Pediatric and Adolescent Shoulder Instability

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Key points

  • There is a high rate of recurrence after first-time shoulder instability in a young active population.

  • Given the high risk of recurrent instability, young, active patients who seek to return to competitive contact sports should consider surgical stabilization after a first-time instability event.

  • Multidirectional instability should be initially treated with conservative treatment.

  • Traditional surgical options for shoulder instability utilized open techniques. Newer arthroscopic techniques may now

Epidemiology

Shoulder instability is common, with a rate of 11.2 per 100,000 person-years, as noted by Simonet and colleagues.3 These investigators found younger male patients to be most frequently affected. In young ice hockey players, an incidence as high as 7% has been reported.2, 4 The classic study by Rowe1 in 1956 reviewing 500 shoulder dislocations found that 20% of these dislocations occurred in patients between the ages of 10 and 20 years, but only 8 patients who were younger than 10 years had

Anatomy and biomechanics of traumatic and nontraumatic instability in young patients

The shoulder joint begins to form during the sixth week of gestation through different growth rates, known as the interzone.17 At this early point, the glenoid lip is discernible and consists of dense fibrous and some elastic tissue, as opposed to fibrocartilaginous tissue of the knee meniscus. The shoulder capsule and the ligamentous thickenings are visible by the end of the eighth week, increasing in size only through development to adult proportions.18 Variations in the final maturation of

History

Because there is such a wide spectrum of disease with shoulder instability in younger patients, the history and physical examination are paramount in understanding a particular young patient’s disease and prognosis. Instability patterns are classically separated into either traumatic or atraumatic.

Traumatic dislocations occur after falls, altercations, motor or recreational vehicle accidents, or during sports events, particularly contact sports.19 Owens and colleagues20 found the highest rates

Physical examination

The physical examination for the younger patient with shoulder instability starts with an examination that is used in adults. This process includes an examination of the cervical spine and a scapular examination for signs of more central nerve causes of shoulder weakness and pain. Although cervical spine issues are less common in young healthy pediatric and adolescent patients, scapular winging is not uncommon in these patients and is caused by nerve dysfunction or injury along with muscle

Imaging

Evaluation of a young patient with suspected shoulder instability includes a standard trauma series of radiographs with orthogonal views. This strategy is particularly important in the young patient with open physes, because of the risk of proximal humeral physeal fractures mimicking an anteriorly dislocated proximal humerus. A nontraumatic shoulder radiographic series includes an anterioposterior, scapular Y, and axillary view. If the young patient is too uncomfortable to comply with the arm

Acute Management of a Shoulder Dislocation in a Young Athlete

Many providers of sports medicine are faced with the issue of a young patient with a suspected shoulder dislocation seen on the field of play. Although in older, skeletally mature patients, it is reasonable to consider on-field reduction maneuvers if the provider is comfortable and trained in these techniques, in the young patient with open physes, we recommend that the provider at a minimum should consider appropriate radiographic imaging before reduction attempts to evaluate for a proximal

Our preferred techniques

Our preferred treatment of pediatric or adolescent patients who have failed conservative treatment of traumatic or MDI is arthroscopic labral repair and capsulorrhaphy using suture anchor fixation. We use lateral decubitus positioning with an adjustable arm holder (Spider arm positioner, Smith & Nephew, Memphis, TN) for arthroscopic shoulder instability surgery (Figs. 4 and 5). After examination under anesthesia and diagnostic arthroscopy to document the extent and directions of instability and

Rehabilitation

Rehabilitation after arthroscopic anterior stabilization for anterior shoulder instability or pancapsular capsulorrhaphy for MDI generally begins with a period of immobilization. We generally use an Ultra-sling (DonJoy, Vista, CA) for 6 weeks postoperatively or until normal range of motion is achieved, whichever comes last. Initial rehabilitation centers around maintaining finger, wrist, and elbow motion. Isometric periscapular muscle activation is also begun in the first weeks to assist the

Summary

Instability of the shoulder is a common issue faced by sports medicine providers caring for pediatric and adolescent patients. A thorough history and physical examination can help distinguish traumatic instability from multidirectional or voluntary instability. A systematic understanding of the relevant imaging characteristics and individual patient disease and goals can help guide initial treatment. Given the high risk of recurrent instability, young, active patients who seek to return to

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