Rockwood Children CH19

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CHAPTER 19 • Clavicle and Scapula Fractures and Acromioclavicular and Sternoclavicular Injuries

Surgical Approach A direct approach to the AC joint is used by making an inci- sion along the lateral clavicle and anterior aspect of the joint in Langer skin lines. Sharp dissection is carried out through the skin only. Subsequently, electrocautery is utilized the remainder of the way down to bone so that hemostasis and dissection can occur simultaneously. It is easiest to incise the periosteum of the distal clavicle and acromion before entering the joint. It is imperative to avoid disruption of the CC ligaments in type VI injuries as they are intact. The AC and CC ligaments as well as the deltopectoral fascia are disrupted in types II, IV, and V injuries in the skeletally mature patients; they are attached to the periosteum in younger patients. ❑❑ Skin incision in Langer line directly anterior to acromioclavicular joint ❑❑ Electrocautery down to distal clavicle and acromion ❑❑ Reduce acromioclavicular joint ❑❑ Repair periosteum and ligamentous structures and assess stability ❑❑ Use hook plate if joint remains unstable for segmental fractures or intra-articular fractures ❑❑ Place lateral end of hook plate under acromion and facilitate AC joint reduction by placing medial part of plate on clavicle ❑❑ Place bicortical screws in medial part of hook plate ❑❑ Irrigate wound and close ❑❑ Plate removal 2–3 months postoperatively Once the dissection has exposed the AC joint, an open reduc- tion of the joint is performed. Type IV injuries necessitate care- fully extracting the distal clavicle from the trapezius muscle, type V injuries require reducing the distal clavicle from the subcutaneous tissue, and type VI injuries require removing the distal clavicle from beneath the coracoid process. Once the dis- tal clavicle is reduced to the level of the acromion, temporary pin fixation may be necessary to hold the reduction. As the periosteum is torn but still attached to the acromion, once the clavicle is reduced, simple repair of the periosteum and liga- mentous structures may be all that is required in the pediatric population. If the patient is older and a hook plate is being utilized, the lateral end of the plate is placed deep to the acromion and the medial side is placed on the clavicle, which will facilitate joint reduction and maintenance of the reduction. Bicortical screws are now placed into the clavicle to hold the plate in place. Ligament reconstruction and/or augmentation have been performed, via various methods, as the primary method of treat- ment for the injury in adults. Fortunately, these operations are rare in the acute setting for adolescents. More often these recon- structions are in chronic, painful AC separations in adults. Both semitendinosus autograft and allograft can be used as a loop around the coracoid and clavicle 69 or placed through bone tun- nels in the coracoid and clavicle and secured with interference screws. 97 The interference screws are placed at the locations of the CC ligaments in an attempt to restore normal anatomy. Technique ✔ ✔ ORIF of Acromioclavicular Dislocations: KEY SURGICAL STEPS

Indications/Contraindications

Nonoperative Treatment of Acromioclavicular Dislocations: INDICATIONS AND CONTRAINDICATIONS Indications Relative Contraindications • Type I injuries • Open injuries • Type II injuries • Injuries with associated neurovascular injuries requiring operative treatment OPERATIVE TREATMENT OF ACROMIOCLAVICULAR DISLOCATIONS Indications/Contraindications Indications for operative treatment of AC injuries include com- plete disruptions of the joint, leading to true dislocations in adolescents or fracture dislocations in the pediatric population, mainly types IV, V, and VI injuries. The most common opera- tive indication in the young is a type IV injury with displace- ment and entrapment in the trapezius muscle posteriorly. In addition, an injury that is open or has a concomitant neurovas- cular injury requiring operative intervention should be treated operatively. As noted above, the treatment of type III injuries is somewhat controversial.

Open Reduction and Internal Fixation Preoperative Planning ✔ ✔ ORIF of Acromioclavicular Dislocations: PREOPERATIVE PLANNING CHECKLIST

❑❑ Standard table capable of going into beach chair position ❑❑ Beach chair position with adequate sterile space above the shoulder adjacent to the head

OR table

Position/positioning aids

❑❑ Contralateral side

Fluoroscopy location

❑❑ Implants may include hook plate, cannulated screws, K-wires, heavy nonabsorbable suture, hamstring autograft, allograft

Equipment

Treatment of AC injuries surgically requires planning to ensure that the appropriate equipment is available. If implants are being utilized, these may include a hook plate, cannulated screws, K-wires, or heavy nonabsorbable suture. Reconstruction of the ligaments, however, requires either planning to obtain ham- string autograft or having allograft available. Positioning Whether open reduction or ligament reconstruction is being performed, the beach chair position is utilized. A bump is placed behind the scapula to bring the acromion into a more anterior position.