Fractures of the proximal humerus and humeral shaft are common during birth and childhood. These fractures have an amazing potential to remodel as they heal, and frequently little intervention is necessary. Of course, as children get older, their remodeling potential diminishes and more anatomic reduction is necessary.

Scapula fractures that do not involve the glenoid also heal with little help from a surgeon; however, the associated injuries must be recognized and treated.

Localization of a shoulder fracture, especially in infants, may be difficult. They may present with what appears to be a brachial plexus palsy
as pain will keep them from moving the arm. You may not be able to determine whether there is a neurologic deficit until the fracture has healed. Other conditions in your differential should include a septic shoulder joint or a clavicle fracture.

—Audrey Hepburn

Older children are more cooperative with a neurologic exam. The brachial plexus may be disrupted or stretched by a shoulder injury. The axillary nerve is easily damaged by fractures or dislocations of the shoulder and can be checked by testing sensation over the deltoid. Rare cases may also have an arterial injury.

Scapula fractures are typically the result of great violence and associated injuries are common. Be sure to look for life-threatening injuries (closed head injury, thoracic trauma, spine fractures, etc.).

Separation of the proximal humeral epiphysis frequently occurs during difficult deliveries when the shoulder becomes lodged in the pelvic outlet or when the arm is used to assist in extraction of the infant. The fracture is often difficult to localize and is frequently confused with a brachial plexus injury until abundant callus formation is palpable or noted on x-ray. Clinically, the infant may have an asymmetric Moro reflex as the only sign of injury or may refuse to move the arm at all. It is often impossible to sort out neurologic injury versus immobility secondary to the pain of an acute fracture (“pseudoparalysis”).

The vast majority of shoulder girdle fractures sustained during delivery (Fig. 7-2) can be treated by simply pinning the infant’s shirt sleeve to the shirt or using an elastic bandage around the body to immobilize
the injured upper extremity for 2-3 weeks (Fig. 7-3). Reduction and/or surgery are almost never required in this age group. Birth fractures heal extremely quickly with abundant callus formation and remodel leaving little or no residual deformity. Once the fracture has healed, a better neurologic exam can be completed to evaluate for brachial plexus injury that may have occurred simultaneously.

Traumatic dislocation is typically seen in adolescents after the epiphyses have closed or are closing (Fig. 7-4). Shoulder dislocations can result in a Hills-Sachs lesion which is an indentation of the articular surface of the humeral head (Fig. 7-5) or a Bankart lesion which is an avulsion of the anterio-inferior glenoid labrum. This is the primary lesion in reccurent anterior instability.

This should be treated with relocation and immobilization followed by rehabilitation. Closed reduction in the emergency department can be performed with intravenous sedation or with intra-articular lidocaine. Although the intra-articular anesthetic has been associated with lower complication rates and shorter emergency department stays, there is some concern for chondrotoxicity associated with the injection.

Anterior dislocations should be immobilized in a shoulder immobilizer, but the duration is controversial with some favoring a few days and others preferring 4-6 weeks. Posterior dislocations are rare and often require a gun-slinger splint or spica to maintain the shoulder in external rotation and abduction for 4-6 weeks.

Recurrent dislocation has been reported to be as high as 100% following traumatic dislocation in young patients (Rowe), and many articles report an incidence of 50%-90% regardless of treatment following the first dislocation.

Although conservative treatment for adolescents with a first-time dislocation is still the gold standard, there has been increasing interest in surgically stabilizing the anterior structures, especially in high-risk active patients who seek to return to competitive contact sports. Although many surgical interventions have been described for adults, there are very few reports of long-term outcomes following surgical intervention in children and adolescents. A recent comparison of open and arthroscopic Bankart repairs in a pediatric cohort found an 86% 2-year survival and a 5-year survival of only 49%. Any surgical intervention will require long-term rehab with progressive physical therapy starting with gentle pendulum exercises and advancing to active motion and eventually strengthening.