Fractures and Dislocations
about the Shoulder in the
Pediatric Patient
Joshua Klatt, MD
Original Author: Michael Wattenbarger, MD; March 2004
1st Revision: Steven Frick, MD; August 2006
2nd Revision: Joshua Klatt, MD; December 2009
Shoulder Trauma
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Shoulder trauma is relatively uncommon
Usually easy to diagnose and treat
Rarely require reduction or open treatment
Great remodeling potential
Motion of shoulder joint compensates well
Must differentiate the serious injury from
mild!
Bishop & Flatow: Pediatric Shoulder Trauma. CORR 432:41-8, 2005.
Shoulder Region FracturesIndications for Open Reduction
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Open fractures
Displaced intraarticular fractures
Multiple trauma to facilitate rehabilitation
Severe displacement with suspected soft
tissue interposition
Developmental AnatomyOssification Centers and Physes
• Scapular ossification
centers
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–
–
–
Acromion
Coracoid
Glenoid
Medial border
• Proximal humeral physis
– Tent shaped
– 80% of longitudinal growth
• Medial clavicular epiphysis
– Last to ossify 18-20 yrs
– Last to fuse 23-25 yrs
Medial Clavicular Injuries
• Clavicle 1st bone to ossify
(intrauterine week 5), but
medial clavicular
epiphysis last to appear
and close
– 18 to 20 and 23-25 yrs,
respectively
• Most injuries are SalterHarris type I or II, but true
dislocations may occur
– Important to differentiate,
as treatment differs
Medial Clavicular Injuries
• Clavicle shaft usually
displaces anteriorly
– But may displace
posteriorly
• If no evidence of medial
epiphyseal # but pain and
swelling, must rule out
dislocation
• Serendipity view or CT, if
suspect
– Image both sides
http://emedicine.medscape.com/article/398799-overview
Medial Clavicular Injuries
• Fractures usually heal and
remodel
• Attempt reduction if:
– Injury < 10 days old
– Cardiopulmonary symptoms
• Posterior dislocation warrants
prompt reduction due to
associated complications
–
–
–
–
–
Failure to heal and remodel
Brachial plexus compression
Pneumothorax
Respiratory distress
Vascular compromise
-Wirth & Rockwood: Acute and chronic traumatic injuries of the
sternoclavicular joint. J Am Acad Orthop Surg 4:268–278, 1996.
-Worman &Leagus: Intrathoracic injury following retrosternal
dislocation of the clavicle. J Trauma 7:416–423, 1967.
Medial Clavicular Injuries
Notice: Medial tip of clavicle adjacent to aortic arch!
Medial Clavicular Injuries
• Treatment
– Closed reduction
• Patient supine with general
anesthesia
• Bump between shoulders
• Traction to abducted arm
• Towel clip
– Open reduction
• Have access to CT surgeon
• Same positioning
• Intra-articular disk often stays
with sternum
• Don’t excise epiphysis
• Use suture fixation, NOT
wires
-Wirth & Rockwood: Acute and chronic traumatic injuries of the
sternoclavicular joint. J Am Acad Orthop Surg 4:268–278, 1996.
-Worman &Leagus: Intrathoracic injury following retrosternal
dislocation of the clavicle. J Trauma 7:416–423, 1967.
Diaphyseal Clavicle Fxs
• Most common fx of shoulder in children
– 10-15% of all fractures
• 50% are in children <10 yrs
• Almost always heal, usually clinically
insignificant malunion
– Possible role for operative management if significantly
shortened or displaced
• Excellent remodeling within 1 year
• Complications very uncommon
Diaphyseal Clavicle Fx Patterns
• Most in middle 1/3
(90%)
• 5% distal
• <5% medial
• Beware--nutrient
foramen may look like a
fracture
Clavicle Fractures
Greenstick common
Typical Healing
Adolescent Clavicle Fractures
• ORIF may be
indicated if widely
displaced or shortened
• Adult literature
supports ORIF for
completely displaced
fractures
16 year old female in MVC,
multitrauma patient with widely
displaced right clavicle fracture
Canadian Ortho Trauma Society. Nonop treatment compared with plate fixation
of displaced midshaft clavicle fxs. JBJS-Am 89(1):1-10, 07.
Vander Have et al. Op vs Nonop Tx of Midshaft Clav # in Adolescents
POSNA 2009 Paper Presentation, Boston, MA
Intraoperative C-arm views
ORIF with lag screw and 2.7 mm DCP plate because of
smaller size of adolescent clavicle
High energy displaced clavicle
fractures in adolescents
• Good results reported
with ORIF
– also report good results
with ORIF of
nonunion/malunion for
those failing
nonoperative care
– Vanderhave POSNA
2009
Clinical and radiographic
union at 2 months
Clavicle Birth Fxs
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Large baby
Pseudoparalysis
Simple immobilization
If no plexus palsy active
movement should return
early
Congenital Pseudarthrosis
of the Clavicle
• Usually right side
– If left, suspect
dextrocardia
• Often asymptomatic
• If symptomatic in older
child
– Excise, tricortical graft,
fixation
Schnall et al: Congenital pseudarthrosis of the clavicle: a review of the
literature and surgical results of six cases. J Pediatr Orthop 8:316–21, 1988.
Clavicular Nonunion
• Uncommon
• Treat according to symptoms
• Use same surgical methods as in adults
Kubiak & Slongo: Operative treatment of clavicle fractures in children:
J Pediatr Orthop 22:736–9, 2002.
Endrizzi et al: Nonunion of the clavicle treated with plate fixation.
J Shoulder Elbow Surg 17:951-3, 2008.
Distal Clavicle Fx / “AC” Injury
• AC separation very
uncommon in children
16yrs
<
– Lateral clavicle remains with
periosteal sleeve distally
• Often intact inferior
periosteum
• Usually remodels very well
– Close to physis
– Periosteal sleeve fills in
• Nonoperative tx
– Sling x 3 wks
Distal Clavicle FracturesClassification
• Similar to adults
• Based on amount and
direction of
displacement
Tossy JD, Mead NC, Sigmond HM. Acromioclavicular separation:
useful and practical classification for treatment. Clin Orthop
1963;28:111-9
Rockwood CA, Williams GR, Youg DC. Disorders of the
acromioclavicular joint. In: Rockwood CA, Masten FA II, editors.
The shoulder. Philadelphia: Saunders; 1998. p. 483-553.
Distal Clavicle Injuries –
Periosteal Sleeve
Periosteal Sleeve Fills In
Type IV AC Dislocation
11 yo female
Ped vs car
Initial XR
from front ------------from behind
Distal clavicle
posterior
Acromion
Coracoid
Suture Fixation around Coracoid
POSTOP
PREOP
Final X-ray- Full Motion
Scapula Fractures
• May be a sign of
significant trauma
– Think of NAT in small
children
• Usually nonoperative
treatment, unless intraarticular
• Growth centers may be
confused with fracture
– 8-10 ossification centers
• Axillary view often
helpful
Coracoid base fracture
Scapula Fractures - Classification
• Multiple systems
• Mostly descriptive and
anatomically based
• Can have fracture
through common
growth center of
coracoid and glenoid
(III)
Ideberg R: Unusual glenoid fractures. Acta Orthop Scand 58:191-2, 1987.
Goss TP: Fractures of the glenoid cavity. J Bone Joint Surg [Am] 74:299305, 1992.
Scapula Fractures - Treatment
• Similar to treatment in
adults
• Isolated body fxs do
not affect integrity of
suspensory complex
• Mildly displaced neck
and coracoid fxs
treated conservatively
– unless associated with
clavicle fx
http://www.shouldersurgeon.com/shoulder_injury/fractures_floating_shoulder.htm
Goss TP. Scapular Fractures and Dislocations: Diagnosis and Treatment. J Am
Acad Orthop Surg. Jan 1995;3(1):22-33.
Curtis RJ. Operative management of children's fractures of the shoulder region.
Orthop Clin North Am 1990;21:315-324.
Scapula Fractures - Treatment
• Glenoid rim fxs are treated
according to amount of
shoulder instability
• Glenoid fossa fxs
– ORIF if more than 5mm
displacement or instability
– Posterior approach usually
gives best exposure
Lee S, et al: Open Reducion and Internal Fixation of a Glenoid Fossa Fracture in a
Child:A Case Report and Review of the Literature. J Orthop Trauma 11:452-4, 1997.
Glenohumeral Dislocations
• Rare in young children
– < 2% of all dislocations are in children < 10 yrs
– 20% are in children 10-20 yrs
• Most are anterior, as in adults
– Frequently associated Hill-Sachs lesion
• High rate of recurrent instability in childhood
or adolescence (70-100%)
Traumatic Shoulder Dislocation
• Gentle reduction
– Pre-post neuro exam
• Immobilization for approx
3 weeks
• Shoulder rehabilitation
• Surgical stabilization
/reconstruction reserved
for recurrent instability
– Wait until skeletally mature,
if possible
Glenoid Dysplasia
• May predispose to
instability
• May be primary or
secondary (after
brachial plexus palsy)
Atraumatic Instability
• Often multiple joint
ligamentous laxity
• Multidirectional
instability usually
present
• May be voluntary
(discourage)
• Treat with rotator cuff
strengthening
Proximal Humerus Fxs
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Birth injuries
0-5 yo Salter I
5-11 yo metaphyseal
11 to maturity –
Salter II
• Others rare (III, IV)
Birth Fractures of the
Proximal Humerus
• Often Salter I type
• Great remodeling
potential
• Simple immobilization
with ACE bandage or
wrap
Neer – Horowitz Classification
Proximal Humeral Physeal Fractures
• Grade I- < 5 mm
• Grade II - < 1/3 shaft
width
• Grade III - <= 2/3 shaft
width
• Grade IV - > 2/3 shaft
width
-Proximal fragment sits in flexion,
abduction and external rotation due to cuff
-Distal fragment is shortened and in
adduction due to deltoid and pectoralis
Neer & Horowitz: Fractures of the proximal humeral epiphyseal plate.
Orthopedics 41:24-31, 1965.
Metaphyseal Fxs
Remodeling over 6 Months
Treatment PrinciplesProximal Humerus
• Closed treatment for vast majority
• If markedly displaced, attempt closed reduction
and immobilize
– Reduction is unlikely to hold without fixation
• Reserve closed vs. open reduction and pinning for
fractures with significant displacement
– (> Neer II) in older adolescents, recurrent displacement
• Open reduction if soft tissue prevents reduction
– Deltoid, capsule, long head of biceps
Proximal Humerus –
Acceptable Alignment
• Great remodeling potential
– 80% of humeral length contributed by proximal physis
• Shoulder ROM is compensatory
• Age dependent?
– A few studies state that even older adolescents have
acceptable functional outcomes after nonoperative
treatment of proximal humerus fxs
• Closed reduction not usually successful, nearly
impossible to maintain reduced position
Treatment Algorithm
Shoulder ImmobilizationCoaptation Splint
Early Healing Noted 3 Weeks
after Closed Reduction in Adolescent
Injury film
3 weeks after closed reduc.
Pinning Proximal Humerus
• Usually don’t need to
• Most recent studies quote high complication
rates (pin migration, infection)
• Even in older adolescents some remodeling
occurs
• Few functional deficits
• If used, leave pins long and bend outside
skin, consider threaded tip pins
Percutaneous Pinningthis technique may lead to pin migration
Pinning
BEND PINS TO PREVENT
MIGRATION, THREADED TIPS
Percutaneous Screw Fixation
Elastic Stable
Intramedullary Nails
• More recently proposed
form of fixation
• Avoid morbidity of
percutaneous pins
– Soft tissue irritation
– Migration
• Requires repeat anesthetic
for removal
Fernandez et al: Treatment of severely displaced proximal humerus
fractures in children with retrograde ESIN. Injury 39:1453-9, 2008.
ESIN
Fernandez et al: Treatment of severely displaced proximal humerus
fractures in children with retrograde ESIN. Injury 39:1453-9, 2008.
Complications of Proximal Humerus
Fractures
• Malunion with loss of shoulder ROM –
rarely functionally significant
• Shortening – up to 3 -4 cm seemingly well
tolerated
• Neurologic and vascular compromise less
common than in adults
Humeral Shaft Fractures in Children
• Neonates – birth trauma
• Neonates to age 3 – consider possible nonaccidental trauma
• Age 3-12 – often pathologic fracture
through benign bone tumor or cyst
• Older than age 12 – treatment like adults
Birth Fractures
• Simple immobilization
with ACE bandage or
wrap
• May have
pseudoparalysis
• Little attention to
realignment or
reduction needed
Pathologic Humeral Fracture
through UBC
Note fallen leaf sign and also pseudosubluxation inferiorly
Humeral Shaft Fractures- Treatment
• Usually closed
methods
• Sling and swathe
• Coaptation splint
• Fracture bracing
• Hanging arm cast
Segmental Humeral Fractures“Hanging Arm” Cast Treatment
Use collar and cuff
rather than sling to
allow gravity to help
align fracture
Indications for
surgical management
• Polytrauma
– Allow earlier ambulation
• Neurovascular
compromise
• Note: An open midshaft
humerus fracture is
necessarily not an
indication for fixation!
Humeral Shaft Outcomes
• Malunion common, but usually little functional
loss
• Remodels well
• Initial fx shortening may be compensated for by
later overgrowth
• Nonunion uncommon
• Radial nerve palsy less common, if occurs usually
neuropraxia
Bibliography
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Bishop & Flatow: Pediatric Shoulder Trauma. CORR 432:41-8, 2005.
Wirth & Rockwood: Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg 4:268–
278, 1996.
Worman &Leagus: Intrathoracic injury following retrosternal dislocation of the clavicle. J Trauma 7:416–423, 1967.
Canadian Ortho Trauma Society. Nonop treatment compared with plate fixation of displaced midshaft clavicle fxs. JBJSAm 89(1):1-10, 07.
Schnall et al: Congenital pseudarthrosis of the clavicle: a review of the literature and surgical results of six cases. J
Pediatr Orthop 8:316–21, 1988.
Kubiak & Slongo: Operative treatment of clavicle fractures in children. J Pediatr Orthop 22:736–9, 2002.
Endrizzi et al: Nonunion of the clavicle treated with plate fixation. J Shoulder Elbow Surg 17:951-3, 2008.
Tossy JD, Mead NC, Sigmond HM: Acromioclavicular separation: useful and practical classification for treatment. Clin
Orthop 28:111-9, 1963.
Rockwood CA, Williams GR, Youg DC: Disorders of the acromioclavicular joint. In: Rockwood CA, Masten FA II,
editors. The shoulder. Philadelphia: Saunders; 1998. p. 483-553.
Ideberg R: Unusual glenoid fractures. Acta Orthop Scand 58:191-2, 1987.
Goss TP: Fractures of the glenoid cavity. J Bone Joint Surg [Am] 74:299-305, 1992.
Goss TP. Scapular Fractures and Dislocations: Diagnosis and Treatment. J Am Acad Orthop Surg. Jan 1995;3(1):22-33.
Curtis RJ: Operative management of children's fractures of the shoulder region. Orthop Clin North Am 1990;21:315-324.
Lee S, et al: Open Reducion and Internal Fixation of a Glenoid Fossa Fracture in a Child:A Case Report and Review of
the Literature. J Orthop Trauma 11:452-4, 1997.
Neer & Horowitz: Fractures of the proximal humeral epiphyseal plate. Orthopedics 41:24-31, 1965.
Dobbs, et al: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 23:208-15, 2003.
Fernandez et al: Treatment of severely displaced proximal humerus fractures in children with retrograde ESIN. Injury
39:1453-9, 2008.
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