Fractures and Dislocations about the Shoulder in the Pediatric Patient

1
Fractures and Dislocationsabout 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
43241-8, 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 18-20 yrs
• Last to fuse 23-25 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 23-25 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

http//emedicine.medscape.com/article/398799-overv
iew
7
Medial Clavicular Injuries

• Fractures usually heal and remodel
• Attempt reduction if
• Injury lt 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 4268278, 1996. -Worman
Leagus Intrathoracic injury following
retrosternal dislocation of the clavicle. J
Trauma 7416423, 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
• Dont excise epiphysis
• Use suture fixation, NOT wires

-Wirth Rockwood Acute and chronic traumatic
injuries of the sternoclavicular joint. J
Am Acad Orthop Surg 4268278, 1996. -Worman
Leagus Intrathoracic injury following
retrosternal dislocation of the clavicle. J
Trauma 7416423, 1967.
10
Diaphyseal Clavicle Fxs

• Most common fx of shoulder in children
• 10-15 of all fractures
• 50 are in children lt10 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
• lt5 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
831621, 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
227369, 2002. Endrizzi et al Nonunion of the
clavicle treated with plate fixation. J
Shoulder Elbow Surg 17951-3, 2008.
20
Distal Clavicle Fx / AC Injury

• AC separation very uncommon in children lt
  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
196328111-9
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.
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 58191-2, 1987. Goss TP Fractures of the
glenoid cavity. J Bone Joint Surg Am 74299-
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

http//www.shouldersurgeon.com/shoulder_injury/fra
ctures_floating_shoulder.htm Goss TP. Scapular
Fractures and Dislocations Diagnosis and
Treatment. J Am Acad Orthop Surg. Jan
19953(1)22-33. Curtis RJ. Operative management
of children's fractures of the shoulder region.
Orthop Clin North Am 199021315-324.
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 ChildA
Case Report and Review of the Literature. J
Orthop Trauma 11452-4, 1997.
33
Glenohumeral Dislocations

• Rare in young children
• lt 2 of all dislocations are in children lt 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)

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 theProximal 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- lt 5 mm
• Grade II - lt 1/3 shaft width
• Grade III - lt 2/3 shaft width
• Grade IV - gt 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
4124-31, 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
• (gt 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
3 weeks after closed reduc.
Injury film
47
Pinning Proximal Humerus

• Usually dont 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 391453-9, 2008.
52
ESIN
Fernandez et al Treatment of severely displaced
proximal humerus fractures in children with
retrograde ESIN. Injury 391453-9, 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
  43241-8, 2005.
• Wirth Rockwood Acute and chronic traumatic
  injuries of the sternoclavicular joint. J Am Acad
  Orthop Surg 4268278, 1996.
• Worman Leagus Intrathoracic injury following
  retrosternal dislocation of the clavicle. J
  Trauma 7416423, 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 831621,
  1988.
• Kubiak Slongo Operative treatment of clavicle
  fractures in children. J Pediatr Orthop 227369,
  2002.
• Endrizzi et al Nonunion of the clavicle treated
  with plate fixation. J Shoulder Elbow Surg
  17951-3, 2008.
• Tossy JD, Mead NC, Sigmond HM Acromioclavicular
  separation useful and practical classification
  for treatment. Clin Orthop 28111-9, 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 58191-2, 1987.
• Goss TP Fractures of the glenoid cavity. J Bone
  Joint Surg Am 74299-305, 1992.
• Goss TP. Scapular Fractures and Dislocations
  Diagnosis and Treatment. J Am Acad Orthop Surg.
  Jan 19953(1)22-33.
• Curtis RJ Operative management of children's
  fractures of the shoulder region. Orthop Clin
  North Am 199021315-324.
• Lee S, et al Open Reducion and Internal Fixation
  of a Glenoid Fossa Fracture in a ChildA Case
  Report and Review of the Literature. J Orthop
  Trauma 11452-4, 1997.
• Neer Horowitz Fractures of the proximal
  humeral epiphyseal plate. Orthopedics 4124-31,
  1965.
• Dobbs, et al Severely displaced proximal humeral
  epiphyseal fractures. J Pediatr Orthop 23208-15,
  2003.
• Fernandez et al Treatment of severely displaced
  proximal humerus fractures in children with
  retrograde ESIN. Injury 391453-9, 2008.

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