Fractures and Dislocations about the Shoulder in the Pediatric Patient

1. Fractures and Dislocationsabout the Shoulder in the Pediatric Patient Christopher Bray, MD Original Author: Michael Wattenbarger, MD; March 2004 1st Revision: Steven Frick, MD; August 2006 2nd Revision: Joshua Klatt, MD; December 2009 3rd Revision: Christopher Bray, MD; March 2014

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 (puberty) • Coracoid (1 yo / 10 yo) • Glenoid • Medial border (puberty) • Proximal humeral physis • Tent shaped • 80% of longitudinal growth • Medial clavicular epiphysis • Last to ossify 18-20 yrs • Last to fuse 23-25 yrs 3 yo F

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 Injury film 2.5 months

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. Functional and Radiographic Outcomes of Nonoperative Treatment of Displaced Adolescent Clavicle Fractures • 16 pts with isolated, displaced, shortened midshaft clavicle fractures • 2 year f/u minimum • 100% union rate • Significant remodeling and restoration of clavicular length (97% of uninjured side at f/u) • No significant differences in pain, strength, shoulder range of motion, or subjective outcome scores Injury Film 4 weeks Schulz et al. JBJS Am. 2013; 95: 1159-1165 3 months

15. Adolescent Clavicle Fractures • ORIF may be indicated if widely displaced or shortened • Adult literature supports ORIF for completely displaced fractures • No consensus with pediatric patients yet 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

16. Intraoperative C-arm views ORIF with 2.7 mm lag screws and pre-contoured plate

17. 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

18. Operative Versus Nonoperative Treatment of Midshaft Clavicle Fractures in Adolescents • 43displaced clavicle fractures • 25 nonoperative • 18 operative • All fractures united • Differences • Return to activities • 12 weeks operative • 16 weeks nonoperative • Symptomatic hardware requiring removal (3/18) • Symptomatic malunion requiring corrective osteotomy (5/25) Vander Have et al. JPO 2010; 30: 307-312.

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

20. Congenital Pseudarthrosis of the Clavicle • Usually right side • If left, suspect dextrocardia / situs inversus • 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.

21. Clavicular Nonunion 6 weeks delayed union postop • 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.

22. 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

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

30. 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;21:315-324.

31. 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.

32. Glenohumeral Dislocations • Rare in young children • < 2% of all dislocations are in children < 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%)

33. 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

34. Glenoid Dysplasia • May predispose to instability • May be primary or secondary (after brachial plexus palsy) 3 yo with Erb’s palsy

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

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

37. Birth Fractures of theProximal Humerus • Often Salter I type • Great remodeling potential • Simple immobilization with ACE bandage or wrap 1 day old 2 weeks

38. 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 @ 3 months Neer & Horowitz: Fractures of the proximal humeral epiphyseal plate. Orthopedics 41:24-31, 1965.

39. Metaphyseal Fxs 2.5 year old female - Injury film Hanging arm cast 4 days out from injury

40. Remodeling over 6 Months @ 3 months @ 6 months

41. 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

42. 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

43. Shoulder Immobilization • Closed treatment options: • Coaptation splint • Collar and cuff • Sling and swathe • Hanging arm cast

44. Early Healing Noted 3 Weeks after Closed Reduction in Adolescent 3 weeks after closed reduc. Injury film

45. 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

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

47. Pinning BEND PINS TO PREVENT MIGRATION, THREADED TIPS

48. Percutaneous Screw Fixation

49. Elastic Stable Intramedullary Nails • More recently proposed form of fixation • Avoid morbidity of percutaneous pins • Soft tissue irritation • Migration • Requires repeat anesthetic for removal

50. ESIN