From the Guidelines
Shoulder dislocations in children should be managed with prompt closed reduction under sedation or anesthesia, followed by immobilization in a sling for 3-4 weeks, with a focus on minimizing recurrence risk and promoting recovery through physical therapy and activity modification. The management of shoulder dislocations in children is crucial to prevent long-term complications and recurrence. According to the American College of Radiology Appropriateness Criteria 1, shoulder dislocation or instability is most common in the anterior direction, and younger patients are more likely to have labroligamentous injury and persistent instability after dislocation compared with older patients. Key considerations in the management of shoulder dislocations in children include:
- Initial pain control with age-appropriate doses of acetaminophen or ibuprofen
- Immobilization in a sling for 3-4 weeks to allow for healing and stabilization
- Physical therapy focusing on gentle range of motion exercises and progressive strengthening after immobilization
- Avoidance of contact sports for at least 6 weeks after injury to reduce the risk of recurrence
- Education of parents about potential complications, including growth plate injuries in younger children and long-term instability risks, particularly in athletic adolescents. Radiographic evaluation, including anteroposterior views in internal and external rotation and an axillary or scapula-Y view, is essential to assess for fracture and appropriate shoulder alignment 1.
From the Research
Diagnosis and Management of Shoulder Dislocation in Children
- Shoulder dislocations are a common presentation to the emergency department, and imaging may help diagnose more challenging cases 2.
- Three-view radiographs are important for identifying subtle posterior dislocations, and ultrasonography has been gaining evidence as an alternate diagnostic modality 2.
- Intra-articular lidocaine and nerve blocks may improve pain control and reduce the need for procedural sedation 2, 3.
Treatment Options
- Recommended treatment following a first-time glenohumeral dislocation event in adolescents depends on several factors, but surgical stabilization is becoming more frequently performed 4.
- Surgical indications include bony Bankart lesion, ALPSA lesion, bipolar injury, or off-season injury in an overhead or throwing athlete 4.
- Young children, individuals averse to surgery, or in-season athletes who accept the risk of redislocation may complete an accelerated rehabilitation program for expedited return to play in the absence of structural abnormalities 4.
- Arthroscopic Bankart repair has excellent outcomes in pediatric and adolescent patients with shoulder instability, but higher rates of recurrent instability have been identified in patients with more than one dislocation episode pre-operatively, those with Hill-Sachs lesions, and those under age 16 5.
Reduction Techniques
- Multiple, evidence-based reduction techniques are described, including tips for improving success 2.
- Intra-articular lidocaine may have similar effectiveness as IV sedation in the successful reduction of anterior shoulder dislocations in the ED with fewer adverse events, shorter ED length of stay, and no difference in pain scores or ease of reduction 3.
Routine Prereduction Radiographs
- Prereduction radiographs may not be necessary for pediatric patients with anterior shoulder dislocations clinically apparent after clinical evaluation, as the incidence of fractures is lower than in adult studies 6.
- Forgoing prereduction x-rays might expedite definitive pain relief for patients, lower cost and radiation exposure, and decrease ED length of stay 6.