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

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

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

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

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

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

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

9. Clavicle Fx

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

11. Posterior SC Dislocation

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

13. Cleidocranial Dysostosis

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

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

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)

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

19. Proximal Humerus Fxs

22. 3 ossification centers Tuberosities unite with head (age 7-14) Join shaft by age 19 80% growth from proximal physis

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

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

25. Little Leaguer’s Shoulder

26. UBC

27. Proximal Humerus Fxs Excellent remodeling potential

29. SH II Fx

30. Proximal Humerus Fxs

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

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

33. Proximal Humerus Fxs

34. 14 F SH II

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

36. Rotator Cuff

38. Shoulder Instability

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

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

41. Anterior Dislocation 15M

42. Anterior Post Reduction Hill-Sachs Lesion Bankart Lesion

43. Apprehension Test

44. Relocation Test

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

46. True AP

47. Axillary View

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

49. Multi-Directional Instability Atraumatic Bilateral Global laxity Voluntary Rehab

50. MDI

52. Sulcus Sign

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

54. Thank You