AdultPediatric
Clavicle fractures are the most common pediatric shoulder injury. Glenohumeral dislocation is rare before adolescence — when it occurs, recurrence is high. Always consider referred pain (cardiac, diaphragmatic, splenic).
🚩 Red-flag clues (must not miss)
- •Skin tenting, neurovascular compromise over clavicle = open or impending open fracture
- •Floppy arm in newborn after difficult delivery = brachial plexus injury (Erb / Klumpke)
- •Fever + atraumatic shoulder swelling = septic joint / osteomyelitis
- •Referred pain — diaphragmatic irritation (Kehr sign — splenic), cardiac, pneumonia
History
- Mechanism (FOOSH, direct blow, birth trauma)
- Birth history (clavicle fx common with shoulder dystocia)
- Recurrent dislocation, generalized joint laxity
Exam
- Inspection — deformity, asymmetry, skin tenting
- Palpation — clavicle (entire length), AC joint, SC joint, scapula
- ROM — abduction, ER, IR; apprehension test
- Brachial plexus exam (Erb: waiter's tip; Klumpke: claw hand)
Labs
- Not needed for trauma; CBC/CRP/ESR if atraumatic or febrile
Imaging
- Shoulder XR — AP + axillary or scapular Y for dislocation
- Clavicle XR for clavicle injury
- CXR if posterior SC dislocation suspected (mediastinal injury risk)
- MRI for rotator cuff, labrum, occult fx
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Mid-shaft clavicle fracture | FOOSH or direct blow, deformity, crepitus | Sling 3–6 wk; ortho if shortening > 2 cm, skin tenting, open |
| Distal clavicle / AC separation | Tenderness over AC joint, step-off | Sling, ortho follow-up |
| Sternoclavicular dislocation | Anterior or posterior; posterior is emergent (mediastinal compression) | CT chest, emergent ortho/CT surgery for posterior |
| Glenohumeral dislocation (anterior) | Adolescent, arm held abducted/ER, squared-off shoulder | Reduction, sling, ortho (high recurrence in adolescents) |
| Proximal humerus fracture (SH II) | FOOSH, peri-physeal tenderness | Sling, ortho — most remodel well |
| Little Leaguer's shoulder (proximal humerus epiphysiolysis) | Throwing athlete, lateral physeal widening | Rest 3 mo, no throwing |
| Birth-related clavicle fracture | Newborn, asymmetric Moro, crepitus | Pin sleeve to shirt, heals 1–2 wk |
| Brachial plexus injury (Erb/Klumpke) | Newborn shoulder dystocia, floppy arm | PT, neuro/ortho referral |
| Septic shoulder / osteomyelitis | Fever, atraumatic swelling | Aspiration, IV abx, MRI |
| Referred pain (cardiac, splenic, diaphragmatic, pneumonia) | Atraumatic, normal shoulder exam | Workup source |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Ibuprofen | 10 mg/kg PO q6–8h (max 600 mg) | |
| Acetaminophen | 15 mg/kg PO q4–6h (max 1 g) | |
| Morphine | 0.1 mg/kg IV (max 5 mg) | For reduction analgesia |
Management / next steps
- Most clavicle fractures heal well with sling — surgery rare in children
- Posterior SC dislocation = airway/vascular emergency — CT chest, surgery
- First-time anterior shoulder dislocation in adolescent → discuss surgical stabilization (>80% recurrence)
Pearls
- Pseudoparalysis of the arm in an infant = clavicle fx, brachial plexus injury, or septic shoulder.
- Always examine the chest and neck with shoulder injuries — pneumothorax, brachial plexus.
- Atraumatic shoulder pain in a child → think referred (cardiac, abdominal, pneumonia).