Traumatic Glenohumeral Dislocation in Pediatric Patients Is Associated With a High Risk of Recurrent Instability

Abstract

Background: The natural history of traumatic glenohumeral dislocation is well-established in young adults, but it is less clear in pediatric patients. We aimed to determine the rate of recurrent instability and medium-term functional outcome following shoulder dislocation in patients aged 14 years or younger. Methods: All patients aged 14 years or younger who sustained a glenohumeral dislocation from 2008 to 2019 presenting to our regional health-board were identified. Patients who had subluxations associated with generalized laxity were excluded. Data was collected regarding further dislocations, stabilization surgery, sporting activity and patient-reported outcomes using the Western Ontario Shoulder Instability (WOSI) Index and Quick Disabilities of the Arm, Shoulder, and Hand score.Results: Forty-one patients with a radiologically confirmed traumatic glenohumeral dislocation were suitable for study inclusion [mean age at injury 12.3 y (range: 7.2 to 14.0 y), male sex 29 (70.7%), median 7.9 y follow-up]. The incidence rate of pediatric glenohumeral dislocation was 2.5 cases per 100,000 population (aged 0 to 14 y) per year. Recurrent dislocation occurred in 43.9% (n = 18/41) at a median time of 14.7 months postinjury (range: 1 to 54 mo). Skeletal maturity was associated with significantly higher proportion of recurrent instability (immature 6/24 vs. mature 12/17, P = 0.01). One in 5 patients required surgical intervention for recurrent instability [mean 8 (range: 1 to 14) dislocations before surgery]. Twenty-eight patients had completed outcome questionnaires. The median modified WOSI score was 87.1% [270 (interquartile range: 65 to 795)] and the median Quick Disabilities of the Arm, Shoulder, and Hand score was 3.4 (interquartile range: 0 to 9.7). Recurrent shoulder instability was significantly associated with poorer WOSI score (unstable 71.4% vs. stable 94.3%, 95% confidence interval of the difference 6.2-36.9, P = 0.04). Conclusions: Traumatic glenohumeral dislocation in patients aged 14 years or younger occurs rarely but is not a benign event.One in 2 patients experienced recurrent dislocation and 1 in 5 ultimately underwent surgical stabilization. Level of Evidence: Level IV.

Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population

“…In this age group, patients are also at the highest risk of re-dislocation. In contrast, dislocations and subsequent recurrent instability are rare in the pre-pubertal population [5,[35][36][37]. In keeping with these findings, Old's systematic review of the literature prior to 2015 found that 14-18-year-old patients were 24 times more likely to experience re-dislocation than those aged 13 years and below, and those with a closed physis were 14 times more likely to dislocate than those with an open physis [18].…”

“…Some studies suggest that non-operative management may have greater success in skeletally immature patients [18,35]. This is possibly due to a lower rate of structural damage following a dislocation event, and the fact that these events are likely the result of a combination of type I, II, and III instability.…”

Current Evidence in Shoulder Instability in the Paediatric and Adolescent Population

“…In contrast, dislocations and subsequent recurrent instability are rare in the pre-pubertal population. [19][20][21][22] Table 1. Epidemiological studies on incidence of shoulder instability and recurrence.…”

“…Some studies suggest that non-operative management may have greater success in skeletally immature patients [20,23]. This is possibly due to lower rate of structural damage following a dislocation event, and that these events are likely the result of a combination of type I, II and III instability.…”

What’s New in Pediatric Orthopaedics

“…Skeletal maturity was associated with recurrent instability (6 of 24 immature patients compared with 12 of 17 mature patients; p = 0.01). Twenty percent of patients with recurrent instability and a mean of 8 dislocations required surgical intervention 58 .…”