Traumatic causes of acute shoulder pain and injury in children and adolescents
- Joseph Chorley, MD
Joseph Chorley, MD
- Section Editor — Pediatric Sports Medicine; Adolescent Sports Medicine
- Associate Professor of Pediatrics, Adolescent Medicine, and Sports Medicine
- Baylor College of Medicine
- Gabriel P Brooks, PT, DPT, SCS, MTC
Gabriel P Brooks, PT, DPT, SCS, MTC
- Doctor of Physical Therapy
- Texas Children's Hospital
- Section Editor
- George A Woodward, MD
George A Woodward, MD
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics
- University of Washington School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Diagnosis and treatment for shoulder injuries in the young athlete is different from treating adults because of the higher likelihood of fracture and anterior shoulder dislocations [1,2]. During the teenage years participation in many sports put the young athlete at risk for acute (eg, football, hockey) and repetitive overuse injuries (eg, swimming, baseball, tennis) . Understanding the anatomy and applicable biomechanics of the shoulder is essential to identifying these injuries.
The causes of acute shoulder injury in the young athlete will be reviewed here. The physical examination of the shoulder is reviewed separately. (See "Physical examination of the shoulder".)
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, 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.
●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 [1,4]. 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 .
- Howell SM, Galinat BJ. The glenoid-labral socket. A constrained articular surface. Clin Orthop Relat Res 1989; :122.
- ROWE CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am 1956; 38-A:957.
- National Sporting Good Association, Mt. Prospect, Illinois, Sports Participation in (yr), Annual: Series I and II, based on the US Census Bureau Data, US Department of Commerce, 2006.
- Lippitt, SB, Vanderhooft, JE, Harris, SL, et al. Glenohumeral stability from concavity compression. A quantitative analysis. J Shoulder Elbow Surg 1993; 2:27.
- O'Brien SJ, Neves MC, Arnoczky SP, et al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990; 18:449.
- Urayama M, Itoi E, Hatakeyama Y, et al. Function of the 3 portions of the inferior glenohumeral ligament: a cadaveric study. J Shoulder Elbow Surg 2001; 10:589.
- Schwartz E, Warren RF, O'Brien SJ, Fronek J. Posterior shoulder instability. Orthop Clin North Am 1987; 18:409.
- Szilvássy J. [Estimation of age by the sternal articular surfaces of the clavicle]. Beitr Gerichtl Med 1977; 35:343.
- Cmap JD, Cilley EIL. Diagrammatic chart showing time of appearnce of the various centers of ossification and period of union. Am J Roentgenol Radium Ther 1931; 26:905.
- McClure JG, Raney RB. Anomalies of the scapula. Clin Orthop Relat Res 1975; :22.
- Samilson RL. Congenital and developmental anomalies of the shoulder girdle. Orthop Clin North Am 1980; 11:219.
- Rockwood CA. The Shoulder, Saunders Elsevier, Philadelphia 2009.
- Mudge MK, Wood VE, Frykman GK. Rotator cuff tears associated with os acromiale. J Bone Joint Surg Am 1984; 66:427.
- Bigliani LU, Morrison DS, April EW. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 1986; 10:228.
- Boehm TD, Rolf O, Martetschlaeger F, et al. Rotator cuff tears associated with os acromiale. Acta Orthop 2005; 76:241.
- Habernek H, Hertz H. [Origin, diagnosis and treatment of sternoclavicular joint dislocation]. Aktuelle Traumatol 1987; 17:23.
- Nordqvist A, Redlund-Johnell I, von Scheele A, Petersson CJ. Shortening of clavicle after fracture. Incidence and clinical significance, a 5-year follow-up of 85 patients. Acta Orthop Scand 1997; 68:349.
- Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res 1968; 58:29.
- Sarwark JF, King EC, Janicki JA. Proximal humerus, scapula, and clavicle. In: Rockwood and Wilkins' Fractures in Children, 7th edition, Beaty JH, Kasser JR. (Eds), Lippincott, Williams & Wilkins, Philadelphia 2010. p.620.
- Glass ER, Thompson JD, Cole PA, et al. Treatment of sternoclavicular joint dislocations: a systematic review of 251 dislocations in 24 case series. J Trauma 2011; 70:1294.
- Heinig CF. Retrosternal dislocation of the clavicle: Early recognition, x-ray diagnosis, and management [abstract]. J Bone Joint Surg Am 1968; 50:830.
- Hobbs DW. Sternoclavicular joint: a new axial radiographic view. Radiology 1968; 90:801.
- Doss A, Lang IM, Roberts I, et al. Posterior sternoclavicular joint dislocation in children-role of spiral computed tomography. Pediatr Emerg Care 2005; 21:325.
- Jaggard MK, Gupte CM, Gulati V, Reilly P. A comprehensive review of trauma and disruption to the sternoclavicular joint with the proposal of a new classification system. J Trauma 2009; 66:576.
- Wirth M, Rockwood C. DeLee & Drez's Orthopaedic Sports Medicine: Principles and Practice, 2nd, DeLee J, Drez D (Eds), Saunders, Philadelphia 2003.
- de Jong KP, Sukul DM. Anterior sternoclavicular dislocation: a long-term follow-up study. J Orthop Trauma 1990; 4:420.
- Baskin MN. Injury - Shoulder. In: Textbook of Pediatric Emergency Medicine, 6th edition, Fleisher GR, Ludwig S. (Eds), Lippincott, Williams & Wilkins, Philadelphia 2010. p.353.
- Owens BD, Duffey ML, Nelson BJ, et al. The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med 2007; 35:1168.
- Antonio GE, Griffith JF, Yu AB, et al. First-time shoulder dislocation: High prevalence of labral injury and age-related differences revealed by MR arthrography. J Magn Reson Imaging 2007; 26:983.
- Nordqvist A, Petersson C. Fracture of the body, neck, or spine of the scapula. A long-term follow-up study. Clin Orthop Relat Res 1992; :139.
- Toro FG, Vaisman A, Villalón IE, Calvo R. Fracture dislocation of the glenoid fossa with open physis: a case report. J Pediatr Orthop 2010; 30:336.
- Cain TE, Hamilton WP. Scapular fractures in professional football players. Am J Sports Med 1992; 20:363.
- Carro LP, Nuñez MP, Llata JI. Arthroscopic-assisted reduction and percutaneous external fixation of a displaced intra-articular glenoid fracture. Arthroscopy 1999; 15:211.
- Edeland HG, Zachrisson BE. Fracture of the scapular notch associated with lesion of the suprascapular nerve. Acta Orthop Scand 1975; 46:758.
- Goss TP. Scapular Fractures and Dislocations: Diagnosis and Treatment. J Am Acad Orthop Surg 1995; 3:22.
- Montgomery SP, Loyd RD. Avulsion fracture of the coracoid epiphysis with acromioclavicular separation. Report of two cases in adolescents and review of the literature. J Bone Joint Surg Am 1977; 59:963.
- Froimson AI. Fracture of the coracoid process of the scapula. J Bone Joint Surg Am 1978; 60:710.
- Goss T. The scapula. In: The Shoulder, 3rd, Rockwood, C, Frederick M, Wirth M, Lippitt S (Eds), Saunders, Philadelphia 2004. Vol 1, p.413.
- Neer C. Shoulder Reconstruction, Saunders, Philadelphia 1990.
- Liberson F. OS Acromiale-A contested anomaly. J Bone Joint Surg Am 1937; 19:683.
- McLaughlin HL. Trauma, WB Saunders, Philadelphia 1959. p.239.
- Mariani PP. Isolated fracture of the coracoid process in an athlete. Am J Sports Med 1980; 8:129.
- Garcia-Elias M, Salo JM. Non-union of a fractured coracoid process after dislocation of the shoulder. A case report. J Bone Joint Surg Br 1985; 67:722.
- CLINICAL ANATOMY
- LIFE-THREATENING AND SERIOUS CONDITIONS
- Sternoclavicular injury
- - Diagnosis
- - Management
- - Reduction of posterior sternoclavicular dislocation
- Referred pain
- Pathologic fracture
- COMMON CONDITIONS
- Superficial contusion
- Clavicle injuries
- - Distal clavicle contusion (shoulder pointer)
- - Clavicle fractures
- Proximal humeral fractures
- Shoulder dislocation
- Acromioclavicular injuries
- Burners (stingers)
- OTHER CONDITIONS
- Scapula fractures