Rockwood Children CH19

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SECTION TWO • Upper Extremity

Potential Pitfalls and Preventive Measures

displacement, operative intervention may be warranted. Suture- based periosteal repair or fixation in younger adolescents or preadolescents avoids hardware-related complications, but adequate stability must be ensured through meticulous tech- nique. Utilization of a plate and screw construct also typically yields excellent results with a rapid return to function, a very high union rate, and a low complication rate. Further studies evaluating the treatment and outcomes of these fractures in the pediatric and adolescent are needed.

Distal Clavicle Fractures: SURGICAL PITFALLS AND PREVENTIONS Pitfall Prevention • Nonunion/hardware failure

• Ensure adequate fixation in distal fragment • Supplement fixation with suture and prolonged immobilization until healed • Directly visualize joint and utilize fluoroscopy in multiple planes following plate fixation

• Screw penetration into acromioclavicular joint

Scapula Fractures

Nonunion or hardware failure can occur if there is inadequate fixation of the distal clavicular fragment or excessive activity early. In addition, it is imperative to avoid screw penetration into the AC joint, which can be assessed with direct visualiza- tion and/or utilizing fluoroscopy in multiple planes.

INTRODUCTION TO SCAPULA FRACTURES

Scapula fractures are uncommon accounting for 1% of all frac- tures in adults with an even lower incidence in children. 53,145 Fractures involving the scapular body are most common, accounting for approximately 45% of scapula fractures. The remainder of fractures involve the glenoid neck (25%), glenoid cavity (10%), acromion process (8%), coracoid process (7%), and scapular spine (5%). 98,145 Very rarely, scapulothoracic dis- sociation can occur and has been reported in two separate case reports involving children, one child 8 years old and the other 11 years old. 4,112 Because of the low incidence of scapular frac- tures, mostly case report and retrospective small case series lit- erature exist on their treatment and outcomes in the pediatric and adolescent populations. MECHANISMS OF INJURY FOR SCAPULA FRACTURES When scapula body fractures occur in children, they are likely the result of either high-energy mechanisms, such as a fall from a height, ATV accidents or motor vehicle accidents, or the result of nonaccidental injury. 22,135 Bullock et al. 22 showed that scapula fractures had the highest risk of abuse for any fracture other than rib/sternum fractures, and when they were present, they were more than twice as likely to be associated with child abuse than not. Glenoid fractures most commonly occur due to a direct force on the lateral shoulder, such as that occur during a fall or a colli- sion sport. The force is transmitted to the humeral head, which then is driven into the glenoid surface. 24 An alternative mecha- nism of injury is a fall onto a flexed elbow. 90 The position of the arm at the time of injury will determine whether an anterior or posterior rim fracture occurs. 105 Acromion fractures occur due to a direct blow to the lateral aspect of the shoulder, which typically occurs during a fall or a collision in sport. 98 It is imperative to recognize that com- plete failure of the epiphyses to fuse is a normal anatomic vari- ant known as os acromiale, and should not be mistaken for a ASSESSMENT OF SCAPULA FRACTURES

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO DISTAL CLAVICLE FRACTURES

Distal Clavicle Fractures: COMMON ADVERSE OUTCOMES AND COMPLICATIONS

• Hardware prominence • Hardware migration • Nonunion • Symptomatic malunion

The most common complication of treatment of operative distal clavicle fractures is related to symptomatic hardware, which is easily remedied by removal of hardware. Nonunion and symp- tomatic malunions are best managed by performing ORIF of the fracture. In rare cases of minimal distal fragment bone or bony erosion, the distal fragment can be excised and the AC joint can be reconstructed utilizing a modified Weaver–Dunn procedure, where the coracoacromial ligament is transferred to the distal end of the remaining clavicle. 5 However, this represents a more histor- ical option for adults rarely applied in this younger population.

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO DISTAL CLAVICLE FRACTURES

Most of the literature available on distal clavicle fractures is for the adult population. Typically, if a child or adolescent sustains a fracture in this region, immobilization alone is sufficient to obtain a successful outcome. In older adolescents, highly com- petitive athletes, or instances of severe posterior or superior