Fractures and Dislocations of Shoulder - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

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Fractures and Dislocations

about the Shoulder in the Pediatric

Patient

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

Congenital Pseudarthrosis

of the Clavicle

• Right side
• Except with dextrocardia
• If symptomatic in older child – Excise, tricortical graft, fixation

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

Type IV AC Dislocation

11 yo female

Ped vs car

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

Scapula Fractures

• May be a sign of significant trauma
• Usually nonoperative treatment
• Growth centers may be confused with fracture
• Axillary view often helpful

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

Pinning Proximal Humerus

• Usually don’t 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

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

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