Pediatric shoulder radiograph (an approach)

Pediatric shoulder radiographs are usually performed after trauma in older children. However, seat-belt injuries during motor vehicle accidents can cause shoulder trauma at any age. Birth trauma may also be factor.

Systematic review

Clavicle

Check the cortex and review alignment:

• if there is cortical buckle or breach, think clavicle fracture
• if there is malalignment at the ACJ or SCJ (sternoclavicular joint), think clavicle fracture with physeal injury

Proximal humerus

Check the epiphysis and metaphysis for fracture:

• commonest injury is a physeal fracture
• if there is cortical irregularity or breach, think proximal humeral fracture

Glenohumeral joint

Check alignment of the glenohumeral joint:

• AP
  • the articular surfaces of the humerus and glenoid should appear as two parallel lines with an even joint space
  • if the humeral head lies under the coracoid process, think anterior shoulder dislocation
  • if there is a joint effusion or lipohemarthrosis, think intra-articular fracture
• ensure that the humeral head sits on the glenoid on any other view, e.g. the axial (armpit), lateral scapular (Y view) or apical oblique views

Bone cortex

Check around the cortex of every bone on the film:

• subtle buckle fractures of the humerus or clavicle
• scapula fractures
• rib fractures
• healing rib fractures, in non-accidental injury

Common conditions

Clavicle fracture

• by far the most common pediatric shoulder injury
• mechanism: direct trauma, either while playing sport, or from a seat-belt
• 80% middle-third
• injuries at either end are usually physeal injuries
• usually do not require operative intervention
• more: clavicle fracture

Proximal humeral fracture

• occur in older children, usually after a fall or direct trauma
• usually involve the physis and are classified using the Salter-Harris classification
• more: proximal humeral fracture

Anterior shoulder dislocation

• represent over 95% of all shoulder dislocations
• peak age: older children, usually during sport
• mechanism: forced abduction, external rotation and extension
• humeral head lies anterior, medial and inferior to glenoid fossa
• more: anterior shoulder dislocation

Don't miss

Acromioclavicular joint injury

• very common injury
• range from strain to complete joint disruption
• mechanism: direct blow or fall onto shoulder with adducted arm
• step at AC joint, widening of AC joint and/or increased CC distance
• more: acromioclavicular joint injury

Rib fractures

• healing rib fractures may be seen on a shoulder radiograph
• if seen posteriorly, they point towards non-accidental injury
  • they must be identified
  • appropriate child-protection considerations must be acted upon (see local policy)
• more: non-accidental injury