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Fractures and Dislocations

about the Shoulder in the


Pediatric Patient

Steven Frick, MD

Created March 2004; Revised August 2006


Developmental Anatomy-
Ossification Centers and Physes
Scapular ossification
centers acromion,
coracoid, glenoid,
medial border
Proximal humeral
physis tent shaped,
80% of longitudinal
growth
Medial clavicular
physis last to close
23-25 yrs
Clavicle Fxs
Most common fx in children
50% in <10 yo
Usually midshaft
Almost always heals, usually clinically
insignificant malunion
Remodels within 1 year
Complications very uncommon
Clavicle Fx Patterns

Most in middle
5% distal
<5% medial
Beware nutrient
foramen- not a fx
Clavicle Fractures

Greenstick common
Typical Healing
Clavicle Birth Fxs

Large baby
Pseudoparalysis
Simple immobilization
If no BP palsy active
movement should return
early
Congenital Pseudarthrosis
of the Clavicle

Right side
Except with
dextrocardia
If symptomatic in older
child Excise,
tricortical graft, fixation
Clavicular Nonunion
Distal Clavicle Fx / AC Injury

Often intact periosteum


Usually remodels
Nonoperative tx
Distal Clavicle Fractures-
Classification
Similar to adults
Based on amount and
direction of
displacement
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 Coracoid
posterior

Acromion
Suture Fixation around Coracoid

POSTOP

PREOP
Final X-ray- Full Motion
Medial Clavicular Injuries
Medial clavicular
physis last to close
22-24 yo
Clavicle shaft usually
anterior
May displace
posteriorly
Serendipity view or
CT if suspect
CT Scan Posteriorly Displaced
Medial Clavicle Injury
Scapula Fractures
May be a sign of
significant trauma
Usually nonoperative
treatment
Growth centers may
be confused with
fracture
Axillary view often
helpful
Coracoid base fracture
Scapula Fractures - Classification
Can have fracture
through common
growth center of
coracoid and glenoid
Scapula Fractures - Classification
Body
Neck
Glenoid
Acromion
Coracoid
Intraarticular or
extrarticular
Glenohumeral Dislocations
Rare in children < 12 years old
High risk of recurrent instability when
initial dislocation occurs in childhood or
adolescence
Anterior, Posterior or Inferior direction
Traumatic or Atraumatic etiology
Glenoid Dysplasia
May predispose to
instability
May be primary or
secondary (after
brachial plexus palsy)
Traumatic Shoulder Dislocation
Gentle reduction
Immobilization for
approx 3 weeks
Shoulder rehabilitation
Surgical stabilization
/reconstruction
reserved for recurrent
instability
Atraumatic Instability
Often multiple joint
ligamentous laxity
Multidirectional
instability usually
present
May be voluntary
(discourage)
Rotator cuff
strengthening
Proximal Humerus Fxs
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
Proximal Humerus
Acceptable Alignment
Great remodeling potential 80% of
humeral length contributed by proximal
physis
Shoulder ROM compensatory
Age dependent? some studies state that
even older adolescents have acceptable
functional outcomes after nonoperative
treatment of prox humerus fxs
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
Metaphyseal Fxs
Remodeling over 6 Months
Pinning Proximal Humerus
Usually dont need to
Most recent studies quote high complication
rates (pin migration, infection)
If used leave pins long and bend outside
skin, consider threaded tip pins
Even in older adolescents remodeling
occurs
Few functional deficits
Percutaneous Pinning-
this technique may lead to pin migration
Pinning

BEND PINS TO PREVENT


MIGRATION, THREADED TIPS
Treatment Principles-
Proximal Humerus
Closed treatment for vast majority
If markedly displaced, attempt closed
reduction and immobilize
Reserve closed reduction and pinning, open
reduction for fractures with significant
displacement (> Neer II) in older
adolescents, recurrent displacement
Early Healing Noted 3 Weeks
after Closed Reduction in Adolescent

Injury film 3 weeks after closed reduc.


Percutaneous Screw Fixation
Shoulder Immobilization-
Coaptation Splint
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
Shoulder Region Fractures-
Indications for Open Reduction
Open fractures
Displaced intraarticular fractures
Multiple trauma to facilitate rehabilitation
Severe displacement with suspected soft
tissue interposition
Humeral Shaft Fractures in Children

Neonates birth trauma


Neonates to age 3 consider possible non-
accidental trauma
Age 3-12 often pathologic fracture
through benign bone tumor or cyst
Older than age 12 treatment like adults
Birth Fractures
Simple immobilization
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
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
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