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Treatment of Pediatric Shoulder Instability

Cil, Akin MD*; Kocher, Mininder S. MD, MPH

Journal of Pediatric Orthopaedics: March 2010 - Volume 30 - Issue - p S3-S6
doi: 10.1097/BPO.0b013e3181ba9e7f
Sports
Free

Anterior shoulder dislocation is the most common form of shoulder dislocation and is generally seen in adolescents participating in contact or collision sports among the pediatric age group. Age is the most important denominator for predicting the recurrence. In civilian/adult population, the treatment is generally conservative. However, there are emerging data to support stabilization surgery for the first-time traumatic anterior shoulder dislocation in the active adolescent patients. Traumatic posterior shoulder dislocations are rare, and can be easily missed on radiographs. Treatment is generally conservative. Multidirectional instability occurs in pediatric overhead athlete with generalized ligamentous laxity. A lengthy rehabilitation program involving shoulder girdle and periscapular strengthening is the mainstay of treatment.

*Department of Orthopaedic Surgery, University of Missouri-Kansas City, Truman Medical Center

Department of Orthopaedic Surgery, Harvard Medical School, Children's Hospital, Boston, MA

Reprints: Mininder S. Kocher, MD, MPH, 300 Longwood Avenue, Boston, MA, 02215. E-mail: mininder.kocher@childrens.harvard.edu.

None of the authors received financial support for this study.

The shoulder is the most mobile, but also the least stable joint in the body. Stability is obtained by static and dynamic factors. Static restraints such as glenoid version, humeral version, glenoid labrum, glenohumeral ligaments, and glenohumeral joint capsule provide static stability. Dynamic stability is provided by the rotator cuff, deltoid and biceps muscles through a concavity-compression effect on the humeral head within the glenoid socket.1

Glenohumeral instability is the inability to maintain the humeral head centered in the glenoid fossa. Instability can arise from either a single traumatic episode or may have an atraumatic etiology. Patients with traumatic etiology generally have unidirectional anterior instability with a labral detachment (Bankart lesion), and are frequently successfully treated with surgery when the instability is recurrent; hence the acronym TUBS has been used for these patients (Fig. 1).2 On the contrary, atraumatic instability patients often have multidirectional and bilateral hyperlaxity, an intact labrum, and are often treated with a rehabilitation program. If surgery is needed, it must shift the inferior capsule and close the rotator interval; hence the acronym AMBRII has been used in these patients.2

FIGURE 1.

FIGURE 1.

The anatomic causes of recurrent instability can be multifactorial including lesions such as labrum detachments, humeral head impression fractures, glenoid rim fractures, redundancy of the capsule, rotator interval lesions, and tearing or avulsion of the glenohumeral ligaments. Recurrent instability is a common consequence of traumatic dislocation in adolescents. However, in the skeletally immature, shoulder trauma more commonly results in a proximal humeral physeal or metaphyseal fracture3,4 than a dislocation. In a large series of patients with glenohumeral instability, the proportion of skeletally immature patients ranges from 1% to 5%.5–10

Consequently, there is limited number of studies investigating shoulder instability solely in the pediatric age group. Anterior instability is by far the most common traumatic dislocation seen in adolescent athletes; however, posterior subluxation/dislocation and multidirectional instability are seen frequently, particularly in gymnasts, swimmers, and some throwers. The aim of this review article is to delineate the management of various types of shoulder instability in the pediatric age group.

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TRAUMATIC ANTERIOR SHOULDER DISLOCATION

Traumatic anterior shoulder dislocations represent more than 90% of shoulder dislocations and are commonly seen in adolescents participating in contact or collision sports.11 The patient with a traumatic anterior dislocation presents with pain, limited motion, and deformity. The humeral head may be palpated anteriorly or in the axilla and the arm is typically held in a slightly abducted, externally rotated position. Careful examination, particularly of the axillary nerve for deltoid area sensibility and motor function in addition to brachial, and radial pulses, is essential to rule out neurovascular injury. Anteroposterior and axillary lateral views of the glenohumeral joint show the dislocation and identify associated fractures or Hill-Sachs lesions. Gentle reduction of an anterior dislocation is performed by one of several techniques including traction-countertraction, prone positioning (Stimson maneuver), or abduction maneuvers. In a prolonged dislocation, sedation may be necessary. Post-reduction radiographs are appropriate. After a brief period of immobilization, a rehabilitation program focused on shoulder girdle strengthening and avoiding the apprehension position is initiated.

Recently, there has been increased interest in the position of arm immobilization. The traditional method of positioning is to immobilize the arm in a sling and swathe in adduction and internal rotation. Magnetic resonance imaging,12 arthroscopic observations,13 a cadaveric study,14 and a randomized-controlled clinical trial15 suggest that immobilization in external rotation after shoulder dislocation reduces the risk of recurrence.

Age seems to be the most important factor with respect to the recurrence of anterior unidirectional instability. Rowe8,9 reported 100% recurrence in children less than 10 years old and 94% recurrence in patients from 11 to 20 years old. Marans et al7 reported 100% recurrence, Postacchini et al16 reported 86% recurrence, and Deitch et al17 reported 75% recurrence in adolescent patients. Other investigators have reported similar results, although none of these studies have isolated the pediatric group as the primary focus of their reports.18–20

Traditional treatment for traumatic anterior shoulder dislocation in the civilian population is nonoperative, including a brief period of rest followed by return to activities when the shoulder is asymptomatic. Owing to the high recurrence rate after single traumatic anterior dislocation in adolescents and young adults, several prospective randomized studies have compared nonoperative treatment of patients with first-time, traumatic shoulder dislocation with immediate arthroscopic (Fig. 2) or open Bankart repair. Bottoni et al21 reported 11% recurrent instability in patients who had an arthroscopic Bankart repair with a bioabsorbable tack versus 75% recurrent instability in the nonoperatively treated patients. Kirkley et al22 not only reported 19% recurrent dislocation in the surgical group versus 60% in the nonoperative group, but also showed significant difference in the disease-specific quality of life between the surgically and nonoperatively treated groups. Jakobsen et al23 in a randomized study comparing open repair to nonoperative treatment with a minimum follow-up of 2 years showed 3% recurrence in the open repair group versus 56% recurrence in the nonoperative treatment group. The patients were evaluated after 10 years with the use of Oxford self-assessment score. Satisfactory results were obtained for 72% of the patients in the operative treatment group versus 25% in the nonoperative group because of recurrence, instability, pain, or stiffness. Furthermore, bone loss may begin with the initial instability event and worsens with repetitive subluxations.24 This is especially a risk in athletes because of repetitive trauma (contact/collision sports) and positioning their arms in the provocative position (overhead sports) in addition to being young.

FIGURE 2.

FIGURE 2.

The indications for operative treatment of the acute dislocation in the adolescent athlete are still controversial. Magnetic resonance scans or magnetic resonance arthrograms are obtained to visualize the labrum, capsule, and the ligaments in cases in which surgical repair of a primary dislocation is considered. Surgical repair can be done with open or arthroscopic repair techniques. The 3.5% rate of recurrent instability after open Bankart repair serves as the standard with which all other techniques are compared.25 Several systematic review and meta-analysis studies comparing arthroscopic versus open anterior shoulder stabilization revealed that arthroscopic repairs were originally associated with a significantly higher risk of recurrent instability and reoperation.26,27 With newer anchors and capsulorraphy techniques, the results of randomized controlled trials of arthroscopic versus open anterior repair have showed that open and arthroscopic surgery results are comparable in terms of recurrent instability with more loss of motion in the open treatment group.28,29 In addition, open shoulder stabilization may lead to atrophy or fatty infiltration and hence postoperative dysfunction of the subscapularis muscle.30,31

One of the retrospective series reporting strictly on adolescent patients reported a 31% redislocation rate after surgical stabilization. However, as most of their patients were operated elsewhere, it was impossible to analyze this patient group with regard to open versus arthroscopic techniques.17 Another retrospective series strictly on adolescents treated with arthroscopic Bankart repair showed a 13.3% recurrent instability.32 Mazzocca et al11 used arthroscopic anterior shoulder stabilization in collision and contact athletes younger than 20 years and found an 11% recurrence of dislocations. These redislocation rates are higher than the redislocation rates after arthroscopic Bankart repair in the adult population. This may be explained by activity level modification and better compliance in adults compared with the eagerness of the young athletes to return to unrestricted sports activity despite the risk of possible redislocation.32

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POSTERIOR SHOULDER DISLOCATION

Traumatic posterior instability is unusual, occurring in 2% to 5% of those with shoulder instability.33 With posterior dislocation, the coracoid process may be prominent anteriorly and the arm is often held in internal rotation and adduction. Posterior dislocations can be missed radiographically because of inadequate lateral images. Nonsurgical treatment is successful in 65% to 80% of patients with recurrent posterior subluxation.34,35 The aim is to strengthen the posteror deltoid, external rotators, and periscapular muscles to compensate for the damaged or deficient static stabilizers. Open or arthroscopic surgical approaches addressing posterior capsulolabral injury and redundancy such as posterior Bankart repair or capsular shift with rotator interval closure36–38 have been used in patients who failed a conservative approach.

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MULTIDIRECTIONAL INSTABILITY

Most cases of posterior dislocation in young patients are associated with multidirectional instability. Although there are limited data strictly for children and adolescents, the incidence of multidirectional instability is estimated to be approximately 10% because of increased ligamentous laxity associated with youth.39 Atraumatic instability can be seen in the pediatric athlete without a clear history of trauma and may occur with throwing, hitting, swimming, or overhead serving. There may be an absence of pain with these episodes of subluxation and spontaneous reduction. Clinical examination often reveals signs of generalized ligamentous laxity including hyperextensibility of the elbows, knees, and metacarpophalangeal joints.40 Shoulder examination will reveal signs of multidirectional instability including a sulcus sign that causes apprehension and excessive translation with anterior and posterior drawer tests, and the ability to subluxate the humeral head to the glenoid rim or sometimes past the glenoid rim with the load and shift test. A vigorous and lengthy (up to 6 mo) rehabilitation program stressing shoulder girdle and periscapular strengthening is successful in most patients.21 For patients who fail nonoperative management, an open or arthroscopic capsular shift reconstruction is considered.41 Classically, capsulorraphy and rotator interval closure have been performed via open inferior capsular shift.41 More recently, arthroscopic techniques have been developed.42,43 Arthroscopic thermal capsulorraphy was popular briefly; however, it has been recently abandoned because of high failure rates.44,45

Voluntary (habitual) subluxation is diagnosed when a child develops and then uses the ability to subluxate one or both shoulders in one or more directions. This can be the result of abnormal or poorly synchronized muscle activity.46 Huber and Gerber47 reported long-term follow-up of 25 children with voluntary subluxation, and found that skillful neglect with no restriction of activity was better than any form of surgical treatment. In their operated group, instability recurred, pain was more common, and subjective satisfaction was less. Physical therapy focusing on muscle training and feedback has been reported as successful in up to 82% of the patients.46

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CONCLUSIONS

Traumatic anterior shoulder instability is the most common form of shoulder instability with high recurrence rates in certain subsets of patients. On the basis of the emerging literature, we now currently offer arthroscopic stabilization surgery for the active adolescent patients with first-time traumatic anterior shoulder dislocation. In addition, arthroscopic stabilization surgery is offered to young adult athletes with first-time acute traumatic anterior shoulder dislocation if they are participating in contact or collusion sports or are currently serving in the military. We continue to manage the first-time traumatic anterior shoulder dislocation in the civilian population nonoperatively.

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Keywords:

pediatric; shoulder instability; multidirectional instability; anterior shoulder instability; posterior shoulder instability

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