Christopher C Dodson and Riley J Williams III

In This Chapter

Pectoralis major rupture

Surgery—pectoralis repair Subcapularis rupture

Surgery—subscapularis repair

RUPTURE OF THE PECTORALIS MAJOR

Relevant Anatomy

The pectoralis major is a triangle-shaped muscle that arises from the clavicle, sternum, ribs, and external oblique fascia (Fig. 301). The muscle has two heads: clavicular and sternal. As these various origins converge to their insertion at the lateral aspect of the bicipital groove, the muscle twists. Ultimately, the superior fibers insert distally and the inferior fibers insert proximally. These fibers terminate in a flat tendon that is approximately 4 to 5 cm wide. This tendon consists of two laminae, one anterior to the other. The main function of the pectoralis major is to adduct and internally rotate the humerus. The pectoralis major is innervated by the medial (C8-T1) and lateral (C5-C7) pectoral nerves; the muscle receives its blood supply from the pectoral branch of the axillary artery.

Clinical Features and Evaluation

Rupture of the pectoralis major is a relatively rare injury; approximately 200 case outcomes have been described in the literature.1-3 Few of these reports have more than 20 patients, and to date, there have been no prospective studies that have examined clinical outcomes following surgical repair. The first case report dates back to 1822 and was described by Patissier.4 Most patients sustain a rupture of the pectoralis major while participating in sports. Weight lifting is the most common activity associated with acute pectoralis tendon rupture. Other sports, including football, rugby, wrestling, rodeo riding, and windsurfing have also been reported to have caused pectoralis tendon injury.5 The injury usually occurs in skeletally mature males in the third, fourth, and fifth decades of life; there have been no cases reported in a female.

Pectoralis major ruptures are classified as complete or incomplete and usually involve the humeral attachment of either the sternal or clavicular head. Most cases reports describe a complete rupture in an individual participating in athletics. Incomplete tears or complete tears involving the musculotendinous junction or muscle belly have also been reported.6

Patients with an acute tear of the pectoralis major often present with some inciting event, whether it be weight lifting or a direct blow to the chest. Many patients will report an audible pop and pain that is described as tearing or burning in nature. In most cases, an immediate disability is noted. As most reported cases are associated with bench pressing, the mechanism of injury is thought to be indirect. A forceful eccentric muscle contraction of the pectoralis major muscle in response to a large, acutely applied load results in the muscle injury. Incomplete or complete tears that involve the muscle belly or musculotendinous junction can also be caused by eccentric muscle contraction, but can also occur following direct trauma to the chest wall. Avulsion injuries of the clavicular and sternal heads may also occur in older individuals.7

Physical Examination

A complete physical examination is essential in evaluating patients who are suspected of having a pectoralis major rupture. The patient is examined with a bare chest; symmetry between the two pectoralis muscle bellies is assessed. Patients will often present with a splinted ipsilateral upper extremity often supported by the opposite hand. Ecchymosis may be present in the axilla on the affected side. Physical examination usually demonstrates an obvious defect in the anterior axillary border. Acutely, it can be very difficult to distinguish between complete and incomplete tears because of the local swelling, edema, and ecchymosis in the upper thorax and axillary area. In subacute or chronic injuries, complete tears will often have a bulge where the muscle belly has retracted, a characteristic webbed appearance of the axillary fold, and obvious cosmetic deformity (Fig. 30-2). These findings can be accentuated by having the

INTRODUCTION

• Traumatic muscle ruptures about the shoulder girdle are rare. However, these injuries do occur and are typically avulsion injuries to either the pectoralis major or rotator cuff muscles.

• Rupture of one of these muscles can lead to substantial functional disability.

• Pectoralis major ruptures most commonly occur during weight-lifting activities and in response to external trauma, such as during high-impact contact sports.

• Isolated subscapularis tendon tears are relatively rare and usually occur in conjunction with other injuries about the shoulder.

• The purpose of this chapter is to review the relevant anatomy, presentation, and management of traumatic muscle injuries of the pectoralis major and subscapularis muscles.

Starker Rper
Figure 30-1 Anatomic drawing of the pectoralis major muscle demonstrating its origins from the clavicle and sternum and its insertion onto the humerus.

patient actively contract the muscle by placing both arms in the forward flexed position and having the patient press his or her palms together in front of the abdomen. A great deal of discomfort with minimal movement about the shoulder is present and weakness is noted when the patient tries to adduct and internally rotate the shoulder.

Imaging

Radiographs of the chest (posteroanterior, lateral) and shoulder (anteroposterior, axillary) should be obtained as bony avulsion

Boxer With Pectoralis Rupture
Figure 30-2 A patient with an acute pectoralis major muscle rupture. Notice the webbed appearance of the axillary fold on the right side.
Figure 30-3 Magnetic resonance image demonstrating avulsion of the pectoralis muscle tendon off the humeral insertion (arrow).

type fractures involving the proximal humerus can occur. Typically, radiographs are without significant findings. Magnetic resonance imaging is the gold standard diagnostic imaging modality in detecting pectoralis muscle injury. Connell et al8 found magnetic resonance imaging to be optimal in evaluating the location, size, and degree of the tear Acute injuries often show a high signal intensity near the humeral cortex, due to periosteal stripping off the humerus as the tendon is avulsed from its insertion9 (Figs. 30-3 and 30-4). Chronic injuries are more associated with muscle retraction and dense scarring at the lateral border of the pectoralis major.

Treatment Options

Distinguishing between incomplete and complete tears, as well as the location of the tear, is crucial. Most authors agree that partial ruptures of the pectoralis major tendon and intramuscular strain or crush injuries can be successfully treated without surgery. These injuries typically have less pain, swelling, and

Vibration Reducing Foam
Figure 30-4 Axial magnetic resonance image demonstrating avulsion of the pectoralis muscle tendon off the humeral insertion (hatch marks).

ecchymosis and lack the physical examination characteristics that were previously outlined. Initial management should consist of rest, cryotherapy, and sling wear; activity is increased according to patient tolerance. For the most part, these injuries heal without a significant strength loss. It is important to stress the idea of gradual rehabilitation and patients often will not return to heavy lifting for at least 8 to 12 weeks.

Both surgical and nonsurgical approaches have been described in the literature for the treatment of complete rupture of the pectoralis major. Nonsurgical management of complete tears is usually applied in those cases in which an intramuscular injury has occurred. Complete tears of the pectoralis tendon are generally managed operatively. Park and Espiniella10 reviewed 29 patients and found that only 58% of patients with rupture of the pectoralis major tendon treated by nonoperative means had good results, while nearly 90% in the same series had good to excellent results after surgery. Other studies have also shown poor results after nonoperative management.11 The goal of surgery is to restore strength, function, and cosmesis. The authors recommend operative repair of the pectoralis major for the active patient who wishes to return to his or her previous level of function; this includes participation in sport. It is clear that the clinical results after surgery are significantly better than those that follow nonoperative treatment. We also recommend surgery for patients who are not satisfied with their function despite extensive rehabilitation.

Surgical Technique: Pectoralis Tendon Repair

Patients indicated for pectoralis tendon repair are positioned in the supine position, with the torso flexed to approximately 45 degrees. Regional anesthesia (interscalene block) is used and should be supplemented with local anesthetic injections at the inferior-most portion of the wound. Following a full prep-ping and sterile draping of the operative arm, a deltopectoral approach is used. The cephalic vein should be identified and spared if possible. A deep retractor is placed beneath the distal deltoid to facilitate visualization of the humeral insertion of the pectoralis major. The lateral free tendon end is identified and retracted. The muscle belly should be mobilized and freed from any adhesions or residual hematoma. The humeral insertion of the pectoralis lies just lateral to the biceps tendon. The authors' preferred approach uses suture anchors for fixation of the damaged tendon to the humerus. Alternatively, a bone trough can be fashioned and used to reinsert the torn pectoral tendon (Figs. 30-5 through 30-7). Pectoralis repair is preferable in the acute setting, but repair up to 2 years following injury has been described. Chronic cases occasionally require tendon reconstruction with autograft or allograft tissue. This tissue is woven into the distal muscle and sutured in place, and repair to bone is accomplished as described previously, with suture anchors or a bone trough.

Postoperative Rehabilitation

Patients are kept in a sling for approximately 6 weeks. Passive range-of-motion exercises, including pendulum and Codman exercises, are started immediately. Patients are encouraged to begin active elbow, wrist, and hand exercises immediately following the surgical repair. Isometric abduction and external rotation exercises are employed during this early phase. At 6 weeks after surgery, active, active-assisted, and terminal end range stretch passive range-of-motion exercises are begun. At this point, the patient may start to use the extremity for activities of daily living. A weight limit of 20 pounds is suggested for the operative extremity through the first 12 weeks following surgery. Progressive upper extremity strengthening begins in earnest at 6 weeks postoperatively. In general, most patients are cleared for noncontact sports at 4 months; avid weight lifters and contact athletes are held from full participation for 6 months.

Results and Outcomes

In general, because pectoralis major ruptures typically occur in young athletic patients, most surgeons advocate surgical repair in order to regain strength and optimal function. Several studies have shown the advantages of surgical intervention. Wolfe et al12 found that surgically treated patients showed comparable torque and work measurements, while conservatively treated individuals demonstrated a marked deficit in both peak torque and work repetition. Schepsis et al13 retrospectively reviewed 17 patients with distal pectoralis major rupture to compare acute and chronic injuries as well as conservative versus operative management. Both subjective and objective results were better in the acute group versus the chronic group, and these patients fared significantly better than patients treated nonoperatively.

RUPTURE OF THE SUBSCAPULARS TENDON

Relevant Anatomy

The subscapularis arises from the deep surface of the scapula anteriorly and its broad tendon inserts onto the lesser tuberosity of the humeral head (Fig. 30-8). It also acts as a dynamic stabilizer of the shoulder. It is one of the four rotator cuff muscles and is the only one that is an internal rotator of the shoulder. The subscapularis forms the upper border of the quadrangular space, which contains the axillary nerve and posterior humeral circumflex artery.

Clinical Features and Evaluation

Isolated subscapularis muscle tears are uncommon. However, these are significant injuries because they are often difficult to diagnose and can lead to prolonged disability. These injuries typically occur in an older population, although younger patients are more commonly affected in the traumatic setting. The exact mechanism of injury is poorly described in the literature, but it is thought that the typically affected patient falls on an outstretched arm or experiences a traumatic external rotation of an adducted arm. Deutsch et al14 described a series of 14 shoulders in 13 patients with surgically confirmed isolated subscapularis tears and found that the injuries were a result of violent, traumatic events such as falls, direct blows, or forceful boxing punches. Traumatic hyperextension or external rotation accounted for 11 of the 14 injuries.

Most patients will present with pain, swelling, and disability about the affected shoulder joint. It is important to do a thorough physical examination, looking for other injuries because, as described previously, these injuries are rarely isolated. Weakness of internal rotation along with increased passive external rotation is present. There are a number of tests that are applicable in both diagnosing isolated tears as well as other associated injuries. Gerber et al15 described a "lift-off" test that is performed by bringing the arm passively behind the body into maximum internal rotation away from the small of the back. If the patient is able to maintain the internal rotation, the test is negative for subscapularis rupture. If the patient cannot maintain maximal internal rotation and the hand drops straight back,

Figure 30-7 Intraoperative photograph demonstrating mobilization of the ruptured pectoralis tendon.

then the test is considered positive. If the resistance is weak and the hand drops back more than 5 degrees but not all the way to the spine, it is called a weak test. In the study by Gerber et al15 of 16 patients, 13 tests were positive and three were weak. In the same report, they also describe a "belly press test" for instances in which the patient cannot get the hand behind the back to perform the lift-off test. In the belly press test, the patient sits upright and presses the abdomen with the hand flat and attempts to keep the arm in maximum internal rotation. If active internal rotation is strong, the elbow stays in front of the trunk (Fig. 30-9A). If the function of the

Gluteus Maximus
Figure 30-8 Anatomy drawing of the subscapularis muscle demonstrating its origin and insertion.

Figure 30-9 A, Belly press test as described by Gerber et al.15 The patient in this figure has a negative test. Active internal rotation by the subscapularis is intact; thus, the elbow remains anterior to the patient's torso during the test. B, Positive belly press test. The injured subscapularis cannot internally rotate the humerus during the maneuver; thus, the elbow falls posterior to the torso.

subscapularis is impaired, then, the elbow falls behind the trunk (Fig. 30-9B). The patient exerts pressure on the abdomen by extension of the shoulder. This test was positive for all eight patients with complete subscapularis tears for whom the study was performed.

Figure 30-10 Axial magnetic resonance imaging demonstrating an acute subscapularis tear.

Lesions of the biceps tendon have been reported in the traumatic setting of subscapularis tears. The Speed test and Yerga-son test may be helpful in diagnosing bicipital subluxation or dislocation in the setting of a subscapularis tear. Anterior instability can also be associated with subscapularis tears and can be diagnosed clinically by the apprehension test. Most reported cases of subscapularis tears are associated with supraspinatus tears. We cannot overemphasize the importance of a complete physical examination of the shoulder, even when a diagnosis seems apparent.

Plain radiographs including anteroposterior, lateral, and axillary views of the shoulder will usually not be helpful in diagnosing isolated subscapularis tears. However, they can be crucial in diagnosing avulsion fractures of the lesser tuberosity, sub-acromial pathology, and dislocation when present. Magnetic resonance imaging is the gold-standard imaging modality in confirming this diagnosis. Deutsch et al14 emphasized the importance of high-contrast axial plane images that permit visualization of the subscapularis tendon as it inserts onto the lesser tuberosity, as well as the appearance of the long head of the biceps tendon in the bicipital groove. When the biceps tendon is dislocated medially out of its groove, this is nearly pathogno-monic for subscapularis injury. Axial magnetic resonance imaging of the shoulder demonstrating an acute subscapularis tear is shown in Figure 30-10. The normal insertion onto the lesser tuberosity is completely disrupted.

Treatment Options

When diagnosing a subscapularis tear, it is important to distinguish between isolated tears and tears associated with other injuries. When tears occur in conjunction with anterior instability, the subscapularis should be repaired during anterior stabilization. Tears associated with lesser tuberosity avulsions, biceps tendon subluxation or dislocation, and other injuries to the rotator cuff also require treatment of all injured structures. There are no reports describing conservative management of symptomatic isolated tears. We recommend primary repair of all isolated injuries.

Surgical Technique: Subscapularis Repair

Patients indicated for subscapularis tendon repair are positioned in the beach chair position. Regional anesthesia (interscalene block) is used and should be supplemented with local anesthetic injections at the inferior-most portion of the wound. An arm holder is used for upper extremity positioning. Following a full prepping and sterile draping of the operative arm, a del-topectoral approach is used. The cephalic vein should be identified and retracted. A deep retractor is placed beneath the deltoid laterally and the pectoralis tendon medially to facilitate visualization of the anterior shoulder. The subdeltoid bursa and hematoma are removed. The ruptured lateral free edger of the subscapularis tendon should be within the field of view. If the tendon is not immediately visualized, the surgeon should carefully dissect medially along the glenoid neck, posterior to the conjoined tendon and inferior to the coracoid process. Once the tendon has been identified and tagged, the muscle is mobilized to ensure that the lateral tendon edge reaches the lesser tuberosity of the humerus (Fig. 30-11).

The lesser tuberosity is gently prepared using a bur; suture anchors are used to reattach the free subscapularis tendon to the lesser tuberosity. The rotator interval should also be closed using nonabsorbable sutures.

Alternatively, subscapularis repair can be performed arthro-scopically. The method is similar. Suture anchors are placed in the lesser tuberosity, the tendon is mobilized, the sutures are passed through the tendon, and arthroscopic knots are tied.

Postoperative Rehabilitation

Patients are kept in a sling for approximately 6 weeks. Passive range-of-motion exercises, including pendulum and Codman's exercises are started immediately. Patients are encouraged to begin active elbow, wrist, and hand exercises immediately following the surgical repair. Isometric abduction and external rotation exercises are employed during this early phase. While passive internal rotation can also be started immediately, no active range-of-motion exercises are started until 6 weeks following surgery. At 6 weeks after surgery, active, active-assisted, and terminal end range stretch passive range-of-motion exercises are begun. At this point, the patient may start to use the extremity for activities of daily living. A weight limit of 20 pounds is suggested for the operative extremity through the first 12 weeks following surgery. Progressive upper extremity strengthening begins in earnest at 6 weeks postoperatively.

Figure 30-11 Intraoperative photograph demonstrating mobilization of the subscapularis before reinsertion on the lesser tuberosity.

Results and Outcomes

The management of isolated traumatic subscapularis tears has only been addressed in a few studies, most of which are limited by the number of patients. Gerber et al15 reported on 16 patients treated surgically and found that 82% of the patients assessed their postoperative functional shoulder score as good and that the capacity of the patients to work in their original occupation had increased from 59% preoperatively to 95% postoperatively.

In the study by Deutsch et al,14 with an average follow-up of 2 years, an improvement in preoperative symptoms, including pain with activities of daily living, pain with attempted sports activities, and weakness of the extremity was reported in 100% of the shoulders tested. All patients returned to their previous employment, and 12 of 13 patients returned to their previous sports activities. Other authors have also reported favorable results after operative treatment.16-18

REFERENCES

1. Bak K, Cameron EA, Henderson IJ: Rupture of the pectoralis major: A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrose 2000;8:113-119.

2. Kretzler HH, Richardson AB: Rupture of the pectoralis major muscle. Am J Sports Med 1989;17:453-458.

3. McEntire JE, Hess WE, Coleman SS: Rupture of the pectoralis major muscle. J Bone Joint Surg (Am) 1972;54:1040-1046.

4. Patissier P: Traite des Maladies des Artisans. Paris, 1822, pp 162-165.

5. Dunkelman NR, Collier F, Rook JL, et al: Pectoralis major muscle rupture in windsurfing. Arch Phys Med Rehabil 1994;75:819-821.

6. Zeman SC, Rosenfeld RT, Lipscomb PR: Tears of the pectoralis major muscle. Am J Sports Med 1979;7:343-347.

7. Berson BL: Surgical repair of pectoralis major rupture in an athlete. Am J Sports Med 1979;7:348-351.

8. Connell DA, Potter HG, Sherman MF, et al: Injuries of the pectoralis major muscle: Evaluation with MR imaging. Radiology 1999;210: 785-791.

9. Shubin Stein BE, Potter HG, Wickiewicz TL: Repair of chronic pec-toralis major ruptures. Tech Shoulder Elbow Surg 2002;3:174-179.

10. Park JY, Espiniella JL: Rupture of pectoralis major muscle: A case report and review of the literature. J Bone Joint Surg (Am) 1970;52:577-581.

11. Liu J, Wu JJ, Chang Cy, et al: Avulsion of the pectoralis major tendon. Am J Sports Med 1992;20:366-368.

12. Wolfe SW Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.

13. Schepsis AA, Grafe MW Jones HP, et al: Rupture of the pectoralis major muscle: Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15.

14. Deutsch A, Altchek DW Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, MRI findings, and operative treatment. Am J Sports Med 1997;25:13-22.

15. Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon: Results of operative repair. J Bone Joint Surg Am 1996;78: 1015-1023.

16. Gerber C, Krushell RJ: Isolated ruptures of the tendon of the subscapularis muscle. J Bone Joint Surg Br 1991;73:389-394.

17. McAuliffe TB, Dowd GS: Avulsion of the subscapularis tendon: A case report. J Bone Joint Surg 1987;69:1454-1455.

18. Edwards TB, Walch G, Sirraux F, et al: Repair of tears of the sub-scapularis. J Bone Joint Surg Am 2005; 87:725-730.

In This Chapter

Clavicle fracture Proximal humerus fracture Glenohumeral dislocation/instability

Acromioclavicular (AC) and sternoclavicular (SC) dislocation/instability Little leaguer's shoulder Internal impingement Scapular winging

RELEVANT ANATOMY AND PHYSIOLOGY

The principal anatomic factor differentiating pediatric shoulder injuries from adult shoulder injuries is the presence of open physes. The proximal humerus is formed by the coalescence of three ossification centers (humeral head, greater tuberosity, lesser tuberosity) occurring between 5 and 7 years of age. The remaining proximal humeral physis between the epiphysis and metaphysis contributes 80% of the longitudinal growth to the humerus and completely closes between 19 and 22 years of age.1 The proximal humeral physis is commonly involved in both traumatic and overuse pediatric shoulder injuries.

The clavicle, one of the most frequently fractured bones in childhood, forms via intramembranous ossification. The medial physis of the clavicle is the last to fuse in the body between 22 and 27 years of age and provides 80% of the longitudinal growth of the clavicle.1 The scapula is similarly formed by intramem-branous ossification and is largely protected from injury during sports participation by its close proximity to the thorax and protective muscular covering.

Physeal biomechanics play a role in the type of injuries observed in pediatric athletes. In early childhood, the cartilagi nous nature of the physis protects the ossified portions of the bone by helping absorb forces. When this absorptive capacity is overcome, residual forces are transmitted to the metaphysis resulting in a torus type fracture. In later childhood, the resiliency of the physis is reduced, and, by virtue of its relative biomechanical weakness, the physis becomes the most likely site of fracture.1 The physis is susceptible to not only acute fracture, but also stress fracture from overuse.

The soft tissues of the shoulder girdle are grossly identical to those observed in adults. In our experience, we have noted, however, that the amount of physiologic laxity present in children exceeds that observed in adults. This observation becomes important when evaluating a patient for glenohumeral instability, particularly when evaluating pediatric patients with multidirectional hyperlaxity. As these patients complete adolescence, much of this hyperlaxity will resolve, in many cases resulting in resolution of shoulder symptoms.

RELEVANT BIOMECHANICS

The biomechanics of throwing are well described and have been divided into wind-up, cocking, acceleration, and follow-through.2 Large forces are generated during throwing with peak angular velocity rates exceeding 7000 degrees per second occurring during the acceleration phase.3 The forces generated during throwing have unique implications in the immature athlete. The effects of competitive throwing on a skeletally immature proximal humerus are usually adaptive and protective but in some cases become pathologic.

As the arm enters late cocking and transitions to early acceleration, a large external rotation torsional moment is placed on the arm. As the soft tissues of the shoulder (rotator cuff, cap-suloligamentous structures) reach maximal limits of external rotation, the remaining forces are transmitted to the humerus. These torsional forces preferentially affect the weaker physis. With repetitive throwing, these forces result in an adaptive and protective remodeling of the proximal humerus.

Previously, throwers were thought to have increased external rotation and decreased internal rotation in their dominant shoulder as a result of lax anterior soft tissue and a tight posterior capsule. More recently, however, it has been recognized that osseous change in the form of increased humeral retroversion is largely responsible for this phenomenon.4 The torsional forces occurring with repetitive throwing introduce remodeling of the proximal humerus through the open physis resulting in more humeral retroversion (Fig. 31-1). This remodeling provides two benefits. First, increased external rotation is advantageous to pitching mechanics, allowing for greater throwing velocity. Second, increased humeral retroversion effectively moves the

INTRODUCTION

• Although once considered rare, increasing participation of children in sports has increased the frequency of pediatric shoulder injuries.

• The majority of pediatric shoulder injuries involve fractures of the shoulder girdle, both physeal and extraphyseal.

• The increasing level of competition within organized pediatric athletics, however, has led to a rise in the occurrence of overuse-type injuries.

• Most pediatric shoulder problems, whether traumatic or related to overuse, can be successfully treated nonoperatively.

Bone Ortho Clip Art

Figure 31-1 The torsional forces occurring with repetitive throwing introduce remodeling of the proximal humerus through the open physis resulting in more humeral retroversion.

FRACTURES, DISLOCATIONS, AND INSTABILITY

Figure 31-1 The torsional forces occurring with repetitive throwing introduce remodeling of the proximal humerus through the open physis resulting in more humeral retroversion.

greater tuberosity further away from the posterior superior glenoid rim, minimizing the mechanical contact now referred to as internal impingement (Fig. 31-2).

Unrestricted throwing by skeletally immature patients may create a pathologic effect. The repetitive forces acting on the physis may cause what is effectively a stress fracture. This phenomenon has been well described and tagged with the moniker "little leaguer's shoulder."5

Figure 31-2 Increased humeral retroversion effectively moves the greater tuberosity further away from the posterior superior glenoid rim minimizing the mechanical contact now referred to as internal impingement.

Clavicle Fractures

Clavicle fractures are among the most common injuries observed in childhood sports. These injuries usually result from a fall onto the shoulder during activity. These fractures most often occur in the midshaft of the clavicle but may also be observed at the terminal portions of the bone.

Clinical Features and Evaluation

Pain, swelling, and deformity are the common presenting features of a clavicle fracture. Physical examination of the shoulder girdle is usually limited by pain in the acute setting. Particular attention is paid to skin and soft tissues overlying the area of injury to ensure that fracture fragments do not jeopardize these structures. Additionally, a thorough neurovascular examination is performed to evaluate for compromise caused by displaced fracture fragments.

Physical examination is always followed by radiographic examination of the clavicle. In cases with midshaft deformity, a simple anterior posterior radiograph of the clavicle is sufficient. In cases with lateral deformity, a 20-degree cephalic tilt acromioclavicular joint view is added.1 In cases with medial deformity, a sternoclavicular joint view is added (serendipity view).1 Fractures of the medial and lateral clavicle most commonly occur through the physis and may appear radiographically as a dislocation of the sternoclavicular or acromioclavicular joints. In cases of medial clavicle fractures presenting with signs of neurovascular compromise, difficulties breathing or swallowing, or posterior displacement on plain radiography, computed tomography should be performed as part of the evaluation.

Treatment and Results

Treatment of clavicle fractures in pediatric patients is largely nonoperative. Clavicle fractures generally do not require reduction because of the remarkable ability to remodel in the pedi-atric and adolescent age group. Children up to age 17 years have shown the ability to remodel clavicle fractures with as much as 90 degrees of angulation and as much as 4 cm of overlap.6

The vast majority of middle third clavicle fractures are best treated nonoperatively. Nonoperative treatment of clavicle fractures in the pediatric age group is sling immobilization. Reduction maneuvers are seldom necessary or helpful. Figure-eight strapping is often uncomfortable and unnecessary. Shortening and malunion generally do not occur in children, and the clinical results are usually excellent, with most fractures healing successfully with nonoperative treatment (Fig. 31-3).

In the skeletally immature patient, operative management is indicated in open fractures or when the clavicle impinges on the subclavian vessels or brachial plexus causing neurologic or vascular compromise. "Floating shoulder," a concomitant fracture of the clavicle and scapula, is a relative indication for operative management; however, this severe injury is very rare in childhood athletics, only occurring with severe trauma such as might be seen in junior motor cross.

Occasionally, in adolescents who are approaching or who have reached skeletal maturity, operative management is indicated. These patients often have comminuted fractures or large butterfly fragments, and many have considerable shortening of the clavicle. Highly competitive athletes nearing skeletal maturity, especially those who use their arm for overhead sports or throwing, may benefit from open reduction and internal fixation.

Figure 31-3 A, Displaced midshaft clavicle fracture in a skeletally immature patient. B, Complete healing of the fracture 6 weeks later.

Figure 31-3 A, Displaced midshaft clavicle fracture in a skeletally immature patient. B, Complete healing of the fracture 6 weeks later.

Medial clavicle fractures are usually physeal injuries that successfully remodel in pediatric patients. The best treatment for these injuries is nonoperative. Patients with a posteriorly displaced medial clavicle fracture who have difficulty swallowing or breathing or signs of neurovascular compromise may require operative reduction. Operative reduction is performed under general anesthesia in the operating room with a thoracic surgeon available in case of vascular complications.

The distal clavicle, like the medial clavicle, has tremendous potential for remodeling. Most pediatric distal clavicle fractures can be treated nonoperatively. Some distal clavicle injuries in children are, however, actually periosteal sleeve avulsion injuries.1 In these injuries, the lateral clavicle rips through the thick periosteal sleeve that surrounds the distal clavicle. The acromioclavicular and coracoclavicular ligaments are strongly attached to the periosteum of the distal clavicle. In cases of severe displacement, management involves operative reduction, placing the clavicle back into the thick periosteal sleeve, and repairing the periosteum with sutures.

Rehabilitation after clavicle fracture should begin as soon as pain permits. Initially, pendulum exercises are begun followed by isometric exercises of the triceps, biceps, deltoid, and rotator cuff muscles. Normal activities of daily living are permitted, and active range of shoulder motion is begun 4 to 6 weeks after injury. Strengthening begins when there is radiographic evidence of healing and the patient has regained full range of shoulder motion. When strength has returned to normal, a return to non-contact sports is permitted. Contact sports are permitted when there is adequate radiographic and clinical evidence of healing and sufficient remodeling, usually around 3 months after injury.

Generally, results of treatment of clavicle fractures in children are excellent without residual dysfunction.

Proximal Humerus Fractures

Proximal humeral fractures in children are relatively common and may involve the growth plate or be strictly metaphyseal. Most of these fractures occur as a result of a fall during activity, although rarely insignificant trauma will cause a proximal humeral fracture through a preexisting benign bone cyst. Physeal fractures with varus displacement have been reported in skele-tally immature gymnasts.7 Proximal humeral physeal fractures have tremendous remodeling potential. This fact combined with a wide arc of shoulder motion allows for good shoulder function despite significant fracture displacement.

Clinical Features and Evaluation

Proximal humerus fractures generally present with pain and deformity. The deformity is often obvious with the arm held in internal rotation. Physical examination consists of palpation, which causes pain at the fracture site, and neurovascular examination. Further examination is usually limited by pain. Radiographs are always obtained including perpendicular views of the proximal humerus and of the entire humerus. Fractures are usually obvious on radiographs; however, certain nondisplaced physeal fractures may have normal-appearing radiographs. In this circumstance, diagnosis of nondisplaced physeal fracture is largely clinical.

Treatment and Results

Most proximal humeral fractures can be treated nonoperatively. Metaphyseal and physeal fractures that are nondisplaced or minimally angulated are generally stable and heal quite well with immobilization followed by early pendulum exercises. Displaced fractures often have a bayonet apposition with shortening. These fractures generally heal with minimal residual deformity, especially in younger children. Patients who are approaching skeletal maturity with more limited remodeling potential may require closed reduction with or without internal fixation. Dameron and Rockwood8 have proposed guidelines for managing pediatric proximal humeral fractures. Nonoperative treatment is indicated in patients younger than 5 years of age with less than 70 degrees of angulation and as much as 100% displacement and in patients 5 to 12 years of age with less than 40 degrees of angu-lation and 50% displacement. Patients older than 12 years of age have more limited remodeling potential and should be treated more aggressively in cases of moderate to severe angulation and displacement.

Nonoperative treatment consists of early pendulum exercises as soon as the fracture is stable. Formal rehabilitation is generally begun 3 to 4 weeks after the initial injury when the fracture shows early signs of consolidation. Early passive motion exercises are followed by active range of motion exercises. Subsequent physical therapy focuses on strengthening of the rotator cuff, trapezius, and deltoid muscles. Full return to sports is usually allowed between 3 and 6 months.

In patients approaching skeletal maturity with moderate to severely displaced proximal humeral fractures, reduction should be performed to avoid potential deformity and functional limitation. Specifically, high-level athletes involved with overhead sports or throwing may require operative treatment. These patients require a near anatomic reduction in order to regain full shoulder motion and return to their same level of play. We emphasize, however, that operative treatment should gen erally be reserved for patients with little or no growth remaining who are unlikely to remodel significantly displaced fractures.

Reduction of proximal humeral fractures is generally carried out with the patient under anesthesia. A reduction of maneuver of longitudinal traction, abduction, and external rotation will usually reduce the fracture. Fluoroscopic examination is helpful to assess adequacy of reduction and stability. If the fracture is unstable, percutaneous fixation with Kirschner wires is used (Fig. 31-4). The wires can be left protruding externally allowing for removal in clinic at about 4 weeks postoperatively. Rarely,

closed reduction is not possible because of soft-tissue incarceration. In this scenario, open reduction is necessary. After surgery rehabilitation consists of the same regimen used for nonoperative treatment of proximal humerus fractures with full return to sports expected between 3 and 6 months postoperative.

Glenohumeral Dislocations/Instability

Traumatic dislocations of the shoulder in young skeletally immature patients are rare. However, traumatic dislocations are seen in adolescents, and recurrent instability in these patients is a common problem. Anterior dislocations are far more common than posterior and inferior dislocations.

Clinical Features and Evaluation

Anterior shoulder dislocations present with pain, swelling, and deformity. The acromion often appears prominent, and the pos-terolateral portion of the shoulder may appear flattened. The arm is generally supported and held in an abducted and externally rotated position. Pain is present with movement of the shoulder. The humeral head is usually palpable anterior to the glenoid. Posterior shoulder dislocations present with the arm at the side and the forearm internally rotated. A painful loss of external rotation and inability to supinate the forearm is commonly seen in posterior dislocations. In athletic events, posterior dislocations are often associated with posteriorly directed force acting on the outstretched arm. Inferior shoulder dislocations present with the arm abducted, the elbow flexed, and the hand above the head and may result from a hyperabduction force acting on the arm.

Evaluation of the neurologic and vascular status of the arm is an essential part of the physical examination both initially and after reduction. The remainder of the physical examination is limited in acute dislocations. In patients with initial or recurrent glenohumeral instability presenting in the subacute phase, complete physical examination including stability examination is usually possible (details of shoulder examination for instability are covered in Chapter 16).

With acute shoulder dislocation, two perpendicular radiographic views of the shoulder are obtained. These are used to identify the presence of any fractures as well as the direction of the dislocation. Postreduction radiographs confirm the reduction and help identify any associated injuries. In the subacute setting, we use an anteroposterior radiograph and a glenoid profile radiograph, as described by Bernageau et al9,10 to identify osseous abnormalities consistent with instability. In patients with suspected instability (no clear history of dislocation) and normal radiographs, we obtain secondary imaging with magnetic resonance arthrography to confirm the presence of instability lesions, that is, labral injury.

Treatment and Results

The treatment of acute shoulder dislocations includes sedation or an intra-articular lidocaine injection followed by reduction using one of the standard reduction techniques. Care must be used during the reduction maneuver to prevent a proximal humerus fracture.

Considerable debate exists over proper management of adolescent first-time shoulder dislocations. While some authors recommend surgical stabilization after an initial instability episode to prevent recurrence, new research suggests that a brief period of immobilization in external rotation after reduction of a traumatic anterior dislocation reduces the incidence of recurrent instability.11,12

In the absence of early immobilization in external rotation, the incidence of recurrent shoulder instability after an acute traumatic shoulder dislocation in young patients is extremely high. These patients may benefit from surgery after a traumatic first-time shoulder dislocation. Details of operative treatment of recurrent shoulder instability are detailed in preceding chapters.

Atraumatic Shoulder Instability

Atraumatic shoulder instability is the most common type of instability seen in skeletally immature patients. Rehabilitation should be the mainstay of treatment for nearly all these cases. The goal of treatment is to increase the dynamic stabilization force of the shoulder joint by strengthening the rotator cuff musculature. Second, the scapular stabilizers should be strengthened to maintain proper positioning of the glenoid in relation to the humeral head. Neuromuscular control should also be emphasized during rehabilitation to improve shoulder proprio-ception. A minimum of 12 months of aggressive rehabilitation and avoidance of provocative maneuvers should be achieved before surgical management should be considered. Most patients will eventually improve with the passage of time. Voluntary dis-locators comprise a unique group that should almost universally be treated nonoperatively.13

Acromioclavicular and Sternoclavicular Dislocations/Instability

Since the joint capsule and ligaments in a child are much stronger than the physis, sternoclavicular and acromioclavicular dislocations are extremely rare in the pediatric population. Acromioclavicular separations are generally not seen until adolescence at which time they can be treated like adult injuries (see Chapter 26). Skeletally immature patients may appear to have an acromioclavicular separation, but most of these injuries are actually physeal fractures.

Injuries to the lateral clavicle and acromioclavicular joint are different in children compared to adults. The pediatric distal clavicle has a thick periosteal tube that is continuous with the acromioclavicular joint. The acromioclavicular joint is rarely dislocated in children because the weak link is the physis, not the ligamentous attachments. The acromioclavicular and coraco-clavicular ligaments are tightly connected to the periosteum encasing the distal clavicle. Injuries to this area most commonly result in physeal fractures with the distal clavicle splitting out of the periosteal sleeve. True dislocations of the sternoclavicu-lar joint in children and adolescents are very rare. Medial clavicular injuries usually affect the medial physis of the clavicle.

OVERUSE INJURIES

Proximal Humeral Epiphyseolysis

Proximal humeral epiphyseolysis, more commonly known as little leaguer's shoulder, is an overuse injury occurring exclusively in skeletally immature throwing athletes and almost exclusively in baseball pitchers.5,14 During repetitive throwing, torsional forces act on the arm, externally rotating the humerus distally, while the proximal portion is secured at the gleno-humeral joint via the capsuloligamentous structures. These forces result in remodeling of the proximal humerus through the weakest osseous point, the proximal humeral physis. When throwing becomes excessive, this remodeling phenomenon may become pathologic resulting in a stress fracture through the proximal humeral physis.

Proximal Humerus Physeal Widening

Figure 31-5 A, Radiograph showing physeal widening (arrows) of the throwing shoulder of a 12 year old. B, Contralateral normal physis.

Figure 31-5 A, Radiograph showing physeal widening (arrows) of the throwing shoulder of a 12 year old. B, Contralateral normal physis.

Clinical Features and Evaluation

Individuals presenting with proximal humeral epiphyseolysis are nearly always high level little league baseball pitchers between 10 and 14 years of age.14 They report progressive onset of pain that occurs only with throwing activities. They also commonly report loss of velocity and/or control of their pitches. They usually are able to participate in hitting activities without exacerbation of symptoms.

Physical examination findings may demonstrate mild tenderness over the proximal humeral physis with deep palpation. A provocative maneuver of abduction, external rotation, and extension may produce pain in the dominant shoulder. Alternatively, examination may not reveal any pathologic findings. Mobility examination usually demonstrates greater external rotation and less internal rotation of the dominant shoulder compared to the nondominant shoulder. This discrepancy in the arc of motion between the two shoulders is a result of physiologic remodeling and is a nonspecific finding in pitchers.4

Radiographic examination serves to confirm the diagnosis of proximal humeral epiphyseolysis, which is suspected initially largely based on the history. Proximal humeral radiographs demonstrate widening of the physis, usually most readily apparent on the anteroposterior view. Comparative radiographs of the contralateral proximal humerus are helpful in confirming the pathologic condition of the physis (Fig. 31-5).

Treatment and Results

Treatment of proximal humeral epiphyseolysis involves a period of selective rest and activity modification. After diagnosis of proximal humeral epiphyseolysis, repetitive throwing activities are halted for a period of 3 months. During this time, painless activities such as hitting are allowed. Often pitchers are allowed to play first base, enabling continuation of hitting while minimizing throwing activities. After 3 months of activity restrictions, gradual resumption of throwing is allowed, preferably using a progressive throwing program under the supervision of a qualified athletic trainer or physical therapist. Provided symptoms do not recur, full return to pitching is usually possible within 6 months of initiation of treatment. Recurrence of pain with throwing is treated with prolongation of throwing restrictions until symptoms subside.

Appropriate treatment of proximal humeral epiphyseolysis nearly always results in successful return to throwing activities. Rarely, a patient may have continued symptoms preventing pitching until reaching a more skeletally mature age. We have never observed a case of permanent physeal damage or early physeal closure caused by proximal humeral epiphyseolysis.

Internal Impingement

Internal impingement, or posterosuperior glenoid impingement, is the contact that occurs between the greater tuberosity and the posterosuperior aspect of the glenoid rim during abduction, external rotation, and extension of the arm (Fig. 31-6).15,16 This contact is physiologic, occurring in nearly all individuals including the skeletally immature. In the throwing athlete, the repetitive nature of this contact can result in pathologic glenohumeral lesions including partial thickness rotator cuff tears and/or superior labral tears.

In the skeletally immature throwing athlete, symptomatic internal impingement is uncommon with proximal humeral epiphyseolysis predominating as the cause of pain. When symptomatic internal impingement occurs in pediatric athletes, it usually results from poor pitching mechanics. Davidson et al17

Figure 31-7 A, Hyperangulation occurs from the arm being in excessive extension and/or the scapula being in excessive protraction during late cocking and early acceleration and may result in symptomatic internal impingement. B, Throwing with the arm in the plane of the scapula prevents hyperangulation and minimizes internal impingement.

Figure 31-7 A, Hyperangulation occurs from the arm being in excessive extension and/or the scapula being in excessive protraction during late cocking and early acceleration and may result in symptomatic internal impingement. B, Throwing with the arm in the plane of the scapula prevents hyperangulation and minimizes internal impingement.

reported the role of hyperangulation of the arm during throwing in the development of symptomatic internal impingement. This hyperangulation can occur from the arm being in excessive extension and/or the scapula being in excessive protraction during late cocking and early acceleration (Fig. 31-7). Although some authors maintain that underlying anterior glenohumeral instability is the etiology of symptomatic internal impingement, this has not been scientifically substantiated in the pediatric or adult population as most of these patients lack evidence of anterior capsulolabral injury on imaging studies or during arthroscopy.16

Clinical Features and Evaluation

Symptomatic internal impingement occurs only in throwing athletes including participants in baseball, tennis, volleyball, team handball, and javelin. The athlete's chief complaint is typically shoulder pain during throwing activities that is usually relieved by rest. Pitchers commonly report loss of velocity and/or control of their pitches. Nonthrowing activities are usually unaffected. Frequently, symptoms begin after an increase in frequency of throwing activities.

Physical examination demonstrates pain with abduction, external rotation, and extension of the involved shoulder; no apprehension occurs with this maneuver. The pain is relieved by eliminating the extension component of the maneuver. Rotator cuff testing is usually unremarkable in pediatric patients as they usually lack rotator cuff pathology associated with internal impingement. Poor control of the scapula as evidenced by scapular winging during glenohumeral elevation is usually present in skeletally immature individuals with symptomatic internal impingement. This type of scapular winging results from fatigued or poorly conditioned scapular retractors and not from neurologic deficit. Additionally, individuals will have increased external rotation and decreased internal rotation of the dominant shoulder compared to the nondominant shoulder as a result of physiologic remodeling.3

Walch et al16 described a variety of findings in individuals with symptomatic internal impingement using various imaging modalities and diagnostic arthroscopy in a skeletally mature population. Plain radiography demonstrates changes (sclerosis, geodes, cysts) on the greater tuberosity in 67% of patients and lesions of the posterosuperior glenoid in 33% of patients (Fig. 31-8). Computed tomography demonstrates posterosuperior glenoid changes in 70% of patients. Arthrography demonstrates partial thickness tearing of the supraspinatus and/or infraspina-tus in 50% of adult patients, although this probably occurs much less frequently in pediatric patients. Magnetic resonance imaging shows an abnormal signal at the insertion of the rotator cuff in 95% of adult patients. Labral pathology has been identified in most adult patients with symptomatic internal impingement undergoing arthroscopy including a torn or frayed posterior superior labrum in 83% and frank labral disinsertion in 72%. The arthroscopic hallmark of the diagnosis is the "kissing lesion." During arthroscopy, the arm is positioned in abduction, external rotation, and extension, incurring contact in the area of the labral and rotator cuff lesions (Fig. 31-9).

In our practice, we obtain radiographs on all pediatric patients presenting with shoulder pain at the time of initial evaluation including an anteroposterior view and a glenoid profile view as described by Bernageau et al.9 We only obtain secondary imaging with magnetic resonance arthrography in patients with suspected symptomatic internal impingement who have failed all reasonable nonoperative treatment to evaluate them

Schatzki Ring
Figure 31-8 Posterior glenoid changes (arrows) in an adolescent pitcher with symptomatic internal impingement. This same individual also has physeal changes consistent with proximal humeral epiphyseolysis.
Figure 31-9 Arthroscopic view (looking from the anterior portal) of the contact that occurs between the posterior superior glenoid labrum and the supraspinatus tendon. This patient has a partial thickness supraspinatus tear (arrows) as a result.

for mechanical lesions (labral tears, partial thickness rotator cuff tears).

Treatment and Results

In the pediatric population, almost all cases of symptomatic internal impingement can be treated successfully with nonoperative interventions. A period of relative rest combined with a specific physical therapy regimen addressing the pathomechan-ics of internal impingement is employed. This physical therapy regimen attempts to minimize hyperangulation by strengthening the scapular retractors (trapezius, rhomboids, levator scapulae), controlling scapular protraction, strengthening the subscapularis, and controlling external rotation and extension during throwing activities. Posterior capsular stretching is used to address any posterior capsular tightness. Therapeutic modalities and non-steroidal anti-inflammatory medications are used as indicated. As symptoms subside, a progressive throwing program, preferably under the supervision of a qualified athletic trainer or physical therapist, is initiated. Attempts are made to correct mechanical deficiencies in the throwing motion to avoid recurrence of symptoms. Successful return to throwing activities may be possible in as little as 6 weeks in mild cases but may take up to 6 to 9 months in more severe cases.

Operative treatment is rarely indicated in the skeletally immature patient with symptomatic internal impingement. In select individuals with symptomatic labral tears from internal impingement with persistent pain after appropriate nonoperative treatment and correction of faulty pitching mechanics, arthroscopic labral repair can be considered with or without an associated anterior capsulorrhaphy to control hyperangulation. Although this arthroscopic treatment has been reported successful in as many as 85% of adult patients, results in the pediatric population are unknown.18

Scapular Winging

Traditionally, scapular winging is related to an injury of the long thoracic nerve resulting in serratus anterior paralysis. While this injury pattern occurs in the pediatric population, it is quite rare; more commonly, scapular winging in skeletally immature athletes is caused by overuse and/or poor conditioning of the scapular retractors (trapezius, rhomboids, levator scapulae). Scapular winging leads to hyperangulation (excessive extension angle occurring between the humerus and scapula), which in turn leads to symptomatic internal impingement. The athletes most commonly presenting with scapular winging are those participating in baseball pitching and swimming.

Clinical Features and Evaluation

Most athletes with scapular winging present with findings of internal impingement as described previously caused by overuse and/or poor conditioning of the scapulothoracic musculature. Symptoms, generally shoulder pain, occur almost exclusively with overhead and throwing activities. Rarely, athletes with scapular winging report a direct blow to the thorax just beneath the axilla resulting from a fall onto an object (commonly a piece of equipment in gymnasts) or during contact sports. In this second scenario, blunt injury to the long thoracic nerve causes paralysis of the serratus anterior muscle with resultant scapular winging.

Scapular winging is observed on clinical examination by the examiner standing behind the patient as he or she actively forward flexes the shoulder. Subtle scapular winging may be observed only as asymmetry of the scapula during forward flexion. Having the patient push against a fixed object (wall or closed door) will also demonstrate scapular winging.

Plain radiography is performed and may reveal findings consistent with internal impingement as described previously in patients with scapular winging emanating from overuse/ poor conditioning. Additionally, magnetic resonance arthrogra-phy may show labral tears and/or partial thickness rotator cuff tears in these patients. In patients with scapular winging resulting from an injury to the long thoracic nerve, imaging studies are usually normal. Electromyography and nerve conduction studies will usually demonstrate decreased potentials in the serratus anterior muscle in this second group of patients.

Treatment and Results

Nonoperative treatment is initially indicated in all pediatric patients presenting with scapular winging. Physical therapy concentrating on strengthening of the periscapular and trunk musculature is nearly always successful. Surgical treatment of patients with long thoracic nerve palsy has been reported (nerve exploration, pectoralis major transfer), although we have no experience with this in the pediatric population. Even in cases of electromyographically proven long thoracic nerve palsy, physical therapy and observation usually result in resolution of symptoms in children, although complete resolution may take an average of 9 months.19

CONCLUSIONS

The presence of an open proximal humeral physis leads to some clinical problems unique to the pediatric shoulder.

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