Rockwood Children CH19

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SECTION TWO • Upper Extremity

Coracoclavicular screw placement or loops of heavy nonab- sorbable suture/Dacron tape around the coracoid and clavicle has also been described to treat AC injuries, either by itself or in conjunction with ligament reconstruction. 19 Screw placement requires removal whereas the loop technique can lead to suture cutout or aseptic foreign body reactions. 18,141 The modified Weaver Dunn procedure has been performed in arthritic situ- ations by resecting the distal end of the clavicle, detaching the coracoacromial ligament from the deep surface of the acromion, and transferring it to the distal end of the clavicle. Again, this is very rarely performed in children and adolescents. We treat all types I and II AC injuries as well as most type III injuries nonoperatively, with immobilization in a sling or shoulder immobilizer for 2 to 4 weeks followed by early restoration of range of motion. Contact sports are avoided for at least 6 to 12 weeks. The vast majority of types IV, V, and VI injuries are treated operatively. Once the distal clavicle is exposed, we determine whether repair of the periosteum and ligamentous structures sur- rounding the clavicle is sufficient or if a plate is required. The vast majority can be treated with periosteal repair over the reduced clavicle. Most often operative repair is for type IV fracture–dislocations with entrapment in the trapezius. Hook plates are most commonly utilized in older patients with fractures that are either segmental or intra-articular. Following plate placement, the perios- teum and ligamentous structures are repaired. Postoperative Care Postoperatively, patients are placed in either a sling or shoul- der immobilizer for 4 to 6 weeks. Pendulum exercises are then begun followed by gentle active range of motion below shoulder level for 6 to 8 weeks. At 8 weeks, full active range of motion is permitted. If a hook plate or CC screw was placed, it is removed with sufficient healing, usually at approximately 12 weeks. Contact sports are avoided for a minimum of 3 months following operative intervention. Author’s Preferred Treatment for Acromioclavicular Dislocations

are fairly obvious on AP plain radiographs, type IV injuries, because of their posterior displacement, may not be readily apparent. Furthermore, lateral views may be inadequate or dif- ficult to obtain, thus making it easy to miss a type IV injury. A high index of clinical suspicion, careful examination, and often a CT scan are necessary for accurate diagnosis and appropriate surgical treatment. Outcomes No studies have specifically evaluated the treatment of AC inju- ries in the pediatric and adolescent populations. In our expe- rience, operative treatment of types IV, V, and VI injuries has yielded excellent outcomes in the majority of patients. Resto- ration of joint congruity and stability permits rapid return to function. However, we do not have long-term data to determine how many patients develop degenerative arthritis.

MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO ACROMIOCLAVICULAR DISLOCATIONS

Acromioclavicular Dislocations: COMMON ADVERSE OUTCOMES AND COMPLICATIONS

• Posttraumatic arthritis • Persistent instability • Symptomatic hardware • Pin migration • Persistent pain • Suture cutout • Aseptic foreign body reaction

Development of degenerative arthritis can be treated by distal clavicle resection. However, the results of this are not favorable if the CC ligaments are disrupted as instability will ensue. 31 Per- sistent instability following closed treatment of an AC joint injury can be treated with ligament reconstruction or augmentation. Complications related to open reduction include migration of pins, symptomatic hardware, and persistent pain. As noted earlier, usage of synthetic material can lead to suture cutout or aseptic foreign material reaction. Any technique that passes material around the coracoid may lead to coracoid fracture or injury to the musculocutaneous nerve.

Potential Pitfalls and Preventive Measures

Acromioclavicular Dislocations: SURGICAL PITFALLS AND PREVENTIONS Pitfall Prevention • Missing a type IV injury

SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO ACROMIOCLAVICULAR DISLOCATIONS

• Careful assessment of the radiographs • Adequate lateral radiograph • Utilize physical examination to aid in the diagnosis • CT scan

AC injuries are relatively rare in the pediatric and adolescent populations. The injury patterns are classified similar to the adult population. However, in the young, the periosteum tears permitting the clavicle to displace while the periosteal attachment to the acromion and coracoid remains intact.

One of the biggest pitfalls when treating AC injuries is failure to recognize a type IV injury. Although types V and VI injuries