What is the treatment approach for an 11-year-old with an Acromioclavicular (AC) separation?

Treatment of AC Separation in an 11-Year-Old

For an 11-year-old with acromioclavicular separation, conservative (non-operative) management is the recommended initial approach for low-grade injuries (Rockwood types I-II), while high-grade injuries (types III-VI) require individualized assessment with strong consideration for non-operative treatment first, reserving surgery only for persistent pain or functional limitation after conservative management. 1, 2

Initial Assessment and Imaging

• Obtain standard shoulder radiographs including anteroposterior views in internal and external rotation plus an axillary or scapula-Y view to assess for AC joint displacement and rule out associated fractures 3
• The axillary or scapula-Y views are essential as AC dislocations can be misclassified on AP views alone 3
• Radiographs should be performed upright, as supine positioning can underrepresent shoulder malalignment 3
• CT is not necessary for initial evaluation unless fracture characterization is needed 3

Treatment Algorithm by Injury Grade

Grade I-II Injuries (Mild Sprains)

• Conservative management is the standard of care with excellent outcomes expected 1
• Sling immobilization for comfort (typically 1-2 weeks)
• Ice application and NSAIDs for pain control
• Early range of motion exercises as pain allows
• Progressive strengthening rehabilitation 1

Grade III Injuries (Complete AC Ligament Disruption)

• Initial conservative management is strongly recommended as functional outcomes are equivalent to surgery with faster return to activities and fewer complications 2
• Non-operative treatment includes:
  • Sling for 2-3 weeks for comfort
  • Structured rehabilitation program focusing on scapular stabilization and rotator cuff strengthening 1
  • Serial clinical assessments to monitor progress
• Surgery should be considered only if:
  • Pain remains severe (VAS >7) at 7 days post-injury with no functional improvement 2
  • Persistent symptoms after 3-6 months of appropriate conservative management 1, 2
  • Patient is a high-level athlete with specific demands (though even here, non-operative treatment shows good outcomes) 2

Grades IV-VI (Severe Displacement)

• Surgical reconstruction is typically required for these high-grade injuries 1
• Surgery should be performed within 14 days of acute injury for optimal results 4
• Coracoclavicular stabilization techniques (such as double-button suture procedures) show superior outcomes compared to hook plate fixation 4

Important Considerations for Pediatric Patients

• Children in this age group (11 years old) have unique physiologic characteristics including higher baseline compartment pressures and growth-related changes that must be considered 3
• The "three As" are useful for monitoring complications in children: anxiety, agitation, and analgesic requirement 3
• Pain management should avoid dense regional blocks if used perioperatively; instead use low-concentration local anesthetics (bupivacaine or ropivacaine 0.1-0.25%) to maintain sensory function for monitoring 5

Critical Pitfalls to Avoid

• Do not rush to surgery for grade III injuries - recent evidence shows non-operative treatment achieves identical functional outcomes with faster return to activities and no complications, while 9 of operated patients in one study experienced complications 2
• Do not rely solely on AP radiographs - always obtain axillary or scapula-Y views to avoid missing the true extent of displacement 3
• Do not ignore persistent severe pain (VAS >7) at one week post-injury, as this may indicate need for surgical intervention 2
• Monitor for compartment syndrome risk in any pediatric trauma patient, watching for pain out of proportion to injury and progressive swelling 6

Rehabilitation Principles

• Rehabilitation plays a crucial role regardless of treatment choice (operative or non-operative) 1
• Focus on restoring scapular mechanics and rotator cuff strength
• Progressive loading based on pain tolerance
• Return to sports typically occurs faster with non-operative management 2