Pediatric shoulder radiograph (an approach)

Last revised by Yuranga Weerakkody on 28 Feb 2021

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.

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

Check the epiphysis and metaphysis for fracture:

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

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
  • 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
  • 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
  • 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
  • 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

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