1. Pediatric Shoulder Instability Mark M. Scheffer, M.D. Orthopaedic Surgeon Dartmouth-Hitchcock Concord

2. Shoulder Anatomy • General Anatomy:

3. Shoulder Anatomy • Glenohumeral Ligaments:

4. Shoulder Anatomy • Glenohumeral Ligaments

5. Shoulder Anatomy • Coracoacromial Arch:

6. Shoulder Stability Definition: Static and Dynamic Forces that Interact to Keep the Humeral Head Centered in the Glenoid in order to Maintain Shoulder Function.

7. Shoulder Stability • Static and Dynamic Stabilizers

8. Shoulder Stability • Static Stabilizers: • Bone – glenoid and humeral head • Coracoacromial Arch • Labrum • Capsuloligamentous Complex

9. Shoulder Stability • Dynamic Stabilizers • Rotator Cuff • Deltoid, Trapezius, Lat Dorsi

10. Shoulder Instability • Classification: Traumatic vs. Atraumatic

11. Traumatic vs. Atraumatic • TUBS vs. AMBRI • TUBS: • Traumatic • Unidirectional • Bankart Tear • Surgical Treatment C. Parker, U Tenn

12. Traumatic vs. Atraumatic • TUBS vs. AMBRI • AMBRI • Atraumatic • Multidirectional • Bilateral • Rehab • Inferior Capsular Shift

13. Traumatic vs. Atraumatic Unidirectional vs. Multidirectional

14. Traumatic Dislocation • Bankart Lesion:

15. Traumatic Dislocation • Bankart Lesion:

16. Traumatic Dislocation • Bankart Lesion:

17. Traumatic Dislocation • Boney Bankart Lesion:

18. Traumatic Dislocation • Hill-Sachs Lesion:

19. Traumatic Dislocation • Hill-Sachs Lesion:

20. Traumatic Dislocation • Associated Injuries • Rotator Cuff Tear • Axillary Nerve Injury • Fracture – tuberosities, Salter, Glenoid

21. Atraumatic Dislocation: • Capsule is Large, Stretched Out • Other Shoulder is also Loose • Ankle Sprains, Other Dislocations

22. Traumatic vs. Atraumatic • Evaluation: • History • Physical Exam • Imaging • Treatment

23. History • When did first dislocation occur? • How Many? • What Causes the Dislocation? • PT? • Other Joint Problems?

24. History • Voluntary Component?

25. Physical Exam • Generalized Laxity • Examine both shoulders • Range of Motion • Neuro Exam – Axillary Nerve! • Special Tests

26. Physical Exam • Sulcus Sign:

27. Physical Exam • Apprehension Sign:

28. Physical Exam: • Relocation Test:

29. Physical Exam • Impingement Test : (Kids Don’t Get Primary Impingement!)

30. Xrays: • AP IR and ER:

31. Xrays • Scapular Y and Axillary

32. Xrays • West Point Axillary View:

33. Xrays Dislocation:

34. Xrays • Boney Bankart:

35. Xrays: • Watch Out:

36. MRI • Always Get an MRI/Arthrogram – Gadolineum!

37. MRI • Multidirectional Instability:

38. MRI • Bankart Tear:

39. Treatment - Traumatic • Acute Reduction:

40. Treatment - Traumatic • Sling 1 – 3 Weeks, Rehab • Very high rate of recurrence in Teens (up to 90%) • Case can be made for primary Bankart Repair

41. Treatment - Traumatic • Surgical: • Arthroscopic Bankart • Open Bankart • Possible w/ Capsular Imbrication

42. Treatment - Traumatic • Surgical:

43. Treatment - Atraumatic • Rehab: • Rotator Cuff Strengthening • Scapular Stabilization Exercises TIME! – Tends to get better as people age

44. Treatment - Atraumatic • Surgical – • Arthroscopic Capsular Imbrication • Capsular Shift (arthroscopic or open)

45. Recurrent Dislocations • Bone Involvement: • Humerus • Increased Hill Sachs Lesion size • Glenoid • Anteroinferior Bone/Cartilage Loss

46. Recurrent Dislocations • Bone Loss - glenoid

47. Recurrent Dislocations • Bone Loss – Glenoid and Humeral Head:

48. Posterior Dislocations • Seizures – can be missed (21/24 Zagreb 2003) • Electricution • Muscle Imbalance

49. Posterior Dislocations • Reverse Hill-Sachs:

50. Shoulder Instability Thanks!