Pediatric Shoulder Fractures and Dislocations: Types, Treatments, and Complications
Learn about pediatric shoulder fractures and dislocations, including the types, treatments, and potential complications. Find information on proximal humeral fractures, clavicle fractures, scapula fractures, and glenohumeral dislocations.
Pediatric Shoulder Proximal Humeral Fractures
The pediatric shoulder is a complex joint that undergoes significant changes during growth and development. Proximal humeral fractures in children are commonly seen, and the timing and type of fracture depend on the ossification center of the humerus. The following are some important points to consider:
- The humeral head ossifies at 6 months
- The greater tuberosity ossifies at 1 to 3 years
- The lesser tuberosity ossifies at 4 to 5 years
- Multiple muscular forces contribute to deforming the fracture
- Fractures can be indirect (resulting from a fall backward onto an outstretched hand with the elbow extended and the wrist dorsiflexed) or direct (resulting from direct trauma to the posterolateral aspect of the shoulder)
| Type of Fracture | Description |
|---|---|
| Type I | Transphyseal fracture; usually a birth injury |
| Type II | Transphyseal fracture that exits through the metaphysis; usually occurring in adolescents (>12 years old); metaphyseal fragment always posteromedial |
| Type III | Transphyseal fracture that exits through the epiphysis uncommon; associated with dislocations |
| Type IV | Rare; fracture that traverses the epiphysis and the physis, exiting the metaphysis; associated with open fractures |
Closed reduction is the treatment of choice for stable fractures, achieved by applying gentle traction, 90 degrees of flexion, then 90 degrees of abduction and external rotation. The arm is immobilized against the chest for 5 to 10 days. Unstable fractures may require a shoulder spica cast with the arm in the salute position for 2 to 3 weeks, followed by a sling and progressive return to activity.
Clavicle Fractures in Children
Clavicle fractures in children can occur due to direct or indirect trauma and even birth injuries. Some important points about clavicle fractures in children include:
- Fall onto an outstretched hand is the most common mechanism for indirect fractures
- Direct fractures are the most common and can result in injury to neurovascular and pulmonary structures
- Birth injuries can occur due to direct pressure or obstetric pressure on the clavicle during delivery
| Fracture Type | Description |
|---|---|
| Type I | Middle third (most common) |
| Type II | Distal to the coracoclavicular ligaments (lateral third) |
| Type III | Proximal (medial) third |
Treatment for clavicle fractures usually involves nonoperative management with a sling or figure-eight strap. Surgery may be necessary in rare cases of nonunion or significant displacement.
Scapula Fractures in Children
Scapula fractures in children are rare and often associated with other upper torso injuries. Detection and treatment can be challenging due to the complex anatomy of the shoulder blade. Some important points include:
- Associated with ipsilateral upper torso injuries like fractured ribs or clavicles
- Pneumothorax and pulmonary contusion are common complications
- Neurovascular and spinal column injuries may occur
| Fracture Type | Description |
|---|---|
| IA | Anterior avulsion fracture |
| IB | Posterior rim avulsion |
| II | Transverse with inferior free fragment |
| III | Upper third including coracoid |
| IV | Horizontal fracture extending through body |
| V | Combined II, III, and IV |
| VI | Extensively comminuted |
Glenohumeral Dislocations
Glenohumeral dislocations in children are rare and often occur due to trauma or underlying joint laxity. The following are some important points to consider:
- Neonates may have a pseudodislocation due to a traumatic epiphyseal separation of the proximal humerus
- An anterior dislocation may occur due to an anteriorly directed impact to the posterior shoulder, while a posterior dislocation may occur from force applied to the anterior shoulder
- A subluxation may occur from repetitive injuries or joint laxity
| Dislocation Type | Description |
|---|---|
| Type I | Subcoracoid |
| Type II | Subglenoid |
| Type III | Intrathoracic |
Treatment for glenohumeral dislocations depends on the type and degree of instability. Nonoperative management may be appropriate for some stable dislocations while surgical intervention may be necessary for recurrent or unstable dislocations.
1. Which ossification center of the humerus usually ossifies first in children?
Answer: a) Humeral head. The humeral head is the first ossification center to ossify in children, usually at 6 months.
2. Which type of proximal humeral fracture usually occurs in adolescents and has a posteromedial metaphyseal fragment?
Answer: b) Type II. Type II proximal humeral fractures occur in adolescents (>12 years old) and have a metaphyseal fragment that is always posteromedial.
3. What is the most common mechanism for clavicle fractures in children?
Answer: a) Fall onto an outstretched hand. Clavicle fractures in children usually occur due to a fall onto an outstretched hand.
4. Which type of scapula fracture involves an anterior avulsion?
Answer: a) IA. Type IA scapula fractures involve an anterior avulsion fracture.
5. What is the likely cause of an anterior glenohumeral dislocation in children?
Answer: a) Anteriorly directed impact to the posterior shoulder. An anterior glenohumeral dislocation in children may occur due to an anteriorly directed impact to the posterior shoulder.