Pediatric and adolescent shoulder instability

Pediatric and Adolescent Shoulder Instability

PURPOSE OF REVIEW

Traumatic and atraumatic shoulder instability is common in pediatric and adolescent patients. It is well-established that young patients with anterior shoulder dislocation are at high risk of recurrent instability. This review assesses the current literature pertaining to management of both anterior instability and MDI in the pediatric and adolescent populations.

RECENT FINDINGS

Current research suggests that pediatric and adolescent patients with shoulder instability have excellent outcomes following arthroscopic Bankart repair; however, higher rates of recurrent instability requiring revision surgical management have been identified in patients with more than one dislocation episode pre-operatively, those with Hill-Sachs lesions and those under age 16. The addition of the remplissage procedure to an arthroscopic Bankart repair may be useful in preventing recurrent instability for patients with large Hill-Sachs lesions. Open procedures with bony glenoid augmentation may be indicated in patients with significant glenoid bone loss, or those who have failed primary surgical management, with promising outcomes reported following the Latarjet coracoid process transfer procedure in the adolescent population. Pediatric and adolescent patients with hyperlaxity, and those participating in swimming or gymnastics are more likely to have multidirectional instability (MDI). Non-surgical management with physical therapy is the mainstay of treatment for MDI with positive outcomes reported overall. In young patients with MDI who continue to have symptoms of instability and pain that effects daily activities or sports despite an adequate and appropriate course of rehabilitation, surgical management with capsulorrhaphy may be considered, with promising outcomes reported for both open and arthroscopic techniques. Attentive selection of timing and surgical procedure for pediatric and adolescent patients with anterior shoulder instability may help to prevent recurrent instability following shoulder stabilization. Although most pediatric and adolescent patients with MDI do well following non-surgical management alone, those that fail conservative management have good outcomes following arthroscopic or open capsulorrhaphy.

Dynamic pediatric shoulder instability: Etiology, pathogenesis and treatment

Dynamic shoulder instability in children or adolescents, whose glenohumeral growth plates are still open, is a rare condition with an etiology that is hard to decipher. Atraumatic and recurrent forms are most common, contrary to adults. Disruptions to capsule and ligament maturation, muscle balance or bone growth can lead to glenohumeral instability. The etiology assessment, which needs to be multidisciplinary in atraumatic forms, aims to collect the medical history, analyze the direction of the instability, determine whether it is voluntary or involuntary, and look for a history of trauma, connective tissue abnormality, psychological disorder, neuromuscular pathology or congenital malformation. The initial treatment is conservative. It requires a multidisciplinary team when the shoulder instability is voluntary. Surgical treatment is reserved for symptomatic forms that do not respond to conservative treatment and have an impact on daily life and/or sports participation after a minimum of 6 months of well-conducted rehabilitation. The results of surgical stabilization mainly depend on the features of the instability, the anatomical structures damaged and the etiology. Episodes of recurrent instability in children/adolescents with open glenohumeral growth plates can fade in adulthood or can get worse with the development of structural damage. Early detection of poor outcomes and suitable treatment will help to limit the occurrence of osteoarthritis in the medium and long term. LEVEL OF EVIDENCE: Expert opinion.

Normal Humeral Head Ossification in Pediatric and Adolescent Shoulders Can Mimic Hill-Sachs Lesions: A Magnetic Resonance Imaging-based Study

BACKGROUND

The sequential maturation of the humeral head (HH) as viewed on magnetic resonance imaging (MRI) has not been described to date. Proper assessment may be complicated by the presence of physeal tissue in pediatric patients. Past studies suggest that skeletally immature patients may also have a higher risk of a false-positive diagnosis of Hill-Sachs lesion on MRI. The purpose of this study was to define pediatric HH developmental patterns using MRI and to investigate for any associations with findings of known false-positive Hill-Sachs.

METHODS

Picture Archiving and Communication System (PACS) records at an urban academic tertiary care musculoskeletal facility from 2014 to 2020 were queried for shoulder MRI in patients aged 0 to 15 years. Patients were excluded if they had a history of glenohumeral instability, fracture, growth arrest, brachial plexus injury, surgery, or infection. All images were independently evaluated by a musculoskeletal fellowship-trained radiologist. Each HH was staged based on skeletal maturity.

RESULTS

For both sexes, HHs matured in a predictable manner with increasing chronological age associated with a higher ossification stage. False Hill-Sachs lesions were observed in girls aged 4 to 7 and boys aged 5 to 14, exclusively during stage I to II ossification.

CONCLUSIONS

False Hill-Sachs lesions were visualized on MRI in stage I to II proximal humerus ossification. Due to differential timing of skeletal maturation, males present with false Hill-Sachs lesions at a later age than females on average. When interpreting shoulder MRI for glenohumeral instability, clinicians should be cautious of false Hill-Sachs lesions, especially in younger patients with distinct greater tuberosity and HH ossification centers (stage I to II ossification).

LEVEL OF EVIDENCE

Level III.

Recurrent posterior shoulder instability starting in childhood and adolescence

Aims

We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable.

Methods

Consecutive patients who had an operation for recurrent posterior instability before the age of 18 years were studied retrospectively. All patients had failed conservative treatment for at least six months prior to surgery; and no patients had psychiatric disorders. Two groups were identified and compared: voluntary posterior instability starting in childhood which became uncontrollable and involuntary (group VBI); and involuntary posterior instability (group I). Patients were reviewed and assessed at least two years after surgery by two examiners.

Results

In all 38 patients (40 shoulders) were included: group I (20 shoulders), with involuntary posterior instability (onset at 14 years of age (SD 2.3), and group VBI (20 shoulders), with initially voluntary posterior instability (onset at 9 years of age (SD 2.6) later becoming involuntary (16 years of age (SD 3.5). Mean age at surgery was 20 years (SD 4.6 years; 12 to 35). A posterior bone block was performed in 18 patients and a posterior capsular shift in 22. The mean follow-up was 7.7 years (2 to 18). Recurrence of posterior instability was seen in nine patients, 30% in group VBI (6/20 shoulders) and 15% in group I (3/20 shoulders) (p > 0.050). At final follow-up, the shoulder's of two patients in each group had been revised. No differences between either group were found for functional outcomes, return to sport, subjective, and radiological results.

Conclusion

Although achieving stability in patients with so-called voluntary instability, which evolves into an involuntary condition, is difficult, shoulder stabilization may be undertaken with similar outcomes to those patients treated surgically for involuntary instability. Cite this article: Bone Joint J 2020;102-B(12):1760–1766.

Normal Glenoid Ossification in Pediatric and Adolescent Shoulders Mimics Bankart Lesions: A Magnetic Resonance Imaging-Based Study

PURPOSE

The purpose of this descriptive study was to define patterns of ossification and fusion of growth centers around the pediatric and adolescent glenoid as a function of age using 3-dimensional, frequency-selective, fat-suppressed spoiled gradient recalled echo magnetic resonance (MR) imaging sequences, with a particular focus on the anterior glenoid rim because of its clinical relevance as a potential confounder of glenohumeral instability.

METHODS

Picture Archiving and Communication System records at an urban academic tertiary care orthopaedic facility from October 2005 to December 2018 were queried for shoulder MRI in patients aged 9 to 17 years. Patients were excluded if they had any diagnoses that could alter glenoid development. All images were independently evaluated by a musculoskeletal fellowship-trained radiologist. Secondary ossification centers were characterized as cartilage anlage, ossified, or fused at 3 anatomic sites: the anterior glenoid rim, coracoid, and superior glenoid rim.

RESULTS

A total of 250 MR examinations (143 males, 107 females) were assessed in this study. The glenoid develops in a predictably sequential manner with ossification at the anterior glenoid rim lagging behind the coracoid and superior glenoid rim. The earliest age of anterior glenoid rim ossification was 11 years for both males (range 11-17) and females (range 11-12). Anterior glenoid rim ossification peaked at age 16 among males (34.8%, 8/23) and age 11 among females (27.3%, 3/11).

CONCLUSIONS

Glenoid ossification and fusion progress in a predictable and chronological manner. This pattern should be used as a guideline when interpreting pediatric shoulder MRI examinations. In particular, an anterior glenoid ossification center should not be confused with an anterior glenoid injury (e.g., Bankart lesion), particularly in males 11 to 17 years old and females 11 to 12 years old.

LEVEL OF EVIDENCE

IV (case series).

Arthroscopic Triple Labral Repair in an Adolescent

Traumatic glenohumeral dislocations often result in significant injury to the anterior-inferior labrum, most commonly leading to recurrent anterior instability. While in skeletally immature patients, shoulder trauma more commonly results in fracture versus a true dislocation, shoulder instability does occur and can be difficult to manage in the setting of open physes. In any event, the goal of treatment is to reduce the risk of recurrence and allow full participation in activities, including sports. Arthroscopic stabilization has been shown to be an effective treatment option for young patients, with good return to sport rates; however, the vast majority of literature on shoulder instability in the youth patient population focuses on anterior instability. Concomitant lesions of the anterior, posterior, and superior labrum have been rarely described in youth athletes and present a formidable clinical challenge, particularly in skeletally immature patients. In this Technical Note, we describe the authors' preferred technique for arthroscopic repair of a traumatic triple labral tear, including anterior, posterior, and type IV SLAP components, in adolescent patients.

Overuse Injuries of the Pediatric and Adolescent Throwing Athlete

In the hypercompetitive environment of year round youth baseball, arm pain is commonplace. Although much research has been done about injuries in the overhead throwing athlete, the emphasis has been on the more elite levels, where athletes have reached full development. The anatomy of the skeletally immature athlete, including open physeal plates and increased tissue laxity, raises unique issues in the presentation and treatment of repetitive throwing injuries of the elbow and shoulder. With a focus on "little leaguers," this discussion evaluates five of the most common elbow and shoulder injuries-Little Leaguer's elbow, ulnar collateral ligament sprain or tear, osteochondritis dissecans/Panner's disease, Little Leaguer's shoulder, and multidirectional instability. In the developmentally distinct pediatric athlete, pathogenesis, diagnosis, and treatment may differ from that established for adults. Offering early diagnosis and treatment appropriate to a child's level of development will enable youth to not only continue to play sports but to also maintain full functionality as active adults.

Shoulder Injuries in Pediatric Athletes

Shoulder injuries in pediatric athletes are typically caused by acute or overuse injuries. The developing structures of the shoulder lead to injury patterns that are distinct from those of adult athletes. Overuse injuries often affect the physeal structures of the proximal humerus and can lead to pain and loss of sports participation. Shoulder instability is common in pediatric athletes, and recurrence is also a concern in this population. Fractures of the proximal humerus and clavicle are typically treated with conservative management, but there is a trend toward surgical intervention.

Survey on the management of acute first-time anterior shoulder dislocation amongst Dutch public hospitals

INTRODUCTION

The primary aim of this study was to record how orthopaedic surgeons are currently managing acute first-time anterior shoulder dislocation (AFASD) 8 years after introduction of the Dutch national guideline: "acute primary shoulder dislocation, diagnostics and treatment" in 2005. The second aim was to evaluate how these surgeons treat recurrent instability after AFASD.

MATERIALS AND METHODS

An online questionnaire regarding the management of AFASD and recurrent shoulder instability was held amongst orthopaedic surgeons of all 98 Dutch hospitals.

RESULTS

The overall response rate was 60%. Of the respondents, 75% had a local protocol for managing AFASD, of which 28% had made changes in their treatment protocol after the introduction of the national guideline. The current survey showed wide variety in the overall treatment policies for AFASD. Twenty-seven percent of the orthopaedic surgeons were currently unaware of the national guideline. The variability in treatment for AFASD was present throughout the whole treatment from which policy at the emergency department; when to operate for recurrent instability; type of surgical technique for stabilization and type of fixation of the labrum. As for the treatment of recurrent instability, the same variability was seen: 36% of the surgeons perform only arthroscopic procedures, 7% only open and 57% perform both open and arthroscopic procedures.

CONCLUSIONS

Despite the introduction of the national guideline for the initial management of AFASD in 2005, still great variety among orthopaedic surgeons in the Netherlands was present. As for the surgical stabilization technique, the vast majority of the respondents are performing an arthroscopic shoulder stabilization procedure at the expense of the more traditional open procedure as a first treatment option for post-traumatic shoulder instability.