sustained his first anterior shoulder dislocation to his throwing shoulder three days ago, or three days prior to presentation during pre-season practice, which is just around the corner for many of us. The shoulder was reduced in the emergency room and his post-operative reduction x-rays are shown here. So question, what further imaging studies would you recommend for this young athlete? And then you can answer on your phone and hopefully the responses will show up on the screen, as they're supposed to. Do you have responses? She has no control, I just don't have control. Okay, who would say none for what further imaging is recommended? Okay, plain MRI? MRI with intra-articular contrast? Little bit less? And a CT scan? So nobody. So your thoughts on MRI with contrast versus without? Ben, I think you raised your hand. What's your thoughts on imaging for this young kid? Yeah, the way I was trained, in the first seven to 10 days or so, there's usually some blood and fluid in the joint that will show you a labrum tear just about as well as the contrast. So if it's that early after the injury, plain MRI saves him the trouble of the arthrogram. So it's the first time dislocation in a young athlete, does he or she need any imaging? Is there gonna be discussion for non-operative treatment? Do you get imaging in everybody? Everyone on the panel wanna comment on that? Sure, so my general algorithm with them is that if they have any fracture on radiographs, if they have any evidence, it looks like this kid does some for a Hill Sachs, or certainly if they have any bony bank heart injury, then that definitely buys them an MRI. Because I think in either of those situations, I'd be considering operative intervention as opposed to non-operative intervention. I typically reserve a CT just for those that I'm worried about the amount of bone loss, and I typically use it as a secondary study after an MRI if I'm considering that they're borderline critical bone loss. So what in your mind, Crystal, is critical bone loss? That number seems to go lower and lower every year, certainly with adults, and maybe you can shed your opinion on how it is in kids, but what's your thoughts on critical bone loss? Yeah, so I think that's, I think the idea of bipolar bone loss is probably gaining greater and greater traction, and I think that's probably why the critical bone loss in the glenoid probably continues to drift down, is that I think many of these teenagers also have considerable humeral bone loss as well. I think certainly when I get to 15%, if I'm looking at a kid who's a upper extremity athlete playing at a high-level contact sport, those are kids that I think, at this point, we know 30 or 40% may fail in that cohort with isolated arthroscopic bank heart repair, and so those I'm considering, if they have bipolar bone loss, potentially adding remplisage, if I still think an arthroscopic bank heart's reasonable, or certainly I think there are some candidates for primary latter J. Great. Is it, okay. All right, we'll just keep going then. So next question, 12-year-old male fractures right clavicle shown here. There are no skin or nerve eschar issues. We sort of beat this topic to death a little bit. Which of the following treatment options do you recommend? Would anyone, ask beforehand, maybe, who would recommend surgery before today's session? Nobody? Intermittently. Okay. So I had also prepared some case today. I actually put up one that is, it was not a 12-year-old, it was a 14-year-old that I did end up operating on, and it is, you know, this is, we were talking about this on the way down. There are familial factors, patient factors that can play into it, and I think Dr. Andrews' point is well taken. It's not so much about getting them back to play faster, but to me, a lot of it is a pain management question. So there are kids that come in, and they're, you know, they're five days out from injury, and they're like, yeah, I mean, it hurts a little bit. That kid definitely doesn't need surgery. There are kids that have a very profound amount of scapular dysfunction, they're very guarded, they're in extreme amounts of pain, they're, you know, they and their parents are requesting narcotics, and in those unique situations, I'll consider fixation, but the vast majority of the time, I do not. Does it matter to you how young the kid is, how old the kid is, Jeff? It does. Oh, sorry. I'm sorry, Jeff. No, go ahead, Jeff. Yeah, I think that's where we need to learn more over time. Certainly, the younger part of the 10 to 18-year-old group I think certainly shouldn't have surgery. As you get a little older, I think it's, I think we need to learn more about that, and then the 18 to 21-year-old, are they really like the 40-year-old who gets non-unions and those kind of issues? Probably not, that it's not as much of a sort of cutoff as a continuum that hopefully over time we'll learn more, but I think certainly very unlikely under 16 to have surgery at this point. Any role for nail fixation versus plate in this population? Not for me. I think if you put plates on properly, pre-contoured plates can be well put on and avoid the risk of need for removal. I think often, we've had some nails used at our institution, but often they end up making an incision to reduce it anyway, and then you end up with incisions that aren't that different from what you could have just did in the first place. And for those who do do plates, you favor dual plating or one single plate superiorly given the hardware issues? And maybe the audience can participate. From the audience perspective, for those who you do plate, fixate, who does them on the superior surface? Who favors dual fixation for the hardware issues? Anyone? Superior, everybody? Okay, does anybody like to dual plate? I know that's a big topic in our trauma center. For the adults, they favor dual plating. I guess someone does here as well. Any comments in the pediatric population for types of fixation? I think in the rare instance that you would have to plate a clavicle, particularly in 20-somethings and people who we might consider that more routinely, the literature's pretty clear that dual 2-7 plating is better rates of removal and well tolerated. So I think the trauma world, the adult sports world has certainly moved towards dual plating as a good option. And then for these younger folks, we don't tend to, but in the instances that you do, I think it works well. I think you don't necessarily need big plates. You could probably do four cortices on a side rather than the kind of classic six cortices. It's really do, do well to heal. But when we're doing the surgeries, it's often when something's gone wrong these days. Right. Okay, I'm just hitting next here. Here we go. So 17-year-old male injured his right shoulder when he slipped while rock climbing, causing him to be temporarily suspended by his arms overhead. An MRI with intra-articular contrast is shown here. First of all in the audience, anyone want to venture guesses what the diagnosis is here? Hagel, so good. Which of the following operative treatment, I'm sorry, which of the following treatment options would you recommend? Anybody recommend non-operative for this young man? Arthroscopic labor repair? Arthroscopic remplisage? Open capsular repair? So the vast majority would favor open. Does anybody on the panel prefer to do these arthroscopically? Yeah, I've done, I think it's hard. You know, there are some technical challenges, but with some of the new curved devices and curved anchor devices, sometimes you can get down on the humeral, on the proximal humerus. That makes it a little bit easier with some of the curved anchor devices that we didn't have 10 years ago. So I have found that, at least in my hands, I think arthroscopic repair with the new curved devices is a little bit easier. And so I've started to favor that in the last five years. I think if you're doing posterior, I think they're a little bit easier arthroscopically from a posterior perspective, but so not from anterior. Any other comments on Hagel injuries in young athletes? Do you tend to see them very often, Jonathan, in your practice compared to- I see them quite rare. I mean, and if I do, they tend to be like the 18 to 20-year-olds, sort of the, you know, really probably barely adolescents or really adults at that point. I think this is why you get MRIs on people. They're not frequent, but I think, you know, it's these variations of instability patterns, whether they're just pure capsular lesions, capsular avulsions, Hagels, are the reason to get an MRI, looking for that abnormal pattern that'll encourage you to do a surgery and possibly a different surgery early on. Good. Any questions from the audience? That's our last question of this session. I mean, we talked about a lot of topics here. Dr. Kibler? Thank you all very much. This is a great session. I'm not a pediatric surgeon, but I am a scapula dude, okay? And all the fact studies, I love this. They're fantastic multicenters. I wonder though, in your studies, you didn't look at two variables, which at least when I see these patients who have had their fractures at age 15 or 18, 22, 26, they can't do this very well. It's because their scapula is protracted. And we kind of look at that, and it turns out that it's an anterior rotation distal fragment because of the forces that occur with the arm that is always going to go this way. And it heals. And fact study, you didn't mention any attempt, and it's hard, of course, maybe, to look at rotation or look at the indicator of rotation, which would be, like you said, that patient with acute injuries got that scapular pain. It's because the scapula is protracted because it's all anteriorly rotated. Now, obviously, not everybody needs it, but I see more than enough that I don't want to operate on all those malunions at age 22, 26. There's gotta be a cutoff point of rotation as a component because, once again, humeruses, femurs, radius, you always fix rotational components. And remember, this is a crank handle. This is a curved bone. So just like for y'all who deal with it every day, where do you think this rotation comes? On that last x-ray you showed, you can actually see that that lateral piece is anteriorly rotated. If you posteriorly rotate, then those two pieces will kind of lock back in there. You see that? How you evaluate it, if it's important, if I'm just seeing the few that don't make it, and you're all seeing all the ones that do make it, you're all studying fantastic two years follow-up, oldest one you got's 18, and I'm seeing a 25 who can't throw the ball with her kid or can't work overhead, and then I gotta go take this three-dimensional problem down and fix it again. Just for you all, you deal with it every day. But it bothers me that we're missing, so, for example, those cases, three weeks, four weeks, if they're still protracted, then I fix them. I mean, I tell them, I put them back in that position, if they feel better, then I'll fix those because I know that we've got the mechanics of that whole system working better. Tell me I'm wrong. Yeah, it's a great point. I think our focus early on was sort of understanding the non-union rate compared to that 15% rate in adults that McKee and others have shown that really proved to be under 1%, and so we really didn't think we should be fixing these to prevent non-unions. They still arise per several hundred, so over 12 years, 13 years, I have three. Now, all three of them were asymptomatic, so a 13-year-old went on to baseball and football, even, and a girl played in a summer of showcases with a non-union and got a scholarship, et cetera, and so we're still wondering whether to fix her or what to do with that. But for the symptomatic malunion, that was the bigger question. As younger kids who are more active, would those rates be higher than in the adults, which is 10% in the systematic reviews? So we found as well that those, and we were very conservative with how we define those. So anybody that came back with any complaint past three months of anything, shortening, fatigue, scapular dyskinesis, pain, of course, we said that's a symptomatic malunion, and we had a rate under 1%. For those that did, a couple of them were the sort of prominences that we then did, ostectomies or a couple of those cases, just sort of smoothing out the prominence that somebody didn't like or a parent didn't like, et cetera, but in terms of those that had pain and scapular dyskinesis, usually sent them to PT, and it almost always resolved. So I think that is a real entity, but very rare, and I think it speaks to the difference between adolescent and adults. Like Obrensky and others have talked about the droopy shoulder. So when those bad fractures happen in adults, the periosteum rips, and it's two separate pieces. In adolescence, the periosteum's so much more robust that you don't see the degree of displacement or rotation, and that's why Andy's studies on settling and remodeling have shown such resolution of normal clavicle function. Could you go back to that? There's a picture that you showed from your paper, and it shows a pre, you'll see the middle one right there, glenoids looking at you in the face, or pre-injury, and to me, that means that at some point in time, this person may have difficulties, and they may get by because they never have to do this, I don't know, but if you see the glenoid looking at you in the face on this x-ray, to me, that's probably not the best mechanics that the person needs to live with for the rest of their lifetime. Certainly from our population of adults, you see that in your PC separations, or the clavicular, and that's not a good sign. For those of you who don't know, Dr. Kibler's the world's expert on scapular mechanics, so his points were all well taken. We talked about non-operative treatment to finalize. Any role in different types of treatment for these cases? Collar sling, shoulder mobilizer, how do you prefer to treat them? Is it whatever's comfortable, and how long do you treat them if you're going to pursue non-operative care? Crystal, you wanna start us off? Crystal? Sure, so I typically, they normally come to me in a sling, or a shoulder immobilizer, or a cuff and collar, it depends on what they got in the ER, or local, or urgent care, and I typically just keep them whatever they come in. I think we have good evidence that there's no difference in immobilization in terms of overall ultimate outcomes. I typically tend to get them out within somewhere in the 10 to 14 day range, depending on their comfort, so after the first week I tell them they should be out of it when they're at home, and in the mobilization when they're out and about school, around others, and then by two weeks have them out completely. Typically for non-operative management, I'm kind of eight weeks back to non-contact, 12 weeks back to contact. And for the collision support, the contact's athlete, do you still see some fracture there? Have you ever gotten a CT scan to see if they can go back sooner to play? I personally don't get a CT. I think oftentimes they're healed, but certainly have remodeling to do, but I think from a fact standpoint, we've all agreed on a kind of common treatment algorithm which allows them back at 12 weeks for contact or collision supports. So 12 weeks was your time? All right, any final questions? That pretty much ends our session. Thanks for all the great comments, the speakers, and the questions you've asked. Thank you.

imaging

treatment options

shoulder dislocations

clavicle fractures

young athletes