What are the treatment options for shoulder separation in pediatric patients?

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Treatment Options for Shoulder Separation in Pediatric Patients

For pediatric shoulder separations (acromioclavicular joint injuries), treatment should be primarily conservative with immobilization and rehabilitation for most cases, reserving surgical intervention only for severe dislocations (Rockwood types IV-VI) or cases with persistent symptoms despite conservative management.

Classification and Initial Assessment

  • Shoulder separations (acromioclavicular injuries) in children are classified using the Rockwood system:
    • Type I: Sprain of AC ligaments without displacement
    • Type II: AC ligament tear with minimal displacement
    • Type III: Complete tear of AC and coracoclavicular ligaments with 25-100% displacement
    • Types IV-VI: Severe displacements with various directional components

Treatment Algorithm by Classification

Type I and II Injuries (Mild to Moderate)

  • Conservative management is the standard of care:
    • Immobilization with a sling or posterior splint for 1-3 weeks 1
    • Pain control with appropriate pediatric dosing of analgesics
    • Early mobilization after acute pain subsides (typically within 1-2 weeks)
    • Progressive rehabilitation focusing on range of motion and strengthening

Type III Injuries (Moderate to Severe)

  • Initial conservative management recommended:
    • Immobilization with sling for 3-4 weeks 2, 3
    • Progressive rehabilitation after immobilization period
    • Consider longer immobilization (4-6 weeks) for adolescents with high athletic demands

Type IV-VI Injuries (Severe)

  • Surgical consultation recommended:
    • Referral to pediatric orthopedic surgeon or pediatric surgeon with appropriate training 4
    • Surgical repair typically indicated for these severe displacements
    • Post-surgical rehabilitation protocol determined by surgeon

Rehabilitation Protocol

  1. Acute Phase (0-2 weeks):

    • Immobilization with sling
    • Ice for pain and swelling control
    • Gentle pendulum exercises after first week if pain allows

  2. Intermediate Phase (2-6 weeks):

    • Progressive range of motion exercises
    • Isometric strengthening exercises
    • Continued protection from contact sports

  3. Advanced Phase (6+ weeks):

    • Progressive resistance exercises
    • Sport-specific or activity-specific training
    • Return to full activities when:
      • Full pain-free range of motion achieved
      • Normal strength compared to unaffected side
      • Functional testing demonstrates readiness

Special Considerations for Pediatric Patients

  • Growth plate considerations: Children with open growth plates require careful monitoring to prevent growth disturbances
  • Age-appropriate rehabilitation: Exercises should be tailored to child's developmental level
  • Return to play decisions: More conservative approach recommended for younger patients

Follow-up and Monitoring

  • Initial follow-up within 1-2 weeks of injury
  • Radiographic evaluation at 6-8 weeks to assess healing
  • Long-term follow-up recommended for severe injuries to monitor for:
    • Growth disturbances
    • Development of degenerative changes 2
    • Persistent "step deformity" which may be cosmetic but functionally acceptable

Outcomes and Prognosis

  • Excellent outcomes typically seen with conservative management for Type I-III injuries 2
  • Most pediatric patients return to full activities without limitations
  • Cosmetic deformity (visible "step" at the AC joint) may persist but is rarely functionally limiting
  • Long-term studies show minimal functional deficits at 10-year follow-up even with persistent deformity 2

Pitfalls and Caveats

  • Avoid prolonged immobilization beyond 3-4 weeks as this may lead to shoulder stiffness
  • Don't confuse shoulder separation (AC joint injury) with shoulder dislocation (glenohumeral joint injury), which requires different management
  • Beware of missed associated injuries (clavicle fractures, rotator cuff injuries)
  • Surgical intervention in pediatric patients carries risks of growth disturbance and should be reserved for severe cases

The conservative approach to pediatric shoulder separations is supported by evidence showing excellent functional outcomes with non-operative management, even in cases where cosmetic deformity persists 2, 3.

References

1
Guideline

Management of Supracondylar Fractures in Children

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Research

New insights in the treatment of acromioclavicular separation.

World journal of orthopedics, 2017

4
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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