Pediatric emergency medicine trisk 0858 0858
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sternocleidomastoid muscle spasm. Localized swelling, tenderness, and
crepitations may be noted. A dedicated clavicle radiograph will confirm the
diagnosis.
Osteolysis is an uncommon cause of distal clavicle pain resulting from either
minor trauma or repetitive stress (i.e., weight lifting, overhead athlete). In
general, these patients present with 2 to 3 weeks of chronic pain or edema at the
distal clavicle. Radiographs are diagnostic.
Acromioclavicular (AC) joint injuries usually cause physeal fractures of the
distal clavicle in patients younger than 14 years. Older children may sprain or
separate the AC joint. Either injury is most often caused by a direct blow to the
shoulder. The child will have pain with any motion of the shoulder and tenderness
over the AC joint. Grade I and II injuries are nondisplaced. Grade III and IV
injuries are displaced 25% to 100%, and Grade V injuries are more than 100%
displaced. Bilateral radiographs may be obtained to compare the AC joint on the
normal and affected sides. Cosmetic deformities and degenerative changes of the
distal clavicle may complicate these injuries, even with appropriate therapy.
Scapula fractures are rare in pediatrics and usually occur only after major direct
trauma, such as a motor vehicle accident, a fall from a height, or a direct blow in
sports such as American football. The child will have tenderness over the scapula.
The patient often sustains other more life-threatening injuries (e.g., head injuries,
rib fractures, or pneumothoraces). Dedicated scapular films improve yield over
routine chest or shoulder radiographs.
The glenohumeral joint is shallow, allowing a wide range of motion but
increasing the risk of dislocation. Shoulder or glenohumeral joint dislocations are
rare in children younger than 12 years of age but become common in adolescence
as the skeleton matures. The patient is injured when an already abducted and
externally rotated arm is forcibly extended posteriorly (e.g., blocking in football
or missing a dunk and striking the rim during basketball). This action leverages
the humeral head out of the glenoid fossa. More than 95% of all dislocations are
anterior, and less than 5% are posterior. The patient will be in severe pain,
supporting the affected arm which is internally rotated and slightly abducted (i.e.,
the patient cannot bring the elbow to his or her side). The shoulder contour is
sharp due to the prominent acromion, unlike the round contour of the opposite
shoulder (see Fig. 43.2 ). The trauma can damage the axillary nerve or fracture
the glenoid fossa and/or the humeral head. Sensation over the lateral deltoid
muscle (axillary nerve distribution), lateral proximal forearm (musculocutaneous
nerve distribution), and distal pulses should be evaluated and documented.
Radiographs should always be obtained because a humeral head or clavicular
