Version May 2024
INTRODUCTION — The evaluation of traumatic shoulder injury in children and adolescents will be discussed here. The traumatic causes of shoulder pain and injury in children and adolescents and the physical examination of the shoulder are reviewed separately. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents" and "Physical examination of the shoulder".)
EPIDEMIOLOGY — Pediatric shoulder injuries are very common. Among active children and adolescents, the incidence of shoulder injuries increases as the participation in overhead activities such as baseball and volleyball rises. Among high school athletes in the United States, the overall rate of shoulder injuries is approximately 2.2 injuries per 10,000 athletic exposures (one athlete participating in one practice or competition) [1]. Strains and sprains are most common, followed by shoulder separations or dislocations. Despite the risk for traumatic shoulder injury during any competitive activity, the greatest risk for shoulder injury requiring intervention occurs during contact sports such as football, wrestling, and rugby [1,2].
CLINICAL ANATOMY — A complex network of anatomic structures endows the human shoulder with tremendous mobility, greater than any other joint in the body. The shoulder girdle is composed of three bones (the clavicle, scapula, and proximal humerus) and four articular surfaces (sternoclavicular, acromioclavicular [AC], glenohumeral, and scapulothoracic) (figure 1A-C). The glenohumeral joint, commonly referred to as the shoulder joint, is the principal articulation. The shoulder is an inherently unstable joint that relies on several delicate interactions to minimize the risk for injury. The shape and interaction of the bones and soft tissues of the shoulder girdle are essential to understanding the factors leading to shoulder stability and to identify injury.
●Glenohumeral structures – The glenohumeral joint is loosely constrained within a thin capsule bounded by surrounding muscles and ligaments (figure 1A-C and table 1). The shoulder's great mobility is due in large part to the shallow depth of the glenoid and the limited contact between the glenoid and the humeral head. Only 25 percent of the humeral head surface makes contact with the glenoid. The labrum, a fibrocartilaginous ring attached to the outer rim of the glenoid, provides some additional depth and stability [3,4]. It also serves as a bumper to decrease the potential for humeral head subluxation. The shallowness and small surface area of the glenohumeral joint make it susceptible to instability and injury and require that stability be provided primarily by extrinsic supports.
Surrounding muscles and ligaments provide these supports:
•The glenohumeral ligaments are collagenous reinforcement of the capsule and quite variable in their thickness, anatomic position, and their contribution to shoulder stability (figure 1B). The glenohumeral ligaments serve as the primary static stabilizer [5-7].
The inferior glenohumeral ligament complex (IGHL) is made up of the anterior and posterior bands and the posterior axillary pouch that form a hammock like structure. In abduction and external rotation, the anterior band is the primary restraint to anterior translation of the humeral head [5,6].
In the absence of the anterior IGHL, the middle glenohumeral ligament may provide some restraint to anterior humeral translation [7].
In the flexion and internal rotation, the posterior band of the IGHL and the posterior capsule are the primary restraints for posterior movement (translation) of the humeral head relative to the glenoid [6].
•The rotator cuff serves as the primary dynamic stabilizer. The rotator cuff is composed of four muscles (supraspinatus, infraspinatus, subscapularis, and teres minor) that form a cuff around the head of the humerus, to which these muscles attach (figure 2). The rotator cuff compresses the humoral head in the glenoid fossa, thereby stabilizing the glenohumeral joint, and serves to counterbalance the elevating forces of the deltoid, as well as the forces of other muscles acting on the humerus. (See "Evaluation of the adult with shoulder complaints", section on 'Glenohumeral structures'.)
●Other structures – The clavicle serves as a strut attaching the upper extremity to the axial skeleton through the AC and sternoclavicular joints and the scapulothoracic articulation (figure 1A-C). The function of the clavicle includes supporting the weight of the arm, providing additional dynamic mobility to the arm, and transferring force from the arm to the rest of the skeleton.
The sternoclavicular joint has the least amount of bony stability of the major joints of the body, but paradoxically bears the responsibility of being the only true articulation between the upper extremity and the axial skeleton. The convex articular surface of the clavicle is much larger than the curved notch of the sternum resulting in an incongruous mismatch. Despite this instability, dislocation at this joint is rare. Both bones are covered with thick fibrocartilage (not the usual hyaline cartilage) and are separated by an intervening fibrocartilage disk which provide added cushion to the joint.
The muscles primarily responsible for scapular stability and motion are the trapezius, serratus anterior, rhomboids, and levator scapulae (figure 3).
The AC joint is supported by ligaments that span its anterior, superior, posterior, and inferior aspects (picture 1). These ligaments also envelop the distal 1 to 2 cm of the clavicle. In addition to the AC ligaments, the distal clavicle is held in alignment with the acromion by the strong coracoclavicular (CC) ligaments. These ligaments consist of the conoid ligament medially and the trapezoid ligament laterally.
●Bony development – As a general rule, the bones that form the shoulder girdle (ie, scapula, humerus, and clavicle) are not fully ossified in children and young adolescents (table 2) [8-15]. Thus, the skeletally immature athlete has open epiphyses that are two to five times weaker than the surrounding soft tissues and are prone to fracture.
In some patients, skeletal immaturity or variation in ossification can lead to misdiagnosis because these injuries are not the same as seen in adults. A few examples include:
•A lateral epiphysis fracture of the clavicle can be confused with an AC joint injury (eg, AC sprain or separation).
•Bipartite coracoid may be mistaken as a coracoid fracture.
•Salter I fracture of the proximal humerus may be misdiagnosed as a soft tissue injury.
•Medial clavicular epiphysis fracture can be confused with a sternoclavicular dislocation.
•Os acromiale can be mistaken for an acromion fracture
ETIOLOGY — The location of pain helps to narrow the differential diagnosis of acute traumatic shoulder injury and focus the evaluation (table 3).
EVALUATION — History, physical examination, and imaging typically establishes the diagnosis of acute traumatic shoulder pain.
Identify life-threatening injury — In all traumatized adolescents and children presenting with shoulder pain, begin with a neck examination and assessment of airway, breathing, circulation, and neurologic status to ensure there is no life-threatening injury. (See "Trauma management: Approach to the unstable child", section on 'Primary survey'.)
Patients with a concern for neck injury should undergo cervical spinal motion restriction (immobilization) before further examination. There should be no focal neck tenderness or neurologic deficit before proceeding to evaluate for an isolated shoulder injury.
History — A routine history will aid in the diagnosis of shoulder pain. Understanding the location of pain and mechanism of injury will further guide the physical examination to confirm the diagnosis. Pain with shoulder movement, limited range of motion, and decreased strength compared with the unaffected side suggest intrinsic shoulder pathology. Referred pain to the shoulder is possible with more serious injuries such as abdominal, cardiac, and cervical spine pathology.
Anterior pain
●Sternoclavicular injury – The most common mechanism is an indirect force on the anterolateral or posterolateral shoulder. Less commonly, injuries may also result from direct trauma (eg, misplaced kick to the medial clavicle and sternum during soccer or mixed martial arts competition or a helmet blow during American football). Patients will describe anterior shoulder or chest pain. Posterior sternoclavicular dislocations may present with patients complaining of dyspnea, dysphagia, or hoarseness. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents", section on 'Sternoclavicular injury'.)
●Clavicular injury – The mechanism of injury most commonly consists of a fall onto the point of the shoulder but may include a fall onto outstretched arm or direct trauma. Clavicle fractures often occur in the middle third of the shaft. Focal tenderness and swelling are common following injury. Often a snapping or cracking sensation will be described at time of injury. Patients will also complain of worsening pain with shoulder movement. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents", section on 'Clavicle injuries'.)
If the patient fell directly on the distal shoulder and points to the distal clavicle as the source of pain, the patient may have a distal clavicle fracture, or acromioclavicular (AC) injury. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents", section on 'Distal clavicle contusion (shoulder pointer)'.)
●Biceps tendonitis – Although uncommon, acute injury in adolescents may exacerbate biceps tendonitis with anterior pain over the bicipital groove and may radiate distally toward the biceps muscle. Patients will describe worsening pain with overhead activity or lifting objects. Pain is secondary to overuse from repetitive trauma to the tendon. (See "Biceps tendinopathy and tendon rupture", section on 'Clinical presentation'.)
●Acromioclavicular injury – AC injuries almost always affect adolescents, rather than prepubertal children, and occur from direct trauma to the shoulder, falling on the point of the shoulder with arm adducted, or falling on an outstretched hand. Pain will be anterolateral over the AC joint. Patients will complain of worsening pain with shoulder flexion and adduction. (See "Acromioclavicular joint injuries ("separated" shoulder)", section on 'History and examination'.)
●Superficial contusion – Bruises in the anterior shoulder area typically occur after a direct blow and may cause significant pain with limitation of motion. Patients complain of pain at the site of injury.
Posterior pain
●Scapula fracture – Scapula fractures occur following high force trauma such as from a motor vehicle collision, fall from a height, or direct blow in football. Due to the mechanism of injury, scapula fractures are not often an isolated injury; further evaluation for life-threatening or associated injuries is necessary. Patients will have pain posteriorly that worsens with shoulder movement. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents", section on 'Scapula fractures'.)
●Superficial contusion – Bruises in the posterior shoulder area typically occur after a direct blow and may cause significant pain with limitation of motion. Patients complain of pain at the site of injury.
Poorly localized pain
●Proximal humerus fracture – High-energy direct trauma and falls onto an outstretched hand can cause proximal humerus fractures. Most common is a history of falling backwards on an outstretched arm. Patients will describe pain and swelling of the shoulder. Pain is often diffuse but may localize over the greater tuberosity. They will present with their arm adducted and held tightly against their chest to minimize movement. They may also describe decreased sensation along the axillary nerve distribution (skin over the lateral shoulder ["shoulder badge" distribution]). (See "Proximal humeral fractures in children", section on 'Proximal humerus fractures'.)
Symptoms of proximal humeral fracture after minimal trauma raises the concern for a pathologic fracture through a benign or malignant lesion (eg, osteochondroma, unicameral bone cysts, nonossifying fibromas, malignant chondroblastoma, osteogenic sarcoma, or Ewing sarcoma). (See "Nonmalignant bone lesions in children and adolescents" and "Osteosarcoma: Epidemiology, pathology, clinical presentation, and diagnosis" and "Clinical presentation, staging, and prognostic factors of Ewing sarcoma", section on 'Clinical presentation'.)
Nonfocal shoulder pain (more often chronic than acute) in skeletally immature baseball pitchers suggests proximal humeral epiphysiolysis (Little League shoulder) caused by microtrauma at the proximal humeral physis during throwing. (See "Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach", section on 'Proximal humeral epiphysiolysis (Little League shoulder)'.)
A humeral fracture arising from a reported low-force mechanism (eg, being hit by a toy or other small object) or without a plausible history in any young child should lead to careful evaluation for child abuse, including consultation with a child abuse specialist (table 4 and table 5). (See "Physical child abuse: Recognition", section on 'Fractures' and "Physical child abuse: Diagnostic evaluation and management", section on 'Approach'.)
●Glenohumeral dislocation, subluxation, and instability – Although more common in skeletally mature adolescents and rare in children younger than 12 years of age, anterior and posterior glenohumeral dislocations may still occur in children. Clinicians considering a glenohumeral injury in a child younger than 12 years of age should also assess for the more likely possibilities of a clavicular fracture or proximal humeral fracture. Anterior dislocations typically follow a force to the abducted, externally rotated and extended arm, force to the posterior shoulder, or a fall on an outstretched hand (eg, blocking a basketball shot or arm tackling in American football). Posterior shoulder dislocations result following force to the anterior shoulder or axial loading of an adducted and internally rotated arm (eg, lineman blocking in American football). In either case patients will present with severe shoulder pain and limited movement. Shoulder subluxation and instability often present with similar findings to shoulder dislocations. (See "Shoulder dislocation and reduction".)
Referred pain/extrinsic
●Cervical spine injury – Injuries to the cervical spine occur following an axial load. Patients may also describe hyperflexion or hyperextension of the neck at the time of axial loading. Patients frequently report neck pain. Neurologic symptoms may also be described in the history including transient or permanent paralysis. (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)
●Abdominal injury – Referred pain to the shoulder from an abdominal injury occurs from free intraperitoneal blood irritating the diaphragm. Patients with referred pain will describe a direct force to the abdomen. In addition to also complaining of abdominal pain they may describe symptoms of hypovolemia such as dizziness and light-headedness. (See "Liver, spleen, and pancreas injury in children with blunt abdominal trauma".)
●Myocardial injury – Blunt cardiac trauma may rarely present with myocardial ischemia and referred pain to the shoulder. (See "Initial evaluation and management of blunt cardiac injury".)
●Brachial plexus injuries (burners and stingers) – Injuries occur as a result of compression, traction, or direct force to the brachial plexus. Traction occurs when the shoulder is depressed and the head is forced away from the injured side (eg, during tackling in American football), while compression of the nerve roots occurs when the head is forced to the side of injury. Patients will describe burning or stinging pain down one arm that resolves within seconds to minutes. They may be seen shaking their arm at the time of injury or holding their arm close to the body. (See "Burners (stingers): Acute brachial plexus injury in the athlete", section on 'Clinical features'.)
●Spontaneous axillary or subclavian vein thrombosis (Paget Schroetter disease) – Most often spontaneous axillary or subclavian vein thrombosis (Paget Schroetter disease) is associated with repetitive overhand movements which can compress the axillary and subclavian veins. It may also occur following a single traumatic event around the shoulder or clavicle such as a clavicle fracture. Patients will complain of pain, diffuse swelling, numbness and easy fatigability in the affected arm. An elevated D-dimer raises suspicion for thrombosis and ultrasonography provides a rapid means of confirmation. (See "Primary (spontaneous) upper extremity deep vein thrombosis", section on 'Acute upper extremity deep vein thrombosis' and "Primary (spontaneous) upper extremity deep vein thrombosis", section on 'Diagnosis'.)
●Thoracic outlet syndrome – Thoracic outlet syndrome may rarely be found during evaluation for incidental shoulder trauma. It results from compression of the neurovascular bundle. This may be caused by hypertrophy of the scalene muscles, a long transverse process, cervical ribs or other rib anomalies, fibromuscular bands, or repetitive shoulder movements. Patients may present with neurogenic, venous, or arterial complaints. Often, they will describe symptoms worsening while lifting heavy objects and overhead activity in addition to paresthesia and numbness. (See "Overview of thoracic outlet syndromes", section on 'Clinical evaluation'.)
Physical examination — Examination of the shoulder in children is guided by history. The performance of the shoulder examination is discussed in detail separately. (See "Physical examination of the shoulder".)
In all traumatized adolescents and children presenting with shoulder pain, begin with a neck examination to ensure there is no serious life-threatening injury. Patients with a concern for neck injury should undergo cervical spinal motion restriction (immobilization) before further examination. There should be no focal tenderness or neurologic deficit before proceeding to the shoulder exam.
Pain can limit the physical examination and therefore, should be adequately controlled. (See "Pain in children: Approach to pain assessment and overview of management principles".)
The more relaxed the patient is, the better the exam. If children appear apprehensive, beginning with an exam on the unaffected shoulder may ease the physical examination of the injured one.
The following constellation of findings suggests a specific diagnosis:
Anterior
●Sternoclavicular injury – For both anterior and posterior sternoclavicular dislocations, patients will present with tenderness over the sternoclavicular joint and will be unable to abduct or externally rotate the shoulder due to severe pain. Additional findings by injury include (see "Traumatic causes of acute shoulder pain and injury in children and adolescents", section on 'Diagnosis'):
•Anterior dislocation – An anterior dislocation of the sternoclavicular joint will demonstrate prominence of the medial end of the clavicle on inspection and palpation. Asymmetry will also be noted with the affected arm appearing shorter compared with the unaffected extremity.
•Posterior dislocation – With posterior dislocation the medial end of the clavicle will not be palpable and patients may present with dyspnea, dysphagia, hoarseness, or venous congestion.
●Clavicular injury – Children with clavicular fractures usually have well-localized clavicular swelling and tenderness that is worsened with shoulder movement, especially abduction above horizontal, and may present supporting the affected arm with their other arm or keeping it still at their side. Crepitus is often present. Ecchymosis with tenting of the skin may be seen on inspection with displaced fractures. (See "Clavicle fractures", section on 'Clinical presentation and examination'.)
By contrast, a contusion will not present with clavicular deformity and will have less tenderness or effect on shoulder mobility. Distal clavicle contusion (shoulder pointer) is a contusion to the distal clavicle without ligamentous involvement. The patient has pain over the distal clavicle rather than the AC ligaments and no evidence of clavicle fracture or AC separation on radiographs. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents", section on 'Distal clavicle contusion (shoulder pointer)'.)
●Biceps tendonitis – Patients with biceps tendonitis will demonstrate point tenderness anteriorly over the bicipital groove. Pain may be elicited with resisted shoulder flexion (Speed test (picture 2 and movie 1)) and/or resisted supination with the elbow flexed (Yergason test (picture 2 and movie 2)). (See "Biceps tendinopathy and tendon rupture", section on 'Special tests'.)
●Acromioclavicular injury – AC injury usually occurs in adolescents and is rare in children. Patients with an AC injury will be tender to palpation over the AC joint. A step-off deformity may also be present at the distal clavicle depending upon the severity of the injury. Pain may be elicited by provocative testing (eg, the cross-body adduction test (picture 3), the AC shear test, and the active compression test) as well as overhead movement. (See "Acromioclavicular joint disorders", section on 'Special maneuvers for the AC joint'.)
Posterior
●Scapula fracture – Tenderness to palpation along the scapula in addition to swelling and worsening pain with shoulder motion will be noted on physical exam. Fractures most often occur in the body of the scapula. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents".)
Poorly localized
●Proximal humerus fracture – Pain, swelling, and tenderness of the proximal humerus will be noted on physical exam. Crepitus may also be present. Patients will often self-splint the injured extremity and have limited active range of motion on examination. Ecchymosis may be visible and can spread to the distal extremity, chest wall, or flank. Range of motion at the elbow should be normal. No neurovascular deficits should be identified unless the axillary nerve is affected, in which case one may detect decreased sensation over the deltoid. Both traumatic and pathologic proximal humeral fractures are identified by plain radiographs of the proximal humerus. (See "Proximal humeral fractures in children", section on 'Proximal humerus fractures'.)
●Proximal humeral epiphysiolysis (Little League shoulder) – On physical examination, there is tenderness to palpation of the lateral proximal humerus. (See "Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach", section on 'Proximal humeral epiphysiolysis (Little League shoulder)'.)
●Glenohumeral dislocation, subluxation, and instability – For an anterior shoulder dislocation the patient will usually be in severe pain and the patient's arm will be slightly abducted and slightly externally rotated on inspection. Passive range of motion will be limited and the acromion will appear more prominent (picture 4). Axillary nerve involvement may be noted with decreased sensation over the deltoid ("shoulder badge" distribution). Radiographs are typically performed before and after reduction of an anterior shoulder dislocation. Initial radiographs confirm the diagnosis and exclude fractures (image 1); postreduction radiographs confirm successful reduction and exclude any fracture caused by the procedure. Routine films include an anteroposterior (AP), a scapular "Y" view, and an axillary view. In skeletally mature patients with a prior history of shoulder dislocation, some clinicians may proceed with reduction without obtaining radiographs. (See "Shoulder dislocation and reduction", section on 'Anterior shoulder dislocation'.)
Posterior shoulder dislocations present with prominence of the posterior shoulder and coracoid process (picture 5). The patient will be unable to externally rotate the arm (picture 5 and movie 3). Radiographic evidence of a posterior shoulder dislocation on a standard anteroposterior (AP) view is subtle and may go undetected in up to 50 percent of cases. The axillary view may demonstrate the dislocation more clearly. Clues to the diagnosis include the "light bulb" sign, rim sign, and trough line sign (image 2 and image 3). Posterior shoulder dislocations are commonly associated with tuberosity and surgical neck fractures of the humerus, reverse Hill-Sachs lesions, and injuries to the labrum and rotator cuff. Additional imaging may be necessary to characterize the full extent of injury. (See "Shoulder dislocation and reduction", section on 'Posterior shoulder dislocation'.)
Shoulder subluxation and instability will have more shoulder motion on exam but still have significant pain. Those with anterior instability will have a positive apprehension relocation test (picture 6), and load and shift test on exam. Posterior instability will present with a positive load and shift test, jerk test, and posterior stress test. A positive sulcus sign on examination (picture 7) indicates inferior instability of the shoulder. (See "Multidirectional instability of the shoulder", section on 'Determining the presence of instability'.)
Referred pain/extrinsic
●Cervical spine injury – Patients with suspected cervical spine injury should be immobilized and undergo appropriate diagnostic imaging studies. Cervical spine injury is suggested by localized tenderness to palpation along cervical spine, a step-off defect, and/or deficits in sensation, motor function, or reflexes. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Physical examination' and "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging'.)
●Abdominal injury – Shoulder pain referred from abdominal injury suggests diaphragmatic irritation by intraabdominal hemorrhage. Ecchymoses and abdominal distention and/or hemodynamic instability with tachycardia, hypotension, diaphoresis, or tachypnea may also be present. Abdominal tenderness is found upon physical exam and may be accompanied by rebound tenderness, guarding, and rigidity. Such patients warrant prompt evaluation for serious trauma. (See "Trauma management: Approach to the unstable child", section on 'Initial approach'.)
●Myocardial injury – Blunt cardiac injury may be subtle in children. Suggestive findings include chest wall contusions or deformity, muffled heart tones or a new murmur, abnormal upper or lower extremity pulses, or rarely, hemodynamic instability. (See "Initial evaluation and management of blunt cardiac injury", section on 'Clinical features'.)
●Brachial plexus injuries (burners and stingers) – Brachial plexus injuries display symptoms of burning or stinging pain that radiate down one arm only. No tenderness will usually be elicited on examination for a brachial plexus injury, and patients will have full, normal cervical range of motion. Weakness may be noted in the deltoid, biceps, infraspinatus, or rotator cuff muscles initially, but should resolve. (See "Burners (stingers): Acute brachial plexus injury in the athlete", section on 'Examination findings'.)
●Axillary or subclavian vein thrombosis (Paget Schroetter disease) – In patients with spontaneous axillary or subclavian vein thrombosis (Paget Schroetter disease), pain and diffuse swelling will be noted in the affected arm. The clinician will often see an increased girth of the upper extremity compared with the unaffected side. A bluish discoloration of the skin and prominent superficial veins on the affected side may be seen in addition to weakness of the upper extremity. Symptoms may be reproduced by exercise testing of the upper extremity or by putting the arm in extreme hyperabduction. (See "Primary (spontaneous) upper extremity deep vein thrombosis", section on 'Acute upper extremity deep vein thrombosis' and "Primary (spontaneous) upper extremity deep vein thrombosis", section on 'Diagnosis'.)
●Thoracic outlet syndrome – Patients with incidental trauma and underlying thoracic outlet syndrome will have pain and swelling of the upper extremity that occurs after exercise. Cold intolerance, venous congestion, and ulnar paresthesias may be noted. A positive Roos test (symptoms with the arm overhead, elbows flexed, and hands opening and closing repetitively or inability to perform the test for three minutes) is suggestive of the diagnosis, but false positives are common. (See "Overview of thoracic outlet syndromes", section on 'Clinical evaluation'.)
Imaging — Patients with referred pain from cervical spine, abdominal, or myocardial injury warrant a more comprehensive trauma evaluation, including diagnostic imaging of the neck, abdomen, or chest. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging' and "Trauma management: Approach to the unstable child", section on 'Adjuncts to the primary survey'.)
For patients with isolated shoulder injuries, plain radiographs should be performed in any child with significant shoulder pain and tenderness, especially when the range of motion is decreased.
Appropriate views include:
●All patients – Anteroposterior (AP) (image 4 and image 5), scapular Y (image 6), and axillary views (image 7).
●Findings of acromioclavicular (AC) joint injury – Either a single anterior-posterior (AP) view including both AC joints or two AP radiographs, one of the involved shoulder and a comparison film of the uninvolved side. In children with limited views on initial studies or with a distal clavicle injury or physical findings of a type II AC injury, a Zanca view of both shoulders (10 degree cephalic tilt and 50 percent penetration (image 8)) provides a clearer view of the AC joint [16]. (See "Acromioclavicular joint injuries ("separated" shoulder)", section on 'Plain radiographs'.)
●Findings of sternoclavicular dislocation or medial clavicle fracture – Serendipity view (40 degree cephalic tilt (image 9)) [17]. However, computed tomography (CT) of the region is more definitive and should be used in symptomatic patients when plain radiographs are inconclusive.
●Findings of shoulder dislocation – In most patients with a shoulder dislocation AP, scapular Y, and axillary views establish the diagnosis (image 1). (See "Shoulder dislocation and reduction", section on 'What views to obtain'.)
Additional views are sometimes obtained in selected patients with concern for associated injuries:
•Bony Bankart lesion (anterior glenoid fracture) – May be seen on AP view as well as a West Point axillary lateral (image 10 and image 11) (see "Shoulder dislocation and reduction", section on 'Associated injuries (Hill-Sachs and Bankart)')
•Hill Sachs lesion (posterolateral humeral head compression) – May be seen on an AP view (image 12) as well as a Stryker notch view (image 13) (see "Shoulder dislocation and reduction", section on 'Associated injuries (Hill-Sachs and Bankart)')
●Findings of scapular fracture – Transscapular or Y view [18].
●Findings of proximal humeral osteolysis (Little League shoulder) – Best seen on AP views of the shoulder with the arm in external rotation. Widening may be subtle and may be seen in asymptomatic patients. Thus, clinical correlation is necessary (image 14). Comparative radiographs of the opposite shoulder may help confirm the diagnosis. (See "Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach", section on 'Proximal humeral epiphysiolysis (Little League shoulder)'.)
Plain radiographs establish the diagnosis for patients with fractures, most sternoclavicular dislocation, AC injuries, and shoulder dislocations. For more details regarding diagnostic imaging of specific shoulder injuries, refer to the appropriate topic:
●(See "Clavicle fractures".)
●(See "Acromioclavicular joint injuries ("separated" shoulder)", section on 'Diagnostic imaging'.)
●(See "Shoulder dislocation and reduction", section on 'Imaging studies'.)
●(See "Proximal humeral fractures in children", section on 'Radiographic findings'.)
Because of the potential for impingement on the trachea or associated vascular injury, emergency contrast-enhanced CT is indicated in patients with a suspected posterior sternoclavicular dislocation. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents", section on 'Diagnosis'.)
Otherwise, CT or magnetic resonance imaging (MRI) of the shoulder are infrequently obtained during the acute evaluation of shoulder injuries in children and adolescents. Consultation with a pediatric orthopedist, pediatric sports medicine specialist, and/or a pediatric radiologist is advised before either a CT or MRI is ordered.
Diagnostic imaging for axillary vein thrombosis, thoracic outlet syndrome, or brachial plexus injuries begins with ultrasonography followed by confirmatory imaging as discussed separately:
●(See "Primary (spontaneous) upper extremity deep vein thrombosis", section on 'Imaging'.)
●(See "Overview of thoracic outlet syndromes", section on 'Imaging'.)
Although a clinical diagnosis, advanced imaging in consultation with a neurosurgeon or neuroradiologist is sometimes needed in patients with a suspected acute brachial plexus injury (burner or stinger). (See "Burners (stingers): Acute brachial plexus injury in the athlete", section on 'Cervical imaging'.)
DIAGNOSTIC APPROACH — Pain with shoulder movement, limited range of motion, and decreased strength compared with the unaffected side suggest intrinsic shoulder pathology. Normal shoulder examination despite significant pain suggests referred pain caused by more serious injuries such as abdominal, cardiac, or cervical spine pathology.
The patient is initially evaluated for neurovascular injury, paresthesia, or weakness. If any of these are positive, the cervical spine should be immobilized until a thorough evaluation can be performed. (See "Evaluation of the child or adolescent athlete with neck pain or injury".)
A cervical spine injury should be suspected with major mechanisms of injury (eg, motor vehicle collision or fall from height), given pain is often referred to the shoulder. Myocardial injury and abdominal hemorrhage may also cause referred pain to the shoulder and should be ruled out if there is an abnormal neurovascular assessment. If no blunt trauma to these regions is identified, then further evaluation for the etiology of isolated shoulder pain is warranted.
The location of shoulder pain should be identified and plain film radiographs obtained in patients with significant pain or restriction of motion (algorithm 1). Abnormal radiographs related to trauma include fractures of the clavicle, humerus, or scapula. Dislocations of the glenohumeral, acromioclavicular (AC), or sternoclavicular joint will also result from a traumatic mechanism of injury and present with abnormal plain films.
If radiographs are abnormal without associated trauma, the shoulder pain is due to a pathologic fracture, clavicular osteolysis, clavicular pseudoarthrosis, or malignancy. (See "Traumatic causes of acute shoulder pain and injury in children and adolescents", section on 'Pathologic fracture'.)
In patients with normal plain radiographs, the clinician proceeds to provocative testing. A suggested approach is as follows:
●Start with the apprehension test; a positive test diagnoses glenohumeral subluxation.
●For patients with a negative apprehension test, palpate the biceps tendon in the bicipital groove. If tenderness is present, then biceps tendonitis is confirmed. Speed test (picture 2 and movie 1) and Yergason test (picture 2 and movie 2) may elicit pain.
●A high impact injury with a transient "burning" sensation or pain down one arm, often combined with shoulder muscle weakness confirms a brachial plexus injury ("stinger").
●Nonspecific arm pain and swelling, bluish discoloration, prominent superficial veins over the anterior chest, chest pain, or dyspnea suggest a diagnosis of axillary vein thrombosis.
●If shoulder plain films are negative and there is no evidence for axillary vein thrombosis, the Roos test is performed (see "Physical examination of the shoulder"). A positive Roos test (symptoms with the arm overhead, elbows flexed, and hands opening and closing repetitively or inability to perform the test for three minutes) identifies thoracic outlet syndrome.
●Patients with normal radiographs and normal provocative testing most likely have a contusion or, if the cross body adduction test is positive, an AC sprain or Salter-Harris type I fracture. However, the clinician should also reassess to ensure no findings of abdominal, neck, or myocardial trauma are present and causing referred pain.
SUMMARY AND RECOMMENDATIONS
●Clinical anatomy – Knowledge of clinical anatomy of the shoulder is essential to identifying shoulder injuries and recognizing referred pain arising from other regions. The shoulder girdle is composed of three bones (the clavicle, scapula, and proximal humerus) and four articular surfaces (sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic) (figure 1A-C). The glenohumeral joint, commonly referred to as the shoulder joint, is the principal articulation. (See 'Clinical anatomy' above.)
The bones that form the shoulder girdle (ie, scapula, humerus, and clavicle) are typically not fully ossified in children and young adolescents (table 2). Thus, the skeletally immature athlete has open epiphyses that are two to five times weaker than the surrounding soft tissues and are prone to fracture. (See 'Clinical anatomy' above.)
●Evaluation – In all traumatized adolescents and children presenting with shoulder pain, begin with a neck examination and assessment of airway, breathing, circulation, and neurologic status. (See 'Identify life-threatening injury' above.)
Once multiple trauma is excluded, the location of pain and mechanism of injury helps to narrow the differential diagnosis of acute traumatic shoulder injury and focus the evaluation (table 3). (See 'Etiology' above and 'History' above.)
Examination of the shoulder in children is guided by history. Findings due to specific types of shoulder injuries are provided above by location of pain and tenderness. The performance of the shoulder examination is discussed in detail separately. (See 'Physical examination' above and "Physical examination of the shoulder".)
●Diagnostic approach – A diagnostic approach with suggested imaging is provided in the algorithm (algorithm 1). Pain with shoulder movement, limited range of motion, and decreased strength compared with the unaffected side suggest intrinsic shoulder pathology. Normal shoulder examination despite significant pain suggests referred pain caused by more serious injuries such as abdominal, cardiac, and cervical spine pathology (see 'Diagnostic approach' above):
•Isolated injuries – For patients with isolated shoulder injuries, plain radiographs should be performed in any child with significant shoulder pain and tenderness, especially when the range of motion is decreased. (See 'Imaging' above.)
•Referred pain – Patients with referred pain from cervical spine, abdominal, or myocardial injury warrant a more comprehensive trauma evaluation, including diagnostic imaging of the neck, abdomen, or chest. (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Cervical spine imaging' and "Trauma management: Approach to the unstable child", section on 'Adjuncts to the primary survey'.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
