SC joint injuries, although still uncommon, are being seen with increased frequency. Posterior SC joint injuries are usually traumatic resulting from a direct blow to the medial clavicle.⁸ There is deformity and pain at the SC joint. There may be hoarseness, difficulty swallowing, or vascular insult from posterior displacement of the medial clavicle toward the important mediastinal structures of the esophagus, trachea, and large vessels (Fig. 14-2A). Staying out of trouble with SC joint injuries includes not missing the diagnosis. These injuries are notoriously difficult to view on plain X-ray, including the serendipity view. Three-dimensional imaging (CT or MRI) is required to make the diagnosis and to characterize the injury (Fig. 14-2B). Although traditional teaching is that these injuries are usually medial clavicle physeal fractures since the medial clavicle physis closes late, a recent study showed that nearly half of these injuries in adolescents are true joint dislocations.⁹ Treatment should be urgent and in the operating room with vascular/cardiac surgery backup. Rare cases have been reported of serious blood loss from reduction of a posterior SC joint dislocation. Stay out of trouble and inform your vascular surgeons. Don’t do this case at the surgery center! Closed reduction has been described with abduction of the shoulder in the horizontal plane with a beanbag between the shoulder blades and percutaneous reduction with a towel clamp. Because closed or percutaneous reduction may redislocate or is often unsuccessful, I tend to operate on posterior SC joint dislocations. This involves open reduction, repairing the intra-articular disk if torn, repairing the periosteal
tube, and stabilizing the medial clavicle and sternum with heavy suture. Ligament reconstruction is not typically needed.

Anterior SC joint injuries are different than posterior SC joint. Although some are traumatic, many are atraumatic and associated with ligamentous laxity. Some cases are asymptomatic: they have a pop that is not painful, have full motion, and have full function. These can be observed. Cases that are symptomatic will require surgery: open reduction and ligamentous reconstruction. I usually use allograft gracilis tendon through drill holes in the medial clavicle and sternum weaved in a figure-of-8 fashion (Fig. 14-3). Stay out of trouble by drilling carefully in the mediastinum. Chucking up the drill so it can only extend a few millimeters from the tissue protector and connecting the drill holes with an angled curette saves some angst.

Clavicle fractures are common in sports. Special considerations in athletes include time to return to play and shoulder function. Open reduction internal fixation (ORIF) of displaced clavicle fractures has gained enthusiasm in adolescents extrapolating from treatment trends in adults (Fig. 14-4). However, recent studies have shown similar results in terms of function with nonoperative treatment. Children and younger adolescents have greater remodeling potential. Some sports
parents may push surgical treatment for a sooner return to play. However, in contact sports this may be 6 to 12 weeks with surgery compared with 12 to 16 weeks with nonoperative treatment. Avoid trouble by adopting a shared decision-making approach erring toward nonoperative treatment.

Most AC joint injuries in children and adolescents are sprains without substantial displacement (types 1-3) that are treated nonoperatively. Even displaced AC joint injuries (types 4 and 5) in children and early adolescents may be treated nonoperatively. Unlike in adults, the ligaments are rarely disrupted. Instead, the periosteum remains attached to the intact ligaments, allowing excellent healing—sometimes so abundant that the callus is mistaken for a tumor (Fig. 14-5). Avoid trouble by simply watching these injuries recover in most children.

Shoulder instability is seen frequently in adolescent athletes and can be classified as anterior instability, multidirectional instability (MDI), and posterior instability.¹⁰ Anterior instability is usually traumatic and often results in anteroinferior capsulolabral disruption (Bankart lesion). The risk of recurrent dislocation is high in patients 18 years of age and younger, probably over 70%. Fixing the first-time dislocator versus fixing the recurrent dislocator is controversial. A one-size-fits-all approach does not work. I find an MRI helpful to delineate the extent of injury. In the acute setting, an MRI arthrogram is not necessary due to the arthrogram effect of the hemarthrosis. If there is a more extensive labral tear, ALPSA (anterior labral periosteal sleeve avulsion) lesion, HAGL (humeral avulsion of the glenohumeral ligament) lesion, or loose body, then surgery may be indicated initially. I find, however, that most patients can be managed nonoperatively and have surgery if they dislocate again. If the shoulder has dislocated two or three times, the patient and family usually appreciate that the shoulder is dysfunctional preoperatively. If you operate on a first-time dislocator, the shoulder was “normal” to the family before you operated. Stay out of trouble by adopting a shared decision-making process in these cases. Some families are risk averse and want to avoid surgery. Others are more averse to recurrent instability that may take the athlete out of sports and want to have it fixed initially. Also, the timing of the season may impact decision-making. A patient with a dislocated shoulder in the beginning or middle of the football season can often return to sports and have it fixed at the end of the season. I usually do an arthroscopic labral repair and capsulorrhaphy (Fig. 14-6). Open stabilization may be indicated for instability after prior arthroscopic surgery. However, open surgery has potential complications of subscapularis rup ture or losing external rotation. Latarjet coracoid transfer has become very popular in adults and is being performed more frequently in adolescents. Indications for Latarjet include glenoid bone loss, large engaging Hill-Sachs lesion, and “off track” lesions. However, the Latarjet procedure is a larger operation than arthroscopic stabilization and has substantial risks such as nerve injury, nonunion, and stiffness.

MDI is very different from anterior instability. The direction of instability is usually posteriorly and inferiorly. The pathology is usually capsular laxity, not
a labral tear. The typical patient is a ligamentously lax adolescent female. Look for Ehlers-Danlos syndrome and refer to genetics if appropriate. Do a Beighton score. Staying out of trouble means the initial treatment should be PT. Identify shoulder therapists who like to work with these patients as both physical and mental therapist. The shoulder PT for MDI should address strengthening, scapular mechanics, scapular winging, shoulder posture, snapping scapula, and pain control. Beware of the voluntary dislocator with psychiatric overlay. Although I try to avoid surgery in MDI patients, some patients fail PT and have instability that impairs activities of daily living (ADLs). In these patients, shoulder stabilization can be performed by arthroscopic capsulorrhaphy or open capsular shift. I favor open inferior capsular shift in patients with Ehlers-Danlos syndrome or generalized ligamentous laxity as it reduces capsular volume to a greater extent than arthroscopic capsulorrhaphy.¹¹ Be careful of operating in overhead athletes with MDI such as swimmers, throwers, and gymnasts. If their symptoms are with sports but not ADLs, then they may have difficulty returning to sports because of loss of motion and they may be unhappy. If they are having difficulty with ADLs, then I think surgery is reasonable, and I tell them that return to sports is possible but not assured.

Little league shoulder is widening of the proximal humeral physis from repetitive rotational stress. This is often a cause of chronic shoulder pain in younger pitchers, whereas internal impingement is often the cause of chronic shoulder pain in older adolescent pitchers. Interestingly, proximal humeral physeal changes and acquired increased humeral retroversion is an adaptive change in pitchers to allow for the increased external rotation of the throwing arm seen in adult pitchers. The diagnosis can be made from history, physical examination, and comparison X-rays showing increased widening of the involved arm (Fig. 14-7). The treatment is nonoperative with activity restriction, PT, and pitching mechanics. Stay out of trouble by giving the family a realistic expectation for return to throwing at 4 months instead of 3 to 6 weeks.¹² Emphasize PT and pitching mechanics to avoid recurrence. Try to find a biomotion lab that does pitching mechanics, physical therapists who like pitchers, and pitching coaches who understand pitching mechanics and injury.

Medial epicondyle fractures can occur in throwing or upper extremity weight-bearing athletes such as gymnasts. In throwers, there may be an antecedent history of medial elbow pain before the acute fracture. Whereas there is controversy regarding operative versus nonoperative treatment of displaced medial epicondyle fractures in a typical pediatric patient, I would recommend surgical fixation for the high-demand elbow athlete such as a baseball or softball thrower, or a gymnast (Fig. 14-8). ORTHOPAEDICS 101: The humeral origin of the UCL originates from the medial epicondyle, so the medial epicondyle must be important. Acute fixation followed by early mobilization typically leads to good results. If treated nonoperatively, this can lead to symptomatic nonunion with pain, valgus instability, and ulnar neuropathy. Fixing an established medial epicondyle nonunion is challenging in terms of scar, protecting the ulnar nerve, and mobilizing the fragment back to its base.¹³ Thus, staying out of trouble with this fracture in the athlete involves ORIF to avoid symptomatic nonunion.

Little league elbow describes injuries about the pediatric throwing elbow related to repetitive valgus loading.¹⁴ These injuries include medial injuries from repetitive distraction (medial epicondyle apophysitis), lateral injuries from repetitive compression (OCD [osteochondritis dissecans] of the capitellum), and posterior injuries from repetitive shear (olecranon apophysitis).

Medial epicondyle apophysitis is characterized by medial elbow pain, tenderness at the medial epicondyle, and widening of the apophysis on X-ray. Treatment is nonoperative and similar to little league shoulder: stop throwing, PT, pitching mechanics. Staying out of trouble is setting reasonable expectations regarding returning to throwing, usually in 6 to 8 weeks. If the child throws through medial elbow pain, they can sustain a medial epicondyle avulsion fracture (see above). This warning usually gets the families’ attention and facilitates compliance.

Repetitive compressive loading of the capitellum can lead to OCD in throwers and gymnasts. OCD involves fragmentation of the subchondral bone with articular cartilage and can lead to instability and a loose fragment (Fig. 14-9). OCD can be suspected on X-rays and MRI is useful for staging the lesion. If detected early with intact articular cartilage, OCD can be treated nonoperatively with cessation of sports. Approximately 40% of lesions will heal in the elbow, which is lower than the knee (60%).¹⁵ Lesions that do not heal can be treated with arthroscopic drilling. Later-stage lesions are treated with either fragment removal and microfracture or cartilage resurfacing with OATS (osteochondral autograft transfer system) plugs from the knee. This can be done through a direct anconeus splitting approach in hyperflexion. High-demand athletes such as pitchers and high-level gymnasts may have better results with OATS. Staying out of trouble in OCD of the capitellum means trying to detect the lesions early where treatment is simpler.