Pediatric emergency medicine trisk 861

the body to close and is rarely visible radiographically before age 18 years old.
Therefore, special views (e.g., the cephalic tilt view) or advanced imaging with
CT may be necessary for the identification of posteriorly displaced
sternoclavicular fractures ( Fig. 111.10 ). Radiologic examination in these cases
aims to identify any orthopedic injury as well as potentially lethal complications
of trauma to the mediastinal structures that lie posteriorly, including the aorta and
trachea. Initial imaging for suspected AC joint injury should allow for
comparison of the joints either through a single anteroposterior view, which
includes both AC joints, or separate radiographs of each AC joint to allow for
comparison. Sensitivity for detecting injuries is increased if the x-ray is taken
with the arm in internal rotation; however, stress views are no longer
recommended.
Most clavicle shaft fractures and nondisplaced fractures of the lateral end of the
clavicle in children are treated with nonoperative management due to the ability
of pediatric bones to remodel. Treatment of shaft fractures typically involves
immobilization in either a sling and swathe or a simple sling for 3 weeks and
gradual return to daily activities depending on age and risk of repeat trauma.
Return to contact sports should be delayed until solid bony union occurs
(typically between two to four months). The figure-of-eight splint, an alternative
method of immobilization, can be more uncomfortable and cumbersome and has
not been demonstrated to have superior outcomes. For newborns and toddlers, the
child can be put into a long-sleeved shirt with the distal sleeve of the injured side
pinned to the shoulder area of the shirt of the contralateral side.


FIGURE 111.10 Three images of a patient with sternoclavicular dislocation. A: Apparent
normal anteroposterior (AP) view of the clavicle. B: Serendipity view demonstrating
asymmetry of the right sternoclavicular joint indicative of a posterior dislocation. C: CT scan
showing posterior sternoclavicular dislocation on the right. (Reprinted with permission from
Waters PM, Bae D, eds. Pediatric Hand and Upper Limb Surgery: A Practical Guide .
Philadelphia, PA: Lippincott Williams & Wilkins; 2012.)

Indications for consultation with an orthopedic surgeon include open fractures,
impending open fractures secondary to skin tenting, sternoclavicular dislocation,
any fracture to the medial one-third or 100% displaced fractures of the lateral
one-third, neurovascular compromise, multitrauma patients, and floating shoulder
injuries. Relative indications for urgent orthopedic consultation include
comminuted fractures, displacement ≥2 cm in the midshaft, and shortening ≥1.5
cm, particularly if the adolescent is of advanced skeletal age.
Management of AC joint injuries varies by severity. Typically, types I to III are
nonoperative and patients are treated with rest, ice, analgesics, and support or
immobilization with a sling; however operative repair of type III separations may
be indicated to improve functional outcomes in children and adolescents. Types
IV to VI are severe and require orthopedic evaluation and surgical treatment;
emergent evaluation is required in the setting of neurovascular compromise.
Disposition. The majority of children with clavicle fractures or injuries to the AC
joint can be discharged home. Fractures or injuries requiring operative
intervention as described above should be seen by orthopedics for possible
admission.


Shoulder Dislocation
Goals of Treatment
Traumatic dislocations of the shoulder usually result from an indirect force,
which overcomes the supports provided by the muscles and ligaments. The initial
goal of treatment is to manage the pain and expedite reduction of the shoulder
dislocation after radiographs have been obtained. Postreduction radiographs
should be obtained to confirm relocation and evaluate for fractures after
reduction.
CLINICAL PEARLS AND PITFALLS
Complications of shoulder dislocation include fracture of the humeral

head (Hill–Sachs lesion), tearing of the anteroinferior glenoid labrum
with or without associated bony injury (Bankart lesion), and
neurovascular injuries (Fig. 111.11 ).
Due to its close association with the glenohumeral joint, the axillary
nerve may be injured with shoulder dislocation, resulting in motor and
sensory defects.
There is a high rate of recurrence or joint instability in young active
patients 14 years and older. Consequently, patients who plan to return
to competitive contact sports may be candidates for surgical
stabilization after a first-time instability event.
Recurrence rates are lower in patients with open relative to closed
proximal humeral physis at the time of primary dislocation.
Current Evidence
Anterior shoulder dislocation is the most common joint dislocation seen in the
pediatric ED, and accounts for greater than 90% of shoulder dislocations.
Shoulder dislocation is rare in infants and children aged less than 10 years, but
becomes increasingly common through adolescence following physeal closure. In
the skeletally immature child, fracture of the proximal humerus is more common
than dislocation due to the anatomy of the physis. Shoulder dislocations are
associated with a 70% to 90% recurrence rate.
Intravenous sedation and analgesia has been the mainstay of pain control for
shoulder reduction when indicated; however, adult literature supports the use of
intra-articular injection of lidocaine as adjunctive or alternative approach to pain
control. Although no studies in strictly pediatric populations exist, consideration


of intra-articular lidocaine may be worthwhile in skeletally mature adolescents
given the added benefits of decreased procedure time and potentially reduced
cost.
Clinical Considerations

Clinical Recognition. The patient with a shoulder dislocation usually presents
with substantial pain, holding their injured arm supported by the uninjured arm.
There is often an obvious abnormality with loss of the usual rounded contour of
the shoulder with the dislocation.

FIGURE 111.11 Hill–Sachs deformity with anterior humeral dislocation. A: AP shoulder
demonstrating an anteroinferior dislocation of the humerus with impaction between the inferior
glenoid rim and the opposing humeral head (arrow ). The impaction produces the articular
defect that has been referred to as the hatchet deformity (Hill–Sachs defect). B: Postreduction,
AP shoulder. After repositioning the humeral head within the glenoid fossa, the residual effect
of compression of the articular surface is clearly identified (arrow ). (Reprinted with permission
from Yochum TR, Rowe LJ, eds. Yochum and Rowe’s Essentials of Skeletal Radiology . 3rd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2004.)

Triage Considerations. The patient should be given adequate pain medication,
and the injured upper extremity should be placed in a sling. This injury warrants
an expedited triage for timely shoulder reduction.