Rockwood Children CH19

744

SECTION TWO • Upper Extremity

restore stability to the superior shoulder suspensory complex. Absolute contraindications to nonoperative treatment include open injuries and injuries with associated neurovascular injury requiring operative intervention. Techniques Nonoperative treatment is performed using immobilization in a sling or shoulder immobilizer for 2 to 4 weeks. Following the period of immobilization and resolution of the pain, patients are gradually progressed from pendulum exercises to active range of motion. Strengthening is begun once range of motion is equal to the uninjured side. Contact sports are avoided for 6 to 12 weeks following injury to allow for complete ligamentous healing and for prevention of converting an incomplete injury (type II) to a complete injury (type III). 137 Little published data exist regarding the nonoperative treat- ment of types I and II injuries in the pediatric and adolescent populations. The adult literature has demonstrated a 9% to 30% rate of pain and limitation of activities with closed treatment of type I injuries and a 23% to 42% rate for closed treatment of type II injuries, some of which required surgical interven- tion. 17,106 Children and adolescents seem to do better in terms of pain and restoration of function but it has not been studied extensively. Treatment of type III injuries remains controversial because of the outcomes demonstrated in the adult literature. Bannis- ter et al. 12 found that injuries with 2 cm or more of displace- ment treated nonsurgically had 20% good or excellent results compared with 70% in the surgically treated group. However, a study involving athletes and laborers with type III injuries treated nonoperatively showed that they were able to recover adequate strength and endurance to return to their preinjury activities. 159 A meta-analysis by Phillips et al. 120 supported nonoperative treatment of type III injuries as patients treated surgically had a higher complication rate, with patients treated nonoperatively able to return to work and preinjury activities faster.

PATHOANATOMY AND APPLIED ANATOMY RELATED TO ACROMIOCLAVICULAR DISLOCATIONS

The AC joint is formed by the distal end of the clavicle and medial aspect of the acromion with a fibrocartilaginous disk between them. It is an important contribution to the superior shoulder suspensory complex, a bone–soft tissue ring com- posed of the glenoid, coracoid, CC ligaments, distal clavicle, AC joint, and acromion (Fig. 19-13). This complex maintains a normal relationship between the scapula, upper extremity, and axial skeleton to permit fluid scapulothoracic motion. While the clavicle does rotate some relative to the acromion through the AC joint, the majority of motion occurs synchronously. 42 The ligamentous structures about the AC joint provide the vast majority of stability with a smaller component provided by the muscular attachments of the anterior deltoid onto the clavicle and trapezius onto the acromion. Horizontal stability is provided by the AC ligaments that reinforce the joint capsule, mainly the posterior and superior ligaments. 79 Vertical stability is provided by the CC ligaments, including the conoid ligament medially and trapezoid ligament laterally. 45 The normal distance between the coracoid and the clavicle, the CC space, should be 1.1 to 1.3 cm. 16

TREATMENT OPTIONS FOR ACROMIOCLAVICULAR DISLOCATIONS

NONOPERATIVE TREATMENT OF ACROMIOCLAVICULAR DISLOCATIONS

Nonoperative treatment of types I and II AC injuries is uni- formly accepted. However, treatment of type III injuries remains somewhat controversial. The vast majority of types IV, V, and VI injuries should be treated surgically to reduce the AC joint and

Acromioclavicular ligaments

Acromioclavicular ligaments

Clavicle

Clavicle

Acromial process

Coracoclavicular ligaments

Acromion

Coracoid process

Coracoid process

Coracoclavicular ligaments

Glenoid process

Glenoid fossa

A

B

Figure 19-13.  Schematic of the superior shoulder suspensory complex. A: Frontal view. B: Lateral view.