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    Case Report A Rare Acromioclavicular Joint Injury in A Twelve-Year-Old Boy. A

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    A Rare Acromioclavicular Joint Injury in a Twelve-Year-Old Boy. A case report. Lateral physeal separations of the clavicle do occur in children. The combination of a bone fracture and a ligamentous injury is even rarer.

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    Case Report A Rare Acromioclavicular Joint Injury in A Twelve-Year-Old Boy. A

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    Kirubakaran Saraswathy Pattabiraman
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    A Rare Acromioclavicular Joint Injury in a Twelve-Year-Old Boy. A case report. Lateral physeal separations of the clavicle do occur in children. The combination of a bone fracture and a ligamentous injury is even rarer.

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    A Rare Acromioclavicular Joint Injury in a Twelve-Year-Old Boy. A case report. Lateral physeal separations of the clavicle do occur in children. The combination of a bone fracture and a ligamentous injury is even rarer.

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    Case Report A Rare Acromioclavicular Joint Injury in A Twelve-Year-Old Boy. A

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    Kirubakaran Saraswathy Pattabiraman
    A Rare Acromioclavicular Joint Injury in a Twelve-Year-Old Boy. A case report. Lateral physeal separations of the clavicle do occur in children. The combination of a bone fracture and a ligamentous injury is even rarer.

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    This is an enhanced PDF from The Journal of Bone and Joint Surgery

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    A Rare Acromioclavicular Joint Injury in a Twelve-Year-Old Boy. A


    Case Report
    John M. Kirkos, Kyriakos A. Papavasiliou, Ioannis K. Sarris and George A. Kapetanos
    J Bone Joint Surg Am. 2007;89:2504-2507. doi:10.2106/JBJS.F.01549

    This information is current as of November 6, 2007


    Reprints and Permissions

    Click here to order reprints or request permission to use material from this
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    Publisher Information

    The Journal of Bone and Joint Surgery


    20 Pickering Street, Needham, MA 02492-3157
    www.jbjs.org

    Kirkos.fm Page 2504 Thursday, October 11, 2007 12:04 PM

    2504
    COPYRIGHT 2007

    BY

    THE JOURNAL

    OF

    BONE

    AND JOINT

    SURGERY, INCORPORATED

    A Rare Acromioclavicular
    Joint Injury in a Twelve-Year-Old Boy
    A Case Report
    By John M. Kirkos, MD, Kyriakos A. Papavasiliou, MD, Ioannis K. Sarris, MD, and George A. Kapetanos, MD
    Investigation performed at the 3rd Orthopaedic Department of the
    Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece

    njuries to the lateral part of the clavicle in a child with an


    immature skeleton are more likely to be physeal fractures
    than true acromioclavicular separations1,2. Nevertheless,
    lateral physeal separations of the clavicle and acromioclavicular joint dislocations do occur in children, and Dameron and
    Rockwood have classified these injuries according to six distinct types3. The combination of a physeal fracture with a ligamentous injury is even rarer and seems to violate the basic
    principle that a bone will fracture before a ligament will rupture in a child2. The aim of this case report is to remind the

    reader that, although this type of combined lesion can occur,


    it is often misdiagnosed or overdiagnosed; thus, an appropriate and careful evaluation must be performed so that unnecessary treatment can be avoided2.
    We report the case of a twelve-year-old boy who sustained an injury to the left acromioclavicular joint as a result of a fracture of the lateral part of the clavicle and a
    complete rupture of the coracoclavicular ligaments. This
    type of injury could not be categorized as any of the types in
    the classification system of Dameron and Rockwood3. This

    Fig. 1

    Standard anteroposterior radiograph of the left shoulder. Note the increased distance between
    the clavicle and both the acromion and the coracoid process.

    Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a
    member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial
    entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    J Bone Joint Surg Am. 2007;89:2504-7 doi:10.2106/JBJS.F.01549

    Kirkos.fm Page 2505 Thursday, October 11, 2007 12:04 PM

    2505
    THE JOURNAL OF BONE & JOINT SURGER Y JBJS.ORG
    VO L U M E 89-A N U M B E R 11 N O VE M B E R 2007

    A R A R E A C R O M I O C L AV I C U L A R J O I N T I N J U R Y
    TW E L VE -YE A R -O L D B OY

    IN A

    Fig. 2

    The three-dimensional reconstruction of the computed tomography scan confirmed the fracture
    of the clavicle and the increased distance between the clavicle and both the acromioclavicular
    joint and the coracoid process.

    study was approved by the scientific review board at our


    hospital and was conducted in accordance with the World
    Medical Association Declaration of Helsinki of 1964, as revised in 1983. The parents of our patient were informed that
    data concerning the case would be submitted for publication, and they consented.
    Case Report
    twelve-year-old boy fell from his bicycle onto his left
    shoulder. An anteroposterior radiograph of the shoulder (Fig. 1) demonstrated a fracture of the lateral part of the
    clavicle with an increased distance between the clavicle and
    both the coracoid process and the acromion. Because a rupture of the periosteum of the clavicle or of the coracoclavicular and/or the acromioclavicular ligaments was strongly
    suspected, the patient was admitted to the hospital for further evaluation. A magnetic resonance imaging scan was
    suggested, but the patient was afraid of it and refused to undergo the scan, and the patients parents refused to consent
    to have the scan performed with the boy anesthetized.
    Therefore a computed tomography scan was performed,
    which showed the same results as seen on the radiograph
    (i.e., the fracture of the clavicle, the increased distance between the lateral part of the fractured clavicle and the acromioclavicular joint and the increased distance between the
    medial part of the clavicle and the coracoid process) (Fig. 2).
    Because of the extreme likelihood of a concomitant serious
    ligamentous injury and because we were not able to acquire
    additional diagnostic information by means of magnetic resonance imaging, the patient underwent surgery one day after
    the injury. At the time of the operation, the fractured medial

    portion of the clavicle (a Salter-Harris type-II epiphyseal


    fracture) was found to be partially denuded from the periosteum, and the conoid and trapezoid ligaments were completely ruptured, even though the lateral part of the clavicle
    (the epiphysis) was firmly attached to the acromion without
    any signs of disruption or dislocation of the acromioclavicular joint (Fig. 3). The clavicular fracture was reduced and
    stabilized with use of two smooth Kirschner wires (Fig. 4),
    and the ruptured ligaments were repaired with nonabsorbable sutures. The arm was immobilized in a sling for a period

    Fig. 3

    Drawing showing the injury that was encountered at surgery. Note


    the rupture of the periosteal sleeve and complete rupture of the
    trapezoid and conoid ligaments. Also, note that the acromioclavicular
    joint is intact.

    Kirkos.fm Page 2506 Thursday, October 11, 2007 12:04 PM

    2506
    THE JOURNAL OF BONE & JOINT SURGER Y JBJS.ORG
    VO L U M E 89-A N U M B E R 11 N O VE M B E R 2007

    A R A R E A C R O M I O C L AV I C U L A R J O I N T I N J U R Y
    TW E L VE -YE A R -O L D B OY

    IN A

    Fig. 4

    Immediate postoperative radiograph. The fracture was reduced and fixed with two smooth
    Kirschner wires.

    Fig. 5

    Standard anteroposterior radiograph of the shoulder twenty-four months postoperatively. The


    healing of the clavicle is complete.

    of six weeks, at which time the Kirschner wires were removed


    and active exercises were started. Two years postoperatively
    (Fig. 5), full range of shoulder motion was possible.
    Discussion
    racture of the clavicle is very common in children. An injury to the lateral part of the clavicle in a child is more
    likely to be a physeal fracture than a true acromioclavicular

    separation1,2, even though the radiographic findings may


    mimic the latter4. Physeal fracture occurs because, prior to
    epiphyseal closure, the physis is weaker than the ligaments;
    therefore, the conoid and trapezoid ligaments usually remain
    intact5,6. Furthermore, the acromioclavicular joint is additionally stabilized by the trapezius and deltoid muscles. As a
    result of all these factors, a true acromioclavicular joint dislocation is extremely rare in patients who are younger than

    Kirkos.fm Page 2507 Thursday, October 11, 2007 12:04 PM

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    THE JOURNAL OF BONE & JOINT SURGER Y JBJS.ORG
    VO L U M E 89-A N U M B E R 11 N O VE M B E R 2007

    thirteen years of age2. Nevertheless, lateral physeal separation


    of the clavicle and acromioclavicular joint dislocation do occur in children, as reflected in the classification system of
    Dameron and Rockwood, which includes six distinct types
    of injury1,3. Type-I and type-II injuries are practically sprains
    of the acromioclavicular joint, whereas types III and IV represent a complete disruption. Type-V and type-VI injuries
    are caused by severe trauma that leads to the migration of
    the medial part of the clavicle either through the deltoid and
    trapezius muscles into the subcutaneous tissues (type V) or
    below the coracoid process (type VI).
    The injury reported here (Fig. 3) was somewhat different from the previously mentioned types. The periosteum of
    the clavicle was ruptured, so the injury could not be classified as either type I or II. The acromioclavicular joint was
    not dislocated; therefore, the injury could not be classified as
    type III or type IV. Furthermore, both coracoclavicular ligaments (the trapezoid and the conoid) were ruptured. Although this injury appears to be extremely rare, it is possible
    that similar cases of this injury pattern may pass unnoticed
    because, in many cases, advanced imaging is not acquired
    and nonoperative treatment is chosen. Eidman et al.2 were
    the first to report this type of injury, and these authors demonstrated later ossification at the region of the coracoclavicular ligaments (suggesting a possible combined osseous and
    ligamentous injury) in fourteen of twenty-five children who
    were thought initially to have a complete dislocation of the
    acromioclavicular joint.
    It is theorized that the following mechanism may have
    caused this complex type of injury: The patient fell onto the left
    shoulder, resulting in complete (or partial) rupture of the trapezoid and conoid ligaments. Next, the clavicle sustained a direct
    blow that caused it to fracture (possibly completing the rupture
    of the trapezoid and conoid ligaments). Finally, the sternocleidomastoid muscle pulled upward on the medial part of the

    A R A R E A C R O M I O C L AV I C U L A R J O I N T I N J U R Y
    TW E L VE -YE A R -O L D B OY

    IN A

    fractured clavicle, leading to the rupture of the periosteum.


    The treatment for this type of injury remains rather
    controversial. When total rupture of the coracoclavicular ligaments is suspected in a child, surgical repair can be justified to
    treat the deformity7. If this type of injury is left untreated, the
    formation of new bone from the ruptured periosteal envelope
    may lead to the development of a Y-shaped clavicle that may
    become both uncomfortable and unsightly3,4,8. Nevertheless,
    long-term follow-up of such patients after nonoperative treatment of this injury has also demonstrated excellent results4.
    Our patient underwent surgical treatment because it was initially believed that he had a complete acromioclavicular separation, although intraoperative findings revealed an intact
    acromioclavicular joint. If we had been able to acquire a magnetic resonance imaging scan preoperatively to evaluate the
    ligaments as well as the acromioclavicular joint capsule, the
    decision to operate might have been different. It is therefore
    very important to acquire magnetic resonance imaging scans
    as part of a careful evaluation of any injury to the lateral part
    of the clavicle in a child before deciding to proceed with operative treatment, as surgery may be unnecessary.

    John M. Kirkos, MD
    138 Al. Papanastasiou Street, 54249 Thessaloniki, Greece
    Kyriakos A. Papavasiliou, MD
    3 Natalias Mela Street, 546 46 Thessaloniki, Greece. E-mail address:
    [email protected]
    Ioannis K. Sarris, MD
    3rd Orthopaedic Department, Papageorgiou General Hospital, N. Efkarpia, 54603 Thessaloniki, Greece
    George A. Kapetanos, MD
    8 25th Martiou Street, 552 36 Panorama, Thessaloniki, Greece

    References
    1. Tachdjian MO. Upper extremity injuries. In: Herring JA, editor. Tachdjians pediatric orthopaedics. Vol 3. 3rd ed. Philadelphia: W.B. Saunders; 2002. p 2115-50.

    5. Havrnek P. Injuries of distal clavicular physis in children. J Pediatr Orthop.


    1989;9:213-5.

    2. Eidman DK, Siff SJ, Tullos HS. Acromioclavicular lesions in children. Am J


    Sports Med. 1981;9:150-4.

    6. Montgomery SP, Loyd RD. Avulsion fracture of the coracoid epiphysis with
    acromioclavicular separation. Report of two cases in adolescents and review
    of the literature. J Bone Joint Surg Am. 1977;59:963-5.

    3. Dameron TB Jr, Rockwood CA Jr. Fractures and dislocations of the shoulder.


    In: Rockwood CA Jr, Wilkins KE, King RE, editors. Fractures in children. Vol 3.
    Philadelphia: Lippincott; 1984. p 628, 636.
    4. Black GB, McPherson JA, Reed MH. Traumatic pseudodislocation of the
    acromioclavicular joint in children. A fifteen year review. Am J Sports Med.
    1991;19:644-6.

    7. Falstie-Jensen S, Mikkelsen P. Pseudodislocation of the acromioclavicular


    joint. J Bone Joint Surg Br. 1982;64:368-9.
    8. Ogden JA. Distal clavicular physeal injury. Clin Orthop Relat Res. 1984;
    188:68-73.

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