Diagnostic approach to the child or adolescent with an isolated shoulder injury*

AP: anteroposterior.
* This algorithm is meant for the diagnosis of isolated shoulder pain in verbal pediatric patients who can reliably describe their pain. Shoulder pain may be referred from significant injury to the cervical spine, myocardium, or abdomen. Ensure no abnormal findings in these regions before proceeding with evaluation for an isolated shoulder injury. Refer to UpToDate topics on referred shoulder pain.
¶ For a description of the apprehension test, refer to UpToDate graphics and topics on shoulder dislocation.
Δ More than one fracture or dislocation may be demonstrated. Shoulder dislocation is rare in children younger than 12 years of age. The humerus is frequently a site for pathologic fractures in patients with benign and malignant bone lesions. Refer to UpToDate topics on osteosarcoma, Ewing sarcoma, and benign bone tumors in children and adolescents.
◊ Emergency computed tomography may be necessary to demonstrate a posterior sternoclavicular dislocation.
§ For a description of the Speed and Yergason tests, refer to UpToDate content on evaluation of shoulder injury in children.
¥ D-dimer testing and ultrasonography help confirm the diagnosis. Refer to UpToDate topics on primary (spontaneous) upper extremity deep vein thrombosis.
‡ A positive Roos test refers to reproduction of pain, numbness, and/or paresthesias when the patient holds the arms overhead with elbows flexed and rapidly opens and closes the hands for three minutes.
† Pain with passive adduction of the arm that compresses the acromioclavicular joint constitutes a positive cross body adduction test.