 ACJs.
3.7. DataCollection:
3.7.1. Data Collection tools
Reports and radiographs from the Ribat Radiology Department, through data
collectionsheetdesignedtoincludepersonalinformationandallradiologicalstudy
variables.
3.7.2. Data management
Data were represented by figures, tables, charts and pie charts.
3.8. Statisticalanalysis:
By using SPSS (Social Package for Statistically Sciences) version 22, gender
comparison – was done using t- test, age group comparison using Anova test.
3.9. Ethical clearance:
A permission was taken from the review board and Research and Ethical
Committee in the National Ribat University – Faculty of Graduate Studies and
research.
Chapter
FourResults
4. Result
The total number of 100 subjects underwent the study, among them 55 (55%)
subjectwheremales,whereas45(45%)females.Atotalnumberof200ACJ(right & left
sides) were studied carefully, as shown in table (4.1) and Fig(4.1).
Table (4.1): Shows gender distribution of study group.
Gender Frequency Percent
Male 55 55 %
Female 45 45 %
Total 100 100 %
Gender
Fig (4.1): Shows gender distribution of study group.
Male
Studygroupagewasrangedbetween18-70yrs,withagemean43.19yrs.The
participants were catograzied into five age groups as shown in table (4.2) and Fig
(4.2), the most abundant age groups were (18-28) and (29-39) yrs each of them
represent (23%) of the study group. The reliability of data collected was assessed
using Chronbach alpha test; which gave a high degree of reliability(.739).
Table (4.2): Shows the age groups distribution of study participants
Age group (yrs) Frequency Percent
18-28 23 23.0
29-39 23 23.0
40-50 20 20.0
51-61 13 13.0
62-70 21 21.0
Total 100 100.0
Fig (4.2): Shows the age groups distribution of study participants.
AstheACJcomposedoftwoarticularsurfacesacromial,clavicularends,and
according to their articular surfaces shape, the ACJ were classified into nine types
Flat/Flat, flat/curved, flat/oblique, oblique/oblique, oblique/flat, oblique/curved,
curved/curved, curved/flat and curved/ oblique type as shown in figs (4.4) (4.7) ــ.
Thestudyfoundtheflat/curvedtypein49joints(24.5%),flat/flattypein36(18
%)joints,oblique/curvedtype24(12%),curved/flatin23(11.5%),curved/curved
in21(10.5%),oblique/obliquein19(9.5%),oblique/flatin13(6.5%),flat/oblique in 10
(5 %), curved/oblique in 5 (2.5 %) of joints as shown in table (4.3) and fig (4.3).
Therefore the most common types observed in the study were flat/curved type (24.5
%) followed by flat/flat type (18%).
Table (4.3): Shows the distribution of ACJ type.
Joint type Frequency Percent
Flat & Curved 49 24.5
Flat & Flat 36 18.0
Oblique & Curved 24 12.0
Curved & Flat 23 11.5
Curved & Curved 21 10.5
Oblique & Oblique 19 9.5
Oblique & Flat 13 6.5
Flat & Oblique 10 5.0
Curved & Oblique 5 2.5
Total 200 100.0
Fig (4.3): Shows the distribution of ACJ types
Fig (4.4): Shoulder X-ray, shows flat/ curved type of the right ACJ (arrow)
Fig (4.5): Shoulder X-ray, shows curved/ flat type of the left ACJ (arrow)
Fig (4.6): Shoulder X-ray, shows flat/ flat type of the right ACJ (arrow)
Fig (4.7): Shoulder X-ray, shows oblique/ curved type of the left ACJ (arrow)
Thecomparisonbetweenthedistributionofdifferenttypesofrightandleftsides of
ACJ revealed that the flat – curved type was the commonest type in both the
rightandleftsides23(23%),26(26%)respectivelyasshownintable(4.4)andfig
(4.8)
Table (4.4): Shows distribution of ACJ types among right & left sides
ACJ
Right ACJ Left ACJ
Frequency Percent Frequency Percent
Flat-Flat 19 19 18 18
Flat-Oblique 5 5 4 4
Flat-Curved 23 23 26 26
Oblique-Oblique 10 10 10 10
Oblique-Flat 7 7 5 5
Oblique-Curved 13 13 10 10
Curved-Curved 10 10 11 11
Curved-Flat 10 10 14 14
Curved-Oblique 3 3 2 2
Total 100 100 100 100
leftACJ RightACJ
30
25
20
15
10
5
0
Axis Title
Fig (4.8): Shows the distribution of ACJ types among right & left sides
As the result of studying the shapes of acromial and clavicular each side
separately and correlate their shapes (Flat, Oblique, curved) distribution in based
on the gender of study subject, the study found that the most common type in
acromialendonbothsides(right,left)wasFlatinbothgenderbutwithasignificant
difference among them (male, female) (52.7%, 40%), (56.6%, 37.8%).
respectively. While curved type was commonly found in clavicular end in both
sides (right, left) & gender (male, female) (45.5.7%, 46 %), (52.7%, 42.2%)
respectively as shown in table (4.5) and Figs (4.9),(4.10).
1010
Pe
rce
nta
ge
Table: (4.5): Shows the distribution of ACJ articular end shape according to
the gender and side.
Shape
Acromial Clavicular
Male Female Male Female
Rt Lt Rt Lt Rt Lt Rt Lt
Flat
52.7%
56.4%
40.0%
37.8%
32.7%
30.9%
36.0%
42.2%
Oblique
30.9%
23.6%
28.9%
28.9%
21.8%
16.4%
18.0%
15.6%
Curved
16.4%
20.0%
31.1%
33.3%
45.5%
52.7%
46.0%
42.2%
Distribution of right ACJ articular end shape type among gender
52.7%
0% 10% 20% 30% 40% 50% 60%
Curved Obliuqe Flat
Fig (4.9): Shows distribution of right ACJ articular end shape type among
gender
Art
icu
lare
nd
s
Acr
om
ial
Cla
vicu
lar
46.0 %
18.0%
36.0%
45.5%
21.8%
32.7%
31.1%
28.9%
40.0%
16.4%
30.9%
Distribution of left ACJ articularend shape type among gender
56.4%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%
Curved Obliuqe Flat
Fig (4.10): Shows distribution of left ACJ articular end shape type among
gender
As a result of studying 200 ACJs on both right and left sides among different
age groups the mean proximal distance (PD) measures was 5.09 millimeter (mm)
rangedbetween(1.9–8.00),distaldistance(DD)meanwas4.08mm(1-7.20),the
integral ACJ space – literature method (ISD-LM) as calculated in literature using
PD&DDwas4.58mm(1.45-7.60).Basedonthedifferentjointarticularsurface shape
and their effect on integral space and for more accuracy; middle point
distance(MPD)ofjointsweremeasuredandtheintegralspacedistance(ISD)using three
distance was calculated. The MPD mean was 3.68 mm (1.10 – 7.20), ACJ integral
space using three ACJ measures (PD, DD, and MPD) was 4.28 mm(1.33
– 7.47). The mean longitudinal length (LL) of the joint was 10.63 ranged between
(6.50 -15.10) as shown in the table (4.6), fig (4.11).
Art
icu
lar
en
ds
Acr
om
ial
Cla
vicu
lar
Table (4.6): Shows ACJ distances measurements in (mm)
ACJ Measures Mean Minimum Maximum
PD 5.09 1.90 8.00
DD 4.08 1.00 7.20
MPD 3.68 1.10 7.20
ISD- LM (PD,DD) 4.58 1.45 7.60
ISD(PD,
DD,MPD) 4.28 1.33 7.47
LL 10.63 6.50 15.10
Figure (4.11): Shoulder X- ray, shows left ACJ measurements (as labelled PD,
MPD, DD)
On studying the ACJ by different measurements among study age groups, the
mean of PD, DD and MPD was significantly decreasing when age advanced, as
shownintable(4.7)andfig(4.12).IncontrasttheLLshowedanincreasewithage
advancement, as shown in table (4.7), fig(4.13).
Table (4.7): Shows the means of ACJ measurement among study age groups
(mm).
Age group 18-28 29-39 40-50 51-61 62-70
Frequency 46 46 40 26 42
PD 6.15 5.62 4.92 4.42 3.91
DD 4.88 4.34 3.82 3.42 3.55
* ISD- LM 5.51 4.98 4.37 3.92 3.73
MPD 4.47 3.66 3.65 3.06 3.26
** ISD 5.17 4.54 4.13 3.63 3.57
LL 10.17 10.42 10.77 10.86 11.09
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00 PD DD MPD
18-28 29-39 40-50 51-61 62-70
Study age groups (yrs)
Fig (4.12): Shows the means of ACJ (PD, DD and MPD) measurements
among study age groups.
Mea
ure
s in
(m
m)
11.20
11.00
10.80
10.60
10.40
10.20
10.00
9.80
9.60
11.09
18-28 29-39 40-50 51-61 62-70
Study age groups
Fig (4.13): Shows means of ACJ (LL) measures among study age groups.
By comparing the means of ISD-LM and ISD using unpaired t test, there was
asignificantdifferencebetweenISD-LMmeanandISD(4.556±0.1025N=200),
(4.285±0.0724N=200)respectively(Pvalue=0.0312(,asshowninfig(4.14).
ISD-LM ISD
Fig (4.14): Shows the means of ISD- LM & ISD comparison using unpaired t
test.
LL
mea
surs
in
(m
m)
AC
J sp
ace
(mm
)
As the result of measuring ISD, on the right and left side of the ACJ, the mean
was 4.26 mm (1.87- 6.65), 4.30 mm (1.54 - 7.23) respectively. By comparing the
means of right & left side using unpaired t test; the study revealed that there was
no significant difference between the right & left side measurements (P value =
0.7808), as shown in table (4.8) and by sorting the study subjects based on their
gender,itwasrevealedthattheISDmeaninmales(n=55)was4.49mm(SD1.11),
whereasinfemales(n=45)was3.99mm(SD1.03)andwhencomparingthemeans of ISD
of males and females using unpaired t test, it was found that the ISD had a
significantdifferencebetweenmaleandfemalegroups(Pvalue=0.0229),theISD was
more wider in males than females, as shown in table(4.8).
Table (4.8): Shows the means of ISD measurements among study age groups
according to gender and side.
Gender Male (n=55) Female (n=45) All
Means
(SD)
Mean
(SD)
Mean
(SD)
Right Mean
(SD)
Left Mean
(SD)
ACJ
Space
4.4945 (1.11)
3.9930 (1.03)
4.2635 (1.06)
4.3066 (1.13)
Chapter
FiveDiscussio
n
5. Discussion
Adescriptivecross-sectionanalyticstudyunderwent100subjects,examining 200
ACJs (right & left). The main objective of this study is to investigate the
radiologicalmorphologyofnormalACJanatomyamongtheSudanesepopulation.
ThepresentstudyhadclassifiedthemorphologyofACJintoninetypesdepending
ontheirarticularsurfacesshape(acromial/clavicular)namelyflat/flat,flat/curved, flat/
oblique, oblique/ oblique, oblique/ flat, oblique/ curved, curved/ curved, curved/
flat and curved/ oblique type. Additionally elaborated more regarding the
morphological classification, when compared with Colegate -Stone et al study in
(2010), which classified them into three main types; flat, oblique and curved,
further subdivided the oblique type by the inclination angle of the distal end of
clavicle either anteromedial or posteromedial. Accordingly, there were no
significantdifferencesinthedistributionofACJtypes.Incontrastwiththispresent
studyshowedthatflat/curvedtypewasthemostcommontype,followedbyflat/flat and
oblique/ curved. On the other hand, both studies found that there was no significant
difference in ACJ types between the right and leftjoints.
Another significant observation in this study that the most common type of
theacromialendonbothsides(right&left)wasflatinbothgender(male&female)
withasignificantdifferenceamongthem.Whilecurvedtypewascommonlyfound
intheclavicularendonbothsides&gender whichwasnotmentionedinliterature
previously. This study found that the ACJ spaces were decreasing when the age
advanced and supporting the results of De Plama, Oppenheimer and Zanc studies.
Moreover, as the result of this study considered to correlate the space measures in
respect to both age and gender. It was found that ACJ space was wider in men.De
Palma (1957) observed that the narrowing of ACJ space was increasing with age.
However,hedidn’texaminethenormallimitsofnormaljointspace,withdifferent ages
therefore were not investigated. Oppenheimer in (1943) and Zanca in1971
suggested that the limits of the ACJ space in a healthy shoulder varied between 1
and 3 mm without considering variables (age and sex).
All the studies discussed previously, determined ACJ space considering
superior and inferior ends of the joint to measure the integral space (ISD- LM).
Adopting the same literature methods the present study found that ISD- LM was
4.58mm(1.45-7.60),with5.09mm(1.9–8.00)PD,DD4.08mm(1-7.20)which
showed the difference in ISD- LM means between studies. This study agrees with
Petersson & RedlundJohnell study, in light of ISD- LM was not exceeding the
pathological limit. Further more when comparing the means of PD & DD in this
study,itdemonstratedthatthePDwasnoticeablywiderthanDD,compatiblewith what
stated in Petersson & Redlund-Johnell study, which resulted the ACJ mean of 3.1
(±0.8) mm, concerning proximal and distal ends were 3.7 (±1.0), 2.6 (±0.6)
respectively. Their study concluded also that when ACJ space exceeding 7 mm in
men and 6 mm in females, often associated with a pathological complication.
Another study done by Manaster (1997) reported that the normal ACJ integral
space was 5.5 (3 – 8) mm, and the normal space difference between right and left
sides should be not more than 2 – 3mm.
Aninterestingcontributionofthisstudywasconcerningthesidesandgenders
ininvestigatingACJmeans.ConsequentlytheresultofmeasuringISD,ontheright
andleftsideoftheACJ,showedthatISDmeanwere4.26mm(1.87-6.65)and
4.30mm(1.54-7.23)respectively,examiningthesemeansrevealedthattherewas no
significant difference between the right & left side measurements (P value 0.7808),
which agree with which mentioned by De Plama, Oppenheimer andZanc studies.
Innovatively a new method of ISD measurement, on behalf of more
uniformityandaccuracymeasurementsofthejointarticularsurfaces.Accordingly, a
new distance point, MPD was consideredin the present study, while measuring
ISD ACJ space. The mean of MPD was 3.68 mm (1.10 – 7.20), which was not
stated previously in literature. Moreover, the ISD was measured using the average
ofPD,DDandMPDshowedthemean4.28mm(1.33–7.47),insteadofusingPD, DD
only which was 4.58 mm (1.45 - 7.60). And when comparing the means ISD- LM
and ISD, it was found that there was a significant difference with (P value 0.0312).
Another the interesting finding was the measurement of LL of the ACJ,
showedthemeanof10.63mm(6.50-15.10).Additionally,incontrasttootherACJ
measures, LL was increasing with the advancedage.
Chapter Sex
Conclusions &Recommendations
6. Conclusions &Recommendations
6.1 Conclusions:
This study classified ACJ into nine types flat/flat, flat/curved, flat/oblique,
oblique/oblique, oblique/flat, oblique/curved, curved/curved, curved/flat and
curved/ oblique type.
The most common type in both male and female was flat/ curved type.
Therewasnosignificantdifferenceintypesanddistancesassociatedwith right
and leftsides.
The PD mean was 5.09 mm (1.9 – 8.00), DD mean 4.08 mm (1- 7.20),
whereas the MPD mean was 3.68 mm (1.10 –7.20).
The LL mean was 10.63 mm (6.50 -15.10).
The ISD mean using (PD, DD, and MPD) was found as 4.28 mm (1.33 –
7.47). On the other hand, the ISD-LM mean as calculated in the literature
using PD & DD was found to be 4.58 mm (1.45 -7.60).
There was a significant difference between the ISD- LM mean andISD.
The mean of the ISD, PD, DD, and MPD was significantly decreasing
when the age advanced while the LL mean showed increasing with
advancedage.
The ISD mean was 4.49 mm (SD 1.11) in males, whereas in females3.99
mm (SD1.03).
There was a significant difference of ISD between the males andfemales.
6.2 Recommendations:
This study recommend that:
Plain shoulder X-ray involving right & left ACJ is valid and useful
investigation modality to diagnose ACJpathologies.
Comparing the right and left side is useful and valid method in detecting
ACJ pathology.
More studies comparing different radiological methods (CT-Scan, MRI),
with larger study sample arerecommended.
A study of symptomatic patients with ACJ pathology isrecommended
More descriptive multicenter studies arerecommended.
Chapter Seven
References
7. References
1. Henry Gray. Functional anatomy of the musculoskeletal system. In:
Michael A Adams (editor). Gray’s anatomy, 41th ed, London, Elsevier
limited. 2016; Pages 96 -101.
2. DePalma AF. The role of the disks of the sternoclavicular and the
acromioclavicular joints. Clin Orthop 1959; 13:7-12.
3. Salter EG, Nasca RJ, Shelley BS. Anatomical observations of the
acromioclavicular joint and supporting ligaments. Am J Sports Med
1987; 15:199 -206.
4. Henry Gray. Shoulder girdle and arm. In: Simon M Lambert. (editor).
Gray’s anatomy, 41th ed, London, Elsevier limited. 2016; Pages809.
5. Keith L. Moore, Arthur F. Dalley, Anne M. R. Agur. Introduction to
Clinically Oriented Anatomy. In: Clinically Oriented Anatomy, 7th ed,
Philadelphia, Lippincott Williams & Wilkins. 2014; page26.
6. Snell. S. Richard. Introduction. In: Clinical anatomy for medical
students, 9th ed, Boston, Little brown. 1995; page11-13.
7. Keith L. Moore, Arthur F. Dalley, Anne M. R. Agur. Upper limb. In:
Clinically Oriented Anatomy, 7th ed, Philadelphia, Lippincott Williams
& Wilkins. 2014, page796.
8. Colegate-Stone T, Allom R, Singh R et al. Classification of the
morphology of the acromioclavicular joint using cadaveric and
radiological analysis. J Bone Joint Surg Br. 2010;92:743.
9. Rockwood CA Jr, Williams GR, Young D. Disorders of the
acromioclavicular joint. In: Rockwood CA Jr, Matsen F (editors). The
shoulder. Philadelphia, Pennsylvania, USA: Saunders,1998:483–553.
10. Mark D Miller, Stephen R. Thopmson. Sport medicine. In: Mark D
Miller (editors). Review of orthopedics. 7th ed, London, Elsevier
limited. 2016; Pages 390 -392.
11. Zanca P. Shoulder pain: involvement of the acromioclavicular joint
(analysis of 1,000 cases). AMJ. Roentgenol. 1971; 112:493-506.
12. De Palma AF. Surgery of the shoulder. Regional, variational and
surgical anatomy. Philadelphia: JB Lippincott, 1983:35-64.
13. Oppenheimer A. Arthritis of the acromioclavicular joint. J. Bone Joint
Surg. 1943; 25:867-870.
14. Petersson CJ & Redlund-Johnell. Joint space in normal
acromioclavicular radiographs. Acta Orthop. Scand, inpress.1938.
15. Manaster BJ. Upper limb. In: Manaster BJ. Handbook of Skeletal
Radiology, 2nd ed, St Louis, Mosby.1997; page94.
The National Ribat University
Faculty of Graduate Studies & Scientific Research
NORMAL ACROMIOCLAVICULAR JOINT MORPHOLOGY
THESIS
Data collection sheet
SampleNo ParticipantGender M
F Age
ACJMeasures:
Variables Right side Left side
Acromial surface shape Flat Oblique curved Flat Oblique curved
Clavicular surface shape Flat Oblique curved Flat Oblique curved
Proximal distance
Distal distance
Midpoint distance
Longitudinal length
Comment: .......................................................................................................................................................................
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