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Pediatric Shoulder Injuries Joel Gonzales, M. D. Tuckahoe Orthopaedic Associates Slide 2 Clavicle Not just an accessory bone Connects thorax to shoulder SC, CC, AC Joint and ligaments Deltoid, Trapezius, Pec Major Protects Subclavian Vessels and Brachial Plexus Slide 3 Clavicle S shaped double curve Medial end fuses age 22-26 Most common Birth Fx (.27-6%) >4000g 13% incidence Concomitant Plexus Injuries Rare Slide 4 Clavicle Fxs Children usually from direct blow Middle third most common SCM pulls proximal, Pec pulls down Classification (Allman) Type I middle third Type II distal to CC ligaments Type III medial third Slide 5 Clavicle Fxs signs and symptoms Birth Fxs obvious on xray Assymetric Moro Reflex Baby only feeds from one breast U/S Slide 6 Slide 7 Clavicle Fx Treatment Birth Fx - no treatment Proper lifting Pin shirt sleeve to shirt if uncomfortable Absence of calcification in a neonate after 11 days - child abuse Slide 8 Clavicle Fx Treatment Figure of eight vs. sling Same outcome Check skin daily with figure 8 Operative - Open or skin tenting Suture repair Slide 9 Clavicle Fx Slide 10 Medial Clavicle Injuries Most commonly SH Fx Tremendous remodeling potential Anterior most common Posterior impingement on mediastinal structures Slide 11 Posterior SC Dislocation Slide 12 Posterior SC Displacement Can become emergency Venous congestion/diminished pulses Difficulty breathing/swallowing CT Scan ORIF Never Uniformly stable after reduction Figure eight 3-4 weeks Slide 13 Cleidocranial Dysostosis Slide 14 Clavicle Fxs Distal/Lateral Periosteal Tube < 15 y.o. Sling Slide 15 Acromioclavicular Joint Falls Children>15 treat as adult Periosteal tube Tender at joint Limited shoulder motion Slide 16 Slide 17 AC Clinical Findings Type I and II No deformity Types III and V Obvious Deformity Type IV Missed Type VI Rare (NV Exam essential) Slide 18 Treatment AC Non-operative Early ROM/isometrics 4-6 weeks Open reduction for severely displaced or open Slide 19 Proximal Humerus Fxs Slide 20 Slide 21 Slide 22 3 ossification centers Tuberosities unite with head (age 7-14) Join shaft by age 19 80% growth from proximal physis Slide 23 Proximal Humerus Fxs Birth - U/S 5-12 usually do not involve growth plate 13-16 Salter Harris Rapid growth in metaphyseal are III-Dislocation IV never reported Slide 24 Proximal Humerus Fxs Slipped Epiphysis gymnast Little Leaguers Shoulder 4 weeks rest ABC UBC Chondroblastoma Slide 25 Little Leaguers Shoulder Slide 26 UBC Slide 27 Proximal Humerus Fxs Excellent remodeling potential Slide 28 Slide 29 SH II Fx Slide 30 Proximal Humerus Fxs Slide 31 Treatment Try for axillary or Y view (Dislocation) Sling 3 weeks Gentle ROM in 1-2 weeks Closed reduction (1-2cm bayonet acceptable) Slide 32 Operative Treatment Open Fxs Lesser Tuberosity Fxs (Subscap) Polytrauma Speeds healing Little growth remaining Slide 33 Proximal Humerus Fxs Slide 34 14 F SH II Slide 35 Complications Limb length inequality Loss of motion Osteonecrosis Axillary N Injury 4-6 mo recovery graft after 6 months recovery 8-12 months if successful Slide 36 Rotator Cuff Slide 37 Slide 38 Shoulder Instability Slide 39 Instability Subluxator or Dislocator Traumatic vs Atraumatic Anterior or Posterior Dead arm symptoms Voluntary or Involuntary Bilateral?, Lig Lax Hand Dominance Slide 40 Shoulder Instability Traumatic Anterior NV Exam Closed Red 4 weeks sling IR Recurrence high Slide 41 Anterior Dislocation 15M Slide 42 Anterior Post Reduction Hill-Sachs Lesion Bankart Lesion Slide 43 Apprehension Test Slide 44 Relocation Test Slide 45 Shoulder Instability Posterior dislocation easily missed Much less common (seizure d/o) Sling in neutral rotation x 4 weeks Slide 46 True AP Slide 47 Axillary View Slide 48 Surgery Best for anterior dislocators Open (Bankart repair, Neer) Arthroscopic (Caspari) Slide 49 Multi-Directional Instability Atraumatic Bilateral Global laxity Voluntary Rehab Slide 50 MDI Slide 51 Slide 52 Sulcus Sign Slide 53 MDI Treatment Rehab 6-12 Months Thermal Capsulloraphy Open Capsular Shift Slide 54 Thank You