What are the diagnostic criteria for identifying shoulder dislocation (glenohumeral joint dislocation) in pediatric patients?

From the Guidelines

Shoulder dislocations in children should be promptly identified and treated with a combination of physical examination, X-rays, and potentially MRI, to prevent long-term complications and reduce the risk of recurrence, as indicated by the most recent guidelines 1. When evaluating a child for a suspected shoulder dislocation, it is essential to look for visible deformity, limited range of motion, and significant pain following trauma. Children often present with anterior dislocations, showing a squared-off shoulder appearance and reluctance to move the affected arm.

Key Considerations

• Physical examination should include careful assessment of neurovascular status, as brachial plexus injuries can occur.
• X-rays are essential for confirmation, with anteroposterior and axillary lateral views being most helpful, as recommended by the American College of Radiology 1.
• Unlike adults, children have higher recurrence rates (up to 80-90% in adolescents) and are more likely to have associated growth plate injuries.
• Immediate management includes pain control with weight-appropriate doses of analgesics (acetaminophen 15mg/kg or ibuprofen 10mg/kg) and prompt reduction under appropriate sedation.
• Post-reduction, immobilization for 3-4 weeks is typically recommended, followed by gradual rehabilitation.
• Early orthopedic consultation is crucial, as children with open growth plates require specialized care.
• The presence of a Hill-Sachs lesion or Bankart lesion on imaging indicates a higher risk of recurrence and may warrant surgical consideration, especially in athletic adolescents, as highlighted in the 2018 guidelines 1.

Imaging Recommendations

• MRI without contrast may be preferred to MR arthrography in the setting of acute shoulder dislocation, as suggested by the American College of Radiology 1.
• The choice of imaging modality should be guided by the clinical presentation and the need to assess both osseous and labroligamentous pathology in patients with shoulder dislocation or instability.

From the Research

Identifying Shoulder Dislocation in Children

• Shoulder dislocations are a common presentation to the emergency department, and it is essential to diagnose and manage them properly, especially in children 2.
• The diagnosis of shoulder dislocation can be made by history and clinical examination alone, but imaging such as three-view radiographs and ultrasonography may be helpful in more challenging cases 2.
• Intra-articular lidocaine and nerve blocks can improve pain control and reduce the need for procedural sedation during reduction 2, 3.

Reduction Techniques

• There are multiple reduction techniques available, each with its advantages and limitations, and emergency physicians should be familiar with several techniques in case the initial attempt is unsuccessful 4.
• The success rate of reduction techniques can range from 60-100%, and it is crucial to choose the most appropriate technique based on patient-specific characteristics 4.
• Intra-articular lidocaine injection is a viable alternative to intravenous procedural sedation with narcotics and benzodiazepines for reduction of anterior shoulder dislocations, with a lower complication rate and shorter time spent in the ED 3.

Management and Treatment

• The management of shoulder dislocation in children depends on several factors, including the presence of structural abnormalities, the patient's age, and their activity goals 5.
• Surgical stabilization is becoming more frequently performed, especially in adolescents with bony Bankart lesions, ALPSA lesions, or bipolar injuries 5.
• Immobilization strategies, such as bracing in external rotation, may provide a clinically important benefit over traditional sling immobilization, but the ideal duration and position of immobilization are still debated 6.