Pediatric Shoulder Injuries Joel Gonzales, M. D. Tuckahoe Orthopaedic Associates

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

Clavicle S shaped double curve Medial end fuses age Most common Birth Fx (.27-6%) >4000g 13% incidence Concomitant Plexus Injuries Rare

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

Clavicle Fxs signs and symptoms Birth Fxs obvious on xray Assymetric Moro Reflex Baby only feeds from one breast U/S

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

Clavicle Fx Treatment Figure of eight vs. sling Same outcome Check skin daily with figure 8 Operative - Open or skin tenting Suture repair

Clavicle Fx

Medial Clavicle Injuries Most commonly SH Fx Tremendous remodeling potential Anterior most common Posterior impingement on mediastinal structures

Posterior SC Dislocation

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

Cleidocranial Dysostosis

Clavicle Fxs Distal/Lateral Periosteal Tube < 15 y.o. Sling

Acromioclavicular Joint Falls Children>15 treat as adult Periosteal tube Tender at joint Limited shoulder motion

AC Clinical Findings Type I and II No deformity Types III and V Obvious Deformity Type IV Missed Type VI Rare (NV Exam essential)

Treatment AC Non-operative Early ROM/isometrics 4-6 weeks Open reduction for severely displaced or open

Proximal Humerus Fxs

3 ossification centers Tuberosities unite with head (age 7-14) Join shaft by age 19 80% growth from proximal physis

Proximal Humerus Fxs Birth - U/S 5-12 usually do not involve growth plate Salter Harris Rapid growth in metaphyseal are III-Dislocation IV never reported

Proximal Humerus Fxs Slipped Epiphysis –gymnast Little Leaguer’s Shoulder 4 weeks rest ABC UBC Chondroblastoma

Little Leaguer’s Shoulder

UBC

Proximal Humerus Fxs Excellent remodeling potential

SH II Fx

Proximal Humerus Fxs

Treatment Try for axillary or Y view (Dislocation) Sling 3 weeks Gentle ROM in 1-2 weeks Closed reduction (1-2cm bayonet acceptable)

Operative Treatment Open Fxs Lesser Tuberosity Fxs (Subscap) Polytrauma Speeds healing Little growth remaining

Proximal Humerus Fxs

14 F SH II

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

Rotator Cuff

Shoulder Instability

Instability Subluxator or Dislocator Traumatic vs Atraumatic Anterior or Posterior Dead arm symptoms Voluntary or Involuntary Bilateral?, Lig Lax Hand Dominance

Shoulder Instability Traumatic Anterior NV Exam Closed Red 4 weeks sling IR Recurrence high

Anterior Dislocation 15M

Anterior Post Reduction Hill-Sachs Lesion Bankart Lesion

Apprehension Test

Relocation Test

Shoulder Instability Posterior dislocation easily missed Much less common (seizure d/o) Sling in neutral rotation x 4 weeks

True AP

Axillary View

Surgery Best for anterior dislocators Open (Bankart repair, Neer) Arthroscopic (Caspari)

Multi-Directional Instability Atraumatic Bilateral Global laxity Voluntary Rehab

MDI

Sulcus Sign

MDI Treatment Rehab 6-12 Months Thermal Capsulloraphy Open Capsular Shift

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