Paediatric Shoulder Instability

  • Mattthew F. NixonEmail author
  • Allen StevensonEmail author


In this chapter, we will explore the differences in pathology, diagnosis and management of paediatric shoulder instability along with the additional challenges and benefits that the paediatric population hold. By covering the anatomical and behavioural difference we aim to enable surgeons to be better equipped to approach this often-daunting condition in the young. Differences in classification of instability in the young have important bearings on the management and prognosis.


  1. 1.
    Trueta J, Amato VP. The vascular contribution to osteogenesis. III. Changes in the growth cartilage caused by experimentally induced ischaemia. J Bone Joint Surg Br. 1960;42-B:571–87. PubMed PMID: 17533673.CrossRefGoogle Scholar
  2. 2.
    Kwong S, Kothary S, Poncinelli LL. Skeletal development of the proximal humerus in the pediatric population: MRI features. AJR Am J Roentgenol. 2014;202(2):418–25. PubMed PMID: 24450686.CrossRefPubMedGoogle Scholar
  3. 3.
    Ogden JA, Conlogue GJ, Jensen J. Radiology of the postnatal skeletal development: the proximal humerus. Skelet Radiol. 1978;2:153–60.CrossRefGoogle Scholar
  4. 4.
    Caffrey J. Pediatric x-ray diagnosis. 8th ed. Chicago: Year Book Medical Publishers; 1972. p. 434–43.Google Scholar
  5. 5.
    Zember JS, Rosenberg ZS, Kwong S, Kothary SP, Bedoya MA. Normal skeletal maturation and imaging pitfalls in the pediatric shoulder. Radiographics. 2015;35(4):1108–22. PubMed PMID: 26172355.CrossRefPubMedGoogle Scholar
  6. 6.
    Asher MA. Dislocations of the upper extremity in children. Orthop Clin North Am. 1976;7(3):583–91. PubMed PMID: 958684.PubMedGoogle Scholar
  7. 7.
    Hovelius L. Anterior dislocation of the shoulder in teen-agers and young adults. Five-year prognosis. J Bone Joint Surg Am. 1987;69(3):393–9. PubMed PMID: 2434509.CrossRefGoogle Scholar
  8. 8.
    Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am. 1992;74(8):1242–4. PubMed PMID: 1400553.CrossRefGoogle Scholar
  9. 9.
    Rowe CR. Anterior dislocation of the shoulder: prognosis and treatment. Surg Clin North Am. 1963;43:1609–14. PubMed PMID: 14090208.CrossRefGoogle Scholar
  10. 10.
    Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956;38-A(5):957–77. PubMed PMID: 13367074.CrossRefGoogle Scholar
  11. 11.
    Olds M, Donaldson K, Ellis R, Kersten P. In children 18 years and under, what promotes recurrent shoulder instability after traumatic anterior shoulder dislocation? A systematic review and meta-analysis of risk factors. Br J Sports Med. 2016;50(18):1135–41. Epub 2015 Dec 23. Review. PubMed PMID: 26701925.CrossRefPubMedGoogle Scholar
  12. 12.
    Zaremski JL, Galloza J, Sepulveda F, Vasilopoulos T, Micheo W, Herman DC. Recurrence and return to play after shoulder instability events in young and adolescent athletes: a systematic review and meta-analysis. Br J Sports Med. 2016. pii: bjsports-2016-096895. [Epub ahead of print] PubMed PMID: 27834676.CrossRefGoogle Scholar
  13. 13.
    Bottoni CR, Wilckens JH, Deberardino TM, D'Alleyrand JC, Rooney RC, Harpstrite JK, Arciero RA. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med. 2002;30(4):576–80. PubMed PMID: 12130413.CrossRefGoogle Scholar
  14. 14.
    Jakobsen BW, Johannsen HV, Suder P, Søjbjerg JO. Primary repair versus conservative treatment of first-time traumatic anterior dislocation of the shoulder: a randomized study with 10-year follow-up. Arthroscopy. 2007;23(2):118–23. PubMed PMID: 17276217.CrossRefGoogle Scholar
  15. 15.
    Cools AM, Witvrouw EE, Declercq GA, Danneels LA, Cambier DC. Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms. Am J Sports Med. 2003;31(4):542–9. PubMed PMID: 12860542.CrossRefGoogle Scholar
  16. 16.
    Wagner KT Jr, Lyne ED. Adolescent traumatic dislocations of the shoulder with open epiphyses. J Pediatr Orthop. 1983;3(1):61–2. PubMed PMID: 6841604.CrossRefGoogle Scholar
  17. 17.
    Nixon MF, Keenan O, Funk L. High recurrence of instability in adolescents playing contact sports after arthroscopic shoulder stabilization. J Pediatr Orthop B. 2015;24(3):173–7. PubMed PMID:25569537.CrossRefPubMedGoogle Scholar
  18. 18.
    Ochs BG, Rickert M, Schmelzer-Schmied N, Loew M, Thomsen M. Post-traumatic shoulder instability in adolescence. Orthopade. 2005;34(2):152–8. German. PubMed PMID: 15480544.CrossRefGoogle Scholar
  19. 19.
    Kraus R, Pavlidis T, Dongowski N, Szalay G, Schnettler R. Children and adolescents with posttraumatic shoulder instability benefit from arthroscopic stabilization. Eur J Pediatr Surg. 2010;20:253–6.CrossRefGoogle Scholar
  20. 20.
    Cordischi K, Li X, Busconi B. Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patients aged 10 to 13 years. Orthopedics. 2009;32(9). pii: PubMed PMID: 19750998.CrossRefGoogle Scholar
  21. 21.
    Deitch J, Mehlman CT, Foad SL, Obbehat A, Mallory M. Traumatic anterior shoulder dislocation in adolescents. Am J Sports Med. 2003;31(5):758–63. PubMed PMID: 12975198.CrossRefGoogle Scholar
  22. 22.
    Lampert C, Baumgartner G, Slongo T, Kohler G, Horst M. Traumatic shoulder dislocation in children and adolescents. Eur J Trauma. 2003;29:375–8.CrossRefGoogle Scholar
  23. 23.
    Gigis I, Heikenfeld R, Kapinas A, Listringhaus R, Godolias G. Arthroscopic versus conservative treatment of first anterior dislocation of the shoulder in adolescents. J Pediatr Orthop. 2014;34(4):421–5. PubMed PMID: 24172677.CrossRefPubMedGoogle Scholar
  24. 24.
    Zaremski JL, Galloza J, Sepulveda F, Vasilopoulos T, Micheo W, Herman DC. Recurrence and return to play after shoulder instability events in young and adolescent athletes: a systematic review and meta-analysis. Br J Sports Med. 2016;pii:bjsports-2016-096895. [Epub ahead of print] PubMed PMID: 27834676.CrossRefGoogle Scholar
  25. 25.
    Longo UG, van der Linde JA, Loppini M, Coco V, Poolman RW, Denaro V. Surgical versus nonoperative treatment in patients up to 18 years old with traumatic shoulder instability: a systematic review and quantitative synthesis of the literature. Arthroscopy. 2016;32(5):944–52. Epub 2016 Feb 23. Review. PubMed PMID: 26921126.CrossRefPubMedGoogle Scholar
  26. 26.
    Castagna A, Delle Rose G, Borroni M, Cillis BD, Conti M, Garofalo R, Ferguson D, Portinaro N. Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports. Arthroscopy. 2012;28(3):309–15. PubMed PMID: 22130494.CrossRefGoogle Scholar
  27. 27.
    Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, Bach BR Jr, Romeo AA, Verma NN. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013;29(5):920–33. Feb 5. Review. PubMed PMID: 23395467.CrossRefGoogle Scholar
  28. 28.
    Hovelius L, Vikerfors O, Olofsson A, Svensson O, Rahme H. Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up. J Shoulder Elb Surg. 2011;20(7):1095–101. PMID: 21602067.CrossRefGoogle Scholar
  29. 29.
    DeBerardino TM, Arciero RA, Taylor DC, Uhorchak JM. Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two- to five-year follow-up. Am J Sports Med. 2001;29(5):586–92. PubMed PMID: 11573917.CrossRefGoogle Scholar
  30. 30.
    Larrain MV, Montenegro HJ, Mauas DM, Collazo CC, Pavón F. Arthroscopic management of traumatic anterior shoulder instability in collision athletes: analysis of 204 cases with a 4- to 9-year follow-up and results with the suture anchor technique. Arthroscopy. 2006;22(12):1283–9. PubMed PMID: 17157726.CrossRefGoogle Scholar
  31. 31.
    Wheeler JH, Ryan JB, Arciero RA, Molinari RN. Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy. 1989;5(3):213–7. PubMed PMID: 2775396.CrossRefGoogle Scholar
  32. 32.
    Ahmed I, Ashton F, Robinson CM. Arthroscopic Bankart repair and capsular shift for recurrent anterior shoulder instability: functional outcomes and identification of risk factors for recurrence. J Bone Joint Surg Am. 2012;94(14):1308–15. PubMed PMID: 22810402.CrossRefGoogle Scholar
  33. 33.
    Hovelius L, Saeboe M. Neer award 2008: Arthropathy after primary anterior shoulder dislocation--223 shoulders prospectively followed up for twenty-five years. J Shoulder Elb Surg. 2009;18(3):339–47. PubMed PMID: 19254851.CrossRefGoogle Scholar
  34. 34.
    Khan A, Samba A, Pereira B, Canavese F. Anterior dislocation of the shoulder in skeletally immature patients: comparison between non-operative treatment versus open Latarjet's procedure. Bone Joint J. 2014;96-B(3):354–9. PubMed PMID: 24589791.CrossRefPubMedGoogle Scholar
  35. 35.
    Schmid SL, Farshad M, Catanzaro S, Gerber C. The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair: a retrospective case series of forty-nine consecutive patients. J Bone Joint Surg Am. 2012;94(11):e75. PubMed PMID:22637215.CrossRefPubMedGoogle Scholar
  36. 36.
    Tobias JH, Deere K, Palmer S, Clark EM, Clinch J. Joint hypermobility is a risk factor for musculoskeletal pain during adolescence: findings of a prospective cohort study. Arthritis Rheum. 2013;65(4):1107–15. PubMed PMID: 23450628.CrossRefGoogle Scholar
  37. 37.
    Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991;73(1):105–12. PubMed PMID: 1985978.CrossRefGoogle Scholar
  38. 38.
    Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy. 2007;23(10):1033–41. Erratum in: Arthroscopy. 2007 Dec;23(12):A16. Criswell, Tim [corrected to Cresswell, Tim]. PubMed PMID: 17916467.CrossRefGoogle Scholar
  39. 39.
    Johnson SM, Robinson CM. Shoulder instability in patients with joint hyperlaxity. J Bone Joint Surg Am. 2010;92(6):1545–57. Review. PubMed PMID: 20516333.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Vavken P, Tepolt FA, Kocher MS. Open inferior capsular shift for multidirectional shoulder instability in adolescents with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome. J Shoulder Elb Surg. 2016;25(6):907–12. PubMed PMID: 26775746.CrossRefGoogle Scholar
  41. 41.
    Martetschlaeger F, Kircher J, Magosch P, Lichtenberg S, Habermeyer P. Arthroscopic stabilization of antero-inferior shoulder instability with concomitant hyperlaxity in a 10-year-old girl. Obere Extremitat. 2010;5(4):229–33.CrossRefGoogle Scholar
  42. 42.
    Greiwe RM, Galano G, Grantham J, Ahmad CS. Arthroscopic stabilization for voluntary shoulder instability. J Pediatr Orthop. 2012;32(8):781–6. PubMed PMID: 23147620.CrossRefPubMedGoogle Scholar
  43. 43.
    Rolfes K. Arthroscopic treatment of shoulder instability: a systematic review of capsular plication versus thermal capsulorrhaphy. J Athl Train. 2015;50(1):105–9. Epub 2014 Oct 20. Review. PubMed PMID: 25329347; PubMed Central PMCID: PMC4299727.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Levy HP. Ehlers-Danlos syndrome, hypermobility type In: Pagon R, Adam M, Ardinger H, Bird TD, Dolan CR, Fong C, et al, editors. Gene reviews [Internet]. Seattle: University of Washington, Seattle; 1993–2016.
  45. 45.
    Beighton P, De Paepe A, Steinmann B, Tsipouras P, Wenstrup RJ. Ehlers-Danlos syndromes: revised nosology, Villefranche, 1997. Ehlers-Danlos National Foundation (USA) and Ehlers-Danlos Support Group (UK). Am J Med Genet. 1998;77:31–7.CrossRefGoogle Scholar
  46. 46.
    Stern CM, Pepin MJ, Stoler JM, Kramer DE, Spencer SA, Stein CJ. Musculoskeletal conditions in a pediatric population with Ehlers-Danlos syndrome. J Pediatr. 2017;181:261–6. Epub 2016 Nov 28. PubMed PMID: 27908650.CrossRefPubMedGoogle Scholar
  47. 47.
    Scheper MC, Engelbert RH, Rameckers EA, Verbunt J, Remvig L, Juul-Kristensen B. Children with generalised joint hypermobility and musculoskeletal complaints: state of the art on diagnostics, clinical characteristics, and treatment. Biomed Res Int. 2013;2013:121054. PubMed PMID: 23971021; PubMed Central PMCID: PMC3736514.CrossRefGoogle Scholar
  48. 48.
    Rombaut L, Malfait F, De Paepe A, Rimbaut S, Verbruggen G, De Wandele I, Calders P. Impairment and impact of pain in female patients with Ehlers-Danlos syndrome: a comparative study with fibromyalgia and rheumatoid arthritis. Arthritis Rheum 2011;63(7):1979–1987. PubMed PMID: 21391202.CrossRefGoogle Scholar
  49. 49.
    Aldridge JM 3rd, Perry JJ, Osbahr DC, Speer KP. Thermal capsulorraphy of bilateral glenohumeral joints in a pediatric patient with Ehlers- Danlos syndrome. Arthroscopy. 2003;19:E41.CrossRefGoogle Scholar
  50. 50.
    Rodeo SA, Suzuki K, Yamauchi M, Bhargava M, Warren RF. Analysis of collagen and elastic fibers in shoulder capsule in patients with shoulder instability. Am J Sports Med. 1998;26(5):634–43. PubMed PMID: 9784809.CrossRefGoogle Scholar
  51. 51.
    Gomes N, Hardy P, Bauer T. Arthroscopic treatment of chronic anterior instability of the shoulder in Marfan's syndrome. Arthroscopy. 2007;23(1):110. e1–5. Epub 2006 Sep 20. PubMed PMID: 17210441.CrossRefGoogle Scholar
  52. 52.
    Malone AA, Jaggi A, Calvert PT, et al. Muscle patterning instability—classification and prevalence in reference shoulder service. In: Norris TR, Zuckerman JD, JJP W, Lee QT, editors. Surgery of the shoulder and elbow: an international perspective. Illinois: American Academy of Orthopaedic Surgeons; 2006. Section 7.Google Scholar
  53. 53.
    Morris AD, Kemp GJ, Frostick SP. Shoulder electromyography in multidirectional instability. J Shoulder Elb Surg. 2004;13(1):24–9. PubMed PMID:14735069.CrossRefGoogle Scholar
  54. 54.
    Ogston JB, Ludewig PM. Differences in 3-dimensional shoulder kinematics between persons with multidirectional instability and asymptomatic controls. Am J Sports Med. 2007;35(8):1361–70. Epub 2007 Apr 9. PubMed PMID: 17420507.CrossRefGoogle Scholar
  55. 55.
    Illyés A, Kiss RM. Kinematic and muscle activity characteristics of multidirectional shoulder joint instability during elevation. Knee Surg Sports Traumatol Arthrosc. 2006;14(7):673–85. Epub 2005 Dec 14. PubMed PMID: 16362361.CrossRefGoogle Scholar
  56. 56.
    Warth RJ, Spiegl UJ, Millett PJ. Scapulothoracic bursitis and snapping scapula syndrome: a critical review of current evidence. Am J Sports Med. 2015;43(1):236–45. Epub 2014 Mar 24. Review. PubMed PMID: 24664139.CrossRefPubMedGoogle Scholar
  57. 57.
    Pearse EO, Bruguera J, Massoud SN, Sforza G, Copeland SA, Levy O. Arthroscopic management of the painful snapping scapula. Arthroscopy. 2006;22(7):755–61. PubMed PMID: 16843812.CrossRefGoogle Scholar
  58. 58.
    Haus B, Nasreddine AY, Suppan C, Kocher MS. Treatment of snapping ScapulaSyndrome in children and adolescents. J Pediatr Orthop. 2016;36(5):541–7. PubMed PMID: 25887839.CrossRefPubMedGoogle Scholar
  59. 59.
    Rowe CR, Pierce DS, Clark JG. Voluntary dislocation of the shoulder. A preliminary report on a clinical, electromyographic, and psychiatric study of twenty-six patients. J Bone Joint Surg Am. 1973;55(3):445–60. PubMed PMID:4703200.CrossRefGoogle Scholar
  60. 60.
    Butowicz CM, Ebaugh DD, Noehren B, Silfies SP. Validation of two clinical measures of core stability. Int J Sports Phys Ther. 2016;11(1):15–23. PubMed PMID: 26900496; PubMed Central PMCID: PMC4739044.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Mullick MS. Somatoform disorders in children and adolescents. Bangladesh Med Res Counc Bull. 2002;28(3):112–22. PubMed PMID: 14509383.PubMedGoogle Scholar
  62. 62.
    Jones KJ, Wiesel B, Ganley TJ, Wells L. Functional outcomes of early arthroscopic bankart repair in adolescents aged 11 to 18 years. Erratum in: J Pediatr Orthop. 2007;27(2):209–13. 2007 27(4):483.CrossRefGoogle Scholar
  63. 63.
    Shymon SJ, Roocroft J, Edmonds EW. Traumatic anterior instability of the pediatric shoulder: a comparison of arthroscopic and open bankart repairs. J Pediatr Orthop. 2015;35(1):1–6. Scholar
  64. 64.
    Postacchini F, Gumina S, Cinotti G. Anterior shoulder dislocation in adolescents. J Shoulder Elb Surg. 2000;9(6):470–4.CrossRefGoogle Scholar
  65. 65.
    Roberts SB, Beattie N, McNiven ND, Robinson CM. The natural history of primary anterior dislocation of the glenohumeral joint in adolescence. Bone Joint J. 2015;97(B4):520–6. Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryRoyal Manchester Children’s HospitalManchesterUK

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