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!

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

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

8. Medial Clavicular Injuries

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

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

13. Typical Healing

14. Adolescent Clavicle Fractures ORIF may be indicated if widely displaced or shortened Adult literature supports ORIF for completely displaced fractures

15. Intraoperative C-arm views

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

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

19. Clavicular Nonunion

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

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

27. Suture Fixation around Coracoid

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 - Classification Multiple systems Mostly descriptive and anatomically based Can have fracture through common growth center of coracoid and glenoid (III)

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

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

33. 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%)

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- < 5 mm Grade II - < 1/3 shaft width Grade III - <= 2/3 shaft width Grade IV - > 2/3 shaft width

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

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

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

52. ESIN

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

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

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

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