Pediatric emergency medicine trisk 0857 0857
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CHAPTER 43 ■ Injury: Shoulder
MEGAN HANNON
INTRODUCTION
This chapter focuses on the diagnosis of the child with an acutely injured
shoulder. Injuries are described anatomically, from the sternoclavicular joint to
the proximal humerus. Figure 43.1 highlights important bony anatomy. For the
preverbal child with a possible shoulder injury presenting with an immobile arm,
see Chapter 38 Immobile Arm .
DIFFERENTIAL DIAGNOSIS
The differential diagnosis depends primarily on the location of the pain and the
mechanism of injury ( Table 43.1 ). As with all pediatric musculoskeletal injuries,
the differential diagnosis of shoulder injuries differs from adults because of the
child’s open physes (growth plates).
In children, trauma to the medial clavicle causes physeal (growth plate)
fracture/separations because the epiphysis of the medial clavicle does not begin to
ossify until 13 to 19 years of age and does not fully fuse until 22 and 25 years of
age. Once fused, trauma in this location generally results in sternoclavicular joint
dislocations. Most clavicular dislocations are anterior, and the patient has
swelling and tenderness over the sternoclavicular joint. If the dislocation is
posterior, major vessels or the trachea may be injured. Although subclavian
vessels and the brachial plexus are just beneath the clavicle, they are rarely
injured because the subclavius muscle is interposed between the bone and vessels,
and the thick periosteum of the clavicle rarely allows it to splinter. However, if
injury to the brachial plexus or trachea does occur, the child may have dysphagia,
hoarseness (laryngeal nerve), or difficulty breathing. Anteroposterior and
superiorly projected lordotic radiographs comparing both clavicles may not
visualize the dislocation and CT is usually necessary. Contrast is recommended to
assess the great vessels as well as the bony anatomy.
The clavicle is a commonly fractured bone in children. The clavicle is subject
to any medially directed force on the upper limb (e.g., a fall on shoulder) but is
commonly fractured by a direct blow. A neonate’s birthing injury or an infant’s
greenstick fracture of the clavicle may go unnoticed until the focal swelling of the
developing callus is noted. In the older child, the arm droops down and forward.
The child’s head may be tilted toward the affected side because of
