Shoulder Dislocation

Shoulder Dislocation

Kids always seem to test gravity… and continually find that it works.  While gravity certainly has its advantages, it also tends to lead to a fair amount of injuries for our pediatric patients.  We have covered numerous orthopaedic topics previous in the PedEM Morsels (ex, osteomyelitis, patellar dislocation, SCFE, supracondylar fractures, nursemaid’s elbow), but let’s take a moment to look at yet another: Shoulder Dislocation.

 

Shoulder Dislocations in Kids

  • Shoulder dislocations are less common in children than adults.
  • ~20% of all glenohumeral dislocations occur in patients <20 years of age.
  • <2% occur in kids younger <10 years of age. [Zacchilli, 2010]

 

Shoulder Anatomy

  • The proximal humerus has 3 primary ossifications centers:
    • Humeral Head
    • Great Tuberosity
    • Lesser Tuberosity
  • Ossification centers close between 5-7 years of age.
  • The proximal humeral physis then fuses to humeral shaft between 14-17 years.
  • Inherently unstable joint:
    • The glenoid fossa is shallow.
    • Stability of the joint is most dependent upon the ligamentous, muscular, and joint capsule structures.
  • The proximal humeral physis is extra-articular in skeletally immature kids.
  • Physeal fractures are possible after shoulder dislocation in the skeletally immature. [Xinning, 2013]
  • The shoulder capsule, however, is more elastic in the younger children, and may help prevent recurrent dislocations in the future.

 

Shoulder Dislocation Presentation

  • Traumatic shoulder dislocations often have obvious deformity.
    • Arm is typically ADDucted and internally rotated (if anteroinferior dislocation).
    • Acromion will appear prominent.
    • Palpable cavity beneath the acromion, where the humeral once was sitting.
  • May also occur without an associated trauma.
    • Often due to prior dislocation related joint instability.
    • May be more subtle and the patient may describe an apprehension that it will dislocate.

 

Shoulder Dislocation Evaluation

  • Axillary nerve is the most commonly injured nerve during shoulder dislocations.
    • As always, assessment of neurologic status is imperative.
  • Do you need prereduction films?
    • If there is a question as to whether it is dislocated, then yes.
    • If there was an associated high-energy mechanism, then yes.
    • If clinically apparent and non-concerning mechanism, then no. [Reid, 2013]
    • May want a lower threshold for imaging before reduction in the skeletally immature patients (<14 years of age).

 

Shoulder Dislocation Management

  1. Don’t be cruel… Manage the pain!
    • Consider some intranasal meds to start with.
    • Consider an intra-articular injection.
      • May use ultrasound guidance to assist with this. [Breslin, 2014]
    • May require procedural sedation – especially if it has been out for a prolonged time.
  2. Be gentle!
    • Do not use forceful jerking or attempt to leverage the humeral head over the glenoid.
    • Take your time to learn several methods (shoulderdislocation.net).
  3. Place in sling. 
    • Conventional therapy is to immobilize for ~3 weeks.
    • This will be followed by aggressive physical therapy for most.
  4. Post-reduction plain films with axillary view.
  5. Arrange for ortho follow-up as they will need physical therapy to help them recover.
    • There is debate about the best management strategy for primary dislocations in children. [Xinning, 2013]
    • For active, young, adults, early surgical stabilization may be beneficial.
      • Especially true for those with evidence of Bankart lesion on MRI.
    • For skeletally immature children (<14 years of age), nonsurgical options are generally favored.
      • This age group has a lower rate of recurrent instability of the joint.
      • If recurrence occurs, surgical correction will be needed, but often it is delayed until skeletal maturity. [Bishop, 2005]

 

References

Breslin K1, Boniface K, Cohen J. Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department. Pediatr Emerg Care. 2014 Mar;30(3):217-20. PMID: 24589815. [PubMed] [Read by QxMD]

Reid S1, Liu M, Ortega H. Anterior shoulder dislocations in pediatric patients: are routine prereduction radiographs necessary? Pediatr Emerg Care. 2013 Jan;29(1):39-42. PMID: 23283261. [PubMed] [Read by QxMD]

Li X1, Ma R, Nielsen NM, Gulotta LV, Dines JS, Owens BD. Management of shoulder instability in the skeletally immature patient. J Am Acad Orthop Surg. 2013 Sep;21(9):529-37. PMID: 23996984. [PubMed] [Read by QxMD]

Zacchilli MA1, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010 Mar;92(3):542-9. PMID: 20194311. [PubMed] [Read by QxMD]

Bishop JY1, Flatow EL. Pediatric shoulder trauma. Clin Orthop Relat Res. 2005 Mar;(432):41-8. PMID: 15738802. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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