Rockwood Children CH19

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SECTION TWO • Upper Extremity

90% of patients. Furthermore, posttraumatic arthritis will be minimal. 76,96

may actually be an epiphyseal separation of the distal clavi- cle termed a “pseudodislocation,” rather than a true AC joint disruption. 133 However, older adolescents can sustain true AC dislocations, especially those involved in competitive sports participation. 35,74 Treatment of these injuries, especially com- plete dislocations, remains somewhat controversial and is based on individual patient demands.

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO SCAPULA FRACTURES

ASSESSMENT OF ACROMIOCLAVICULAR DISLOCATIONS

Scapula Fractures: COMMON ADVERSE OUTCOMES AND COMPLICATIONS • Nonunion • Symptomatic malunion • Glenohumeral subluxation/dislocation Nonunion and symptomatic malunion can occur following treatment of scapular body fractures nonoperatively. 41,94,104 Nonunions can be addressed by performing ORIF with good- to-excellent results expected. In addition, significant displace- ment associated with glenoid neck fractures has been shown to be a poor prognostic indicator. Therefore, fixation of fractures with more than 1 cm of displacement or angulation greater than 40 degrees will yield improved outcomes. 38,81,113 Finally, large glenoid rim fractures should be addressed operatively to pre- vent subluxation/dislocation of the glenohumeral joint. Scapula fractures are rare injuries that occur due to high-energy mechanisms or nonaccidental trauma. Conservative treat- ment with immobilization yields excellent outcomes in the vast majority of cases. However, it is important to recognize fractures that can potentially lead to adverse outcomes and complications. Advanced imaging with CT scans, including three-dimensional reconstruction, can aid the surgeon by pro- viding better understanding of the fracture pattern. Operative fixation should be performed for fractures about the glenoid with significant displacement or those leading to glenohumeral subluxation/dislocation. Because of the rarity of these fractures, it is likely that future multicenter studies will be necessary to provide information regarding the best treatments and their outcomes for pediatric and adolescent scapula fractures. SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO SCAPULA FRACTURES

MECHANISMS OF INJURY FOR ACROMIOCLAVICULAR DISLOCATIONS

Acromioclavicular joint injuries typically occur due to a direct blow to the acromion with the shoulder adducted, as can occur during collision sports, or due to a fall onto the superolateral aspect of the shoulder. The result of this blow is inferior and medial movement of the acromion while the clavicle remains stable because of the sternoclavicular joint ligaments. 127 Propa- gation of the force to the CC ligaments and deltotrapezial fascia can occur following complete disruption of the AC ligaments. 133 Indirect force can also result in injury to the AC joint, as occurs during a fall onto an outstretched hand or elbow. 137

INJURIES ASSOCIATED WITH ACROMIOCLAVICULAR DISLOCATIONS

As with any injury to the shoulder region, the entire shoulder girdle must be examined for a concomitant injury. Anterior sternoclavicular dislocations or additional scapula, humerus, or clavicle fractures can occur simultaneously if enough force was present at the time of impact. In addition, brachial plexus or cervical spine injuries may be present, especially if the injury occurred during a collision sport, such as football.

SIGNS AND SYMPTOMS OF ACROMIOCLAVICULAR DISLOCATIONS

Patients with AC dislocations usually complain of pain in the shoulder region localized to the AC joint area. Numbness and tingling may be present because of swelling or concomitant cer- vical spine/brachial plexus injury. Sometimes, they only com- plain of a “bump” in the region. The physical examination should begin by observation of the shoulder region with the patient in an upright position, which permits the weight of the arm to make any deformity more apparent. Swelling, ecchymosis, abrasions, and skin tent- ing should be noted. Palpation overlying the AC joint will cause significant discomfort and should be reserved until the end of the examination. Additional areas that should be palpated first include the proximal humerus, the midshaft and medial clav- icle, the sternoclavicular joint, and the cervical spine. A thor- ough neurologic examination should be performed to assess for concomitant brachial plexus or cervical spine injury. Most displaced distal clavicle fractures are malpositioned superiorly and have both visual and palpable deformities. However, some

Acromioclavicular Dislocations

INTRODUCTION TO ACROMIOCLAVICULAR DISLOCATIONS

While AC dislocations are common in adults, they are rare in children. Injuries that appear to disrupt the AC joint in a child