Overview
Definition:
Shoulder dislocation in adolescents refers to the displacement of the humeral head from the glenoid cavity of the scapula
In teens, it is often an anterior dislocation resulting from sports activities or trauma, with a significant risk of recurrence.
Epidemiology:
Shoulder dislocations are most common in young adults and athletes
In the pediatric population, incidence increases with age, particularly in teens involved in contact sports or high-risk activities
Recurrence rates are notably higher in younger individuals, with estimates ranging from 50% to over 90% in some studies for first-time dislocations in this age group.
Clinical Significance:
Understanding shoulder dislocations in teens is crucial for pediatricians and orthopedic surgeons due to the high recurrence rate, which can lead to chronic instability, pain, and limitations in physical activity
Prompt and appropriate management, including timely orthopedic referral, is essential to minimize long-term morbidity and optimize functional outcomes for young patients.
Clinical Presentation
Symptoms:
Sudden, severe shoulder pain
Inability to move the arm
Deformity of the shoulder, appearing "squared off"
Numbness or tingling in the arm or hand
A feeling of the shoulder "popping out".
Signs:
Visible deformity of the shoulder contour
Palpable gap between the acromion and humeral head
Limited range of motion in the affected shoulder
Tenderness to palpation
Possible neurological deficits (e.g., axillary nerve injury).
Diagnostic Criteria:
Diagnosis is primarily clinical, confirmed by imaging
Key clinical findings include a characteristic deformity, pain, and loss of function
Radiographic evidence of humeral head displacement from the glenoid is diagnostic.
Diagnostic Approach
History Taking:
Detailed history of the injury mechanism (fall, direct blow, sports activity)
Previous shoulder injuries or dislocations
Dominant arm
Associated symptoms like numbness, tingling, or weakness
Any pre-existing shoulder instability
Red flags include open wounds, neurovascular compromise, or associated fractures.
Physical Examination:
Inspect for asymmetry and deformity
Palpate for tenderness, crepitus, and step-offs
Assess range of motion (active and passive), noting significant limitations
Perform neurovascular assessment of the affected limb, including pulses, sensation (axillary, radial, ulnar, median nerves), and motor strength
Evaluate for specific signs of instability like the sulcus sign or apprehension test, though these may be difficult to elicit due to pain.
Investigations:
Standard anteroposterior (AP) and lateral X-rays of the shoulder are essential to confirm dislocation and identify associated fractures (e.g., Hill-Sachs lesion, Bankart lesion, greater tuberosity fracture)
Axillary or scapular Y-view X-rays may be helpful for posterior dislocations or to better visualize glenoid rim fractures
MRI may be indicated to assess soft tissue injuries (labrum, rotator cuff, ligaments) if there is persistent pain, suspicion of significant soft tissue damage, or before surgical intervention, though not typically for initial reduction in acute settings.
Differential Diagnosis:
Other causes of shoulder pain and dysfunction in teens include rotator cuff tears (less common in young teens without significant trauma), clavicle fractures, scapular fractures, glenohumeral osteoarthritis (rare), and brachial plexus injury.
Management
Initial Management:
Immediate immobilization of the arm in a sling to reduce pain and prevent further injury
Prompt orthopedic consultation and referral for reduction
Pain control with analgesics
Avoidance of any maneuvers to reduce the dislocation in a non-orthopedic setting without appropriate training and equipment.
Reduction Techniques:
Closed reduction is the primary treatment for acute dislocations
Various techniques exist, including the Stimson technique, Milch technique, and external rotation method
Sedation and analgesia (e.g., benzodiazepines and opioids) are often administered
Reduction is confirmed by regaining full range of motion and radiographic assessment
Reduction should be performed by experienced clinicians, ideally in an orthopedic setting.
Immobilization And Rehabilitation:
Following successful reduction, the arm is typically immobilized in a sling for 1-3 weeks, depending on the direction of dislocation and patient factors
Rehabilitation is crucial to regain strength, range of motion, and proprioception
Early gentle passive and active-assisted range of motion exercises are initiated, progressing to strengthening exercises once pain and swelling subside
Emphasis is placed on strengthening the rotator cuff and scapular stabilizers
Gradual return to sports activity is guided by functional recovery and physician assessment.
Orthopedic Referral:
All confirmed shoulder dislocations in teens warrant orthopedic referral
This is critical to ensure timely and appropriate reduction, assess for associated injuries, and develop a personalized management plan, especially considering the high recurrence risk
Orthopedic assessment will guide decisions regarding the need for surgical intervention, particularly after a first-time dislocation in this age group.
Recurrence Risk And Prevention
Risk Factors:
Young age at first dislocation (under 20 years)
Participation in contact or overhead sports
Atraumatic dislocations
Significant glenoid rim fractures or labral tears (e.g., Bankart lesion)
Excessive laxity of the joint capsule.
Prevention Strategies:
For recurrent dislocations, surgical stabilization is often recommended
Procedures like the Bankart repair (arthroscopic or open) aim to reattach the torn labrum to the glenoid rim, restoring joint stability
Rotator cuff strengthening and scapular stabilization exercises are vital for both prevention and post-operative rehabilitation
Educating young athletes about proper techniques and protective equipment can also play a role.
Complications
Early Complications:
Nerve injury (axillary nerve neuropraxia most common)
Vascular injury (rare)
Rotator cuff tears (more common in older adolescents or with repeated trauma)
Fracture of the humeral head (Hill-Sachs lesion) or glenoid rim (Bankart lesion).
Late Complications:
Chronic shoulder instability
Recurrent dislocations
Glenohumeral osteoarthritis
Persistent pain
Loss of range of motion
Adhesive capsulitis.
Prevention Strategies:
Prompt and accurate reduction
Appropriate immobilization duration
Comprehensive rehabilitation program focusing on strengthening and proprioception
Surgical intervention for unstable dislocations or significant structural damage
Patient education regarding activity modification and avoidance of provocative movements.
Prognosis
Factors Affecting Prognosis:
Age at first dislocation
Presence of associated fractures or labral tears
Adherence to rehabilitation protocols
Timeliness and quality of orthopedic care
Involvement in high-risk sports.
Outcomes:
With appropriate management and rehabilitation, many teens can achieve good functional outcomes and return to most activities
However, the high recurrence rate remains a significant concern
Surgical intervention generally offers better long-term stability for those with recurrent dislocations or significant structural damage.
Follow Up:
Regular follow-up with an orthopedic specialist is essential, particularly after a first-time dislocation in a teen, to monitor for signs of instability and assess progress
Long-term follow-up may be required, especially for athletes, to ensure continued strength, stability, and prevention of degenerative changes.
Key Points
Exam Focus:
High recurrence rate in adolescents is a critical concept
Anterior dislocation is most common
Management involves reduction, immobilization, and rehabilitation
Orthopedic referral is mandatory
Recognize Hill-Sachs and Bankart lesions on imaging.
Clinical Pearls:
Always assess neurovascular status pre and post-reduction
Be cautious with reduction maneuvers
if difficulty arises, seek expert orthopedic help
Emphasize aggressive rehabilitation to prevent recurrence, but also counsel on surgical options if instability persists
The younger the patient, the higher the recurrence risk.
Common Mistakes:
Delayed orthopedic referral
Inadequate assessment of neurovascular status
Premature return to full activity without adequate rehabilitation
Failure to recognize associated fractures
Underestimating the recurrence risk in this age group.