1. 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

2. Shoulder Trauma 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.

3. Shoulder Region Fractures- Indications for Open Reduction
Open fractures
Displaced intraarticular fractures
Multiple trauma to facilitate rehabilitation
Severe displacement with suspected soft tissue interposition

4. 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 epiphysis
Last to ossify yrs
Last to fuse yrs

5. Medial Clavicular Injuries
Clavicle 1st bone to ossify (intrauterine week 5), but medial clavicular epiphysis last to appear and close
18 to 20 and yrs, respectively
Most injuries are Salter-Harris type I or II, but true dislocations may occur
Important to differentiate, as treatment differs

6. 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

7. 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.

8. Medial Clavicular Injuries
Notice: Medial tip of clavicle adjacent to aortic arch!

9. 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.

10. 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

11. Diaphyseal Clavicle Fx Patterns
Most in middle 1/3 (90%)
5% distal
<5% medial
Beware--nutrient foramen may look like a fracture

12. Clavicle Fractures
Greenstick common

13. Typical Healing

14. 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

15. Intraoperative C-arm views
ORIF with lag screw and 2.7 mm DCP plate because of smaller size of adolescent clavicle

16. 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

17. Clavicle Birth Fxs Large baby Pseudoparalysis Simple immobilization
If no plexus palsy active movement should return early

18. 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.

19. 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.

20. 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

21. Distal Clavicle Fractures- Classification
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; p

22. Distal Clavicle Injuries – Periosteal Sleeve

23. Periosteal Sleeve Fills In

24. Type IV AC Dislocation
11 yo female
Ped vs car

25. Initial XR

26. from front ------------from behind
Distal clavicle posterior
Coracoid
Acromion

27. Suture Fixation around Coracoid
POSTOP
PREOP

28. Final X-ray- Full Motion

29. Scapula Fractures May be a sign of significant trauma
Think of NAT in small children
Usually nonoperative treatment, unless intra-articular
Growth centers may be confused with fracture
8-10 ossification centers
Axillary view often helpful
Coracoid base fracture

30. 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] 74:299-
305, 1992.

31. 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
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:

32. 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.

33. Glenohumeral Dislocations
Rare in young children
< 2% of all dislocations are in children < 10 yrs
20% are in children yrs
Most are anterior, as in adults
Frequently associated Hill-Sachs lesion
High rate of recurrent instability in childhood or adolescence (70-100%)

34. 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

35. Glenoid Dysplasia May predispose to instability
May be primary or secondary (after brachial plexus palsy)

36. Atraumatic Instability
Often multiple joint ligamentous laxity
Multidirectional instability usually present
May be voluntary (discourage)
Treat with rotator cuff strengthening

37. Proximal Humerus Fxs Birth injuries 0-5 yo Salter I
5-11 yo metaphyseal
11 to maturity –
Salter II
Others rare (III, IV)

38. Birth Fractures of the Proximal Humerus
Often Salter I type
Great remodeling potential
Simple immobilization with ACE bandage or wrap

39. 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.

40. Metaphyseal Fxs

41. Remodeling over 6 Months

42. Treatment Principles- Proximal 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

43. 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

44. Treatment Algorithm

45. Shoulder Immobilization- Coaptation Splint

46. Early Healing Noted 3 Weeks after Closed Reduction in Adolescent
Injury film

47. 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

48. Percutaneous Pinning- this technique may lead to pin migration

49. Pinning
BEND PINS TO PREVENT MIGRATION, THREADED TIPS

50. Percutaneous Screw Fixation

51. 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.

52. ESIN Fernandez et al: Treatment of severely displaced proximal humerus
fractures in children with retrograde ESIN. Injury 39:1453-9, 2008.

53. 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

54. 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

55. Birth Fractures Simple immobilization with ACE bandage or wrap
May have pseudoparalysis
Little attention to realignment or reduction needed

56. Pathologic Humeral Fracture through UBC
Note fallen leaf sign and also pseudosubluxation inferiorly

57. Humeral Shaft Fractures- Treatment
Usually closed methods
Sling and swathe
Coaptation splint
Fracture bracing
Hanging arm cast

58. Segmental Humeral Fractures- “Hanging Arm” Cast Treatment
Use collar and cuff rather than sling to allow gravity to help align fracture

59. Indications for surgical management
Polytrauma
Allow earlier ambulation
Neurovascular compromise
Note: An open midshaft humerus fracture is necessarily not an indication for fixation!

60. 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

61. Bibliography
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. JBJS-Am 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; p
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: , 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:
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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