Anterior shoulder dislocation and clavicle fracture in a 6-year-old boy: a case report and literature review

The occurrence of shoulder dislocation in children under the age of ten is a relatively rare clinical presentation. In skeletally immature patients, the propensity for ligaments to be stronger than the surrounding bone typically results in different injury patterns, such as physeal injuries or proximal metaphyseal fractures, rather than joint dislocations.1Alogayyel N.S. Aldawodi M.D. Ahmed B. Jawadi A.H. Posterior shoulder dislocation in a 10 year old child: Case report.Ann Med Surg (Lond). 2018; 33: 32-35https://doi.org/10.1016/j.amsu.2018.08.005Crossref PubMed Scopus (1) Google Scholar, 2Foster W.S. Ford T.B. Drez Jr., D. Isolated posterior shoulder dislocation in a child. A case report.Am J Sports Med. 1985; 13: 198-200Crossref PubMed Scopus (15) Google Scholar, 3Longo U.G. Salvatore G. Locher J. Ruzzini L. Candela V. Berton A. et al.Epidemiology of paediatric shoulder dislocation: a nationwide study in Italy from 2001 to 2014.Int J Environ Res Public Health. 2020; 17: 2834https://doi.org/10.3390/ijerph17082834Crossref PubMed Scopus (17) Google Scholar A study by Row observed that among 500 cases of shoulder dislocations, only 2% (8) were children, ages between 1 to 10 years.4Rowe C.R. Anterior dislocations of the shoulder: prognosis and treatment.Surg Clin North Am. 1963; 43: 1609-1614Crossref PubMed Scopus (42) Google Scholar Although most shoulder dislocations are seen in teenagers, there is limited literature specifically addressing the incidence in toddlers and young children. This gap is particularly notable in the context of isolated anterior or posterior dislocations. There are few case reports on isolated anterior 5Endo S. Kasai T. Fujii N. Yamada Y. Takakuwa T. Nakae H. et al.Traumatic anterior dislocation of the shoulder in a child.Arch Orthop Trauma Surg. 1993; 112: 201-202Crossref PubMed Scopus (9) Google Scholar, 6Heck C.C. Anterior dislocation of the glenohumeral joint in a child.J Trauma. 1981; 21: 174-175Crossref PubMed Google Scholar, 7Maso G. Pala E. Berizzi A. Ruggieri P. A rare case of anterior shoulder dislocation in 1-year- and 10-month-old toddler: case report and literature review.Arch Orthop Trauma Surg. 2021; 141: 831-835https://doi.org/10.1007/s00402-020-03536-xCrossref PubMed Scopus (0) Google Scholar, 8Seybold D. Schildhauer T.A. Muhr G. Rare anterior shoulder dislocation in a toddler.Arch Orthop Trauma Surg. 2009; 129: 295-298https://doi.org/10.1007/s00402-007-0546-xCrossref PubMed Scopus (4) Google Scholar and posterior shoulder dislocation 1Alogayyel N.S. Aldawodi M.D. Ahmed B. Jawadi A.H. Posterior shoulder dislocation in a 10 year old child: Case report.Ann Med Surg (Lond). 2018; 33: 32-35https://doi.org/10.1016/j.amsu.2018.08.005Crossref PubMed Scopus (1) Google Scholar,2Foster W.S. Ford T.B. Drez Jr., D. Isolated posterior shoulder dislocation in a child. A case report.Am J Sports Med. 1985; 13: 198-200Crossref PubMed Scopus (15) Google Scholar,9Park R. Wood K.S. Case report: pediatric posterior shoulder dislocation.JSES Rev Rep Tech. 2021; 1: 130-134https://doi.org/10.1016/j.xrrt.2020.12.003Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar in this particular pediatric population. Our case report adds to this limited body of knowledge, presenting an anterior shoulder dislocation accompanied by a clavicle fracture in a 6-year-old male with autism and ADHD, and underscores the treatment complexities that arise when managing young patients with additional neurodevelopmental challenges. A 6-year-old male with a known diagnosis of autism and Attention Deficit Hyperactivity Disorder (ADHD) presented to the emergency department, accompanied by his mother, with acute onset of right shoulder pain and functional incapacity of his arm. The patient had a treatment history of Aripiprazole and Atomoxetine for managing ADHD for 3.5 years. During an episode of hyperactivity, the mother described having to restrain the patient by applying pressure to the posterior aspect of his right shoulder while he was prone with his arm abducted and externally rotated. This led to an immediate painful reaction from the child. Clinical examination revealed a distortion in the normal contour of the right shoulder with notable pain, swelling, and tenderness along the right clavicle. The proximal humerus was visibly prominent anterior to the shoulder joint. No signs of joint hyperlaxity or systemic neuromuscular disorders were present. Neurovascular assessment of the affected limb was unremarkable. Plain radiographs confirmed an anterior glenohumeral dislocation and a concomitant clavicle fracture (Figure 1). Under general anesthesia, the shoulder dislocation was reduced with traction, regaining normal joint alignment. Given the concerning circumstances of the injury, legal authorities were notified for potential child welfare evaluation. Concurrently, the parents were guided to obtain educational support, skill training, behavioral therapy, and psychological counseling from a pediatric psychologist to manage the patient's hyperactive behavior effectively. Post-reduction, a 3-week immobilization with a sling was advised. However, compliance was a challenge due to the patient's intolerance of the sling, exacerbated by his ADHD. Approximately one week following injury, as the acute pain diminished, the patient began to use his shoulder contrary to guidance provided. Regular follow-up examinations were arranged to monitor for potential recurrent shoulder dislocation. Subsequent imaging, including radiographs and magnetic resonance imaging (MRI), were performed to assess the healing of the clavicle fracture, integrity of the humeral head physis, and to rule out any associated lesions such as Hill-Sachs or Bankart. (Figure 2) The follow-up imaging demonstrated satisfactory bone healing and joint alignment, with no pathological findings suggestive of recurrent instability. After a month, the patient regained full range of motion in his shoulder. Radiographs at one-month post-injury showed a well-aligned glenohumeral joint and a united clavicle fracture. No Hill-Sachs lesion was observed on the Stryker-notch view, and MRI imaging corroborated these findings, showing a stable anterior labrum and intact capsular insertion. Six months post-injury, radiographs confirmed open proximal humeral physes without growth disturbance. At a two-year follow-up, the patient had not experienced any further dislocations. The clinical team maintained periodic reviews to monitor long-term outcomes. The occurrence of shoulder dislocations in children below the age of ten is notably infrequent, with limited literature specific to this demographic. Row (1963) reported a mere 2% incidence rate of shoulder dislocations among children within this age bracket out of 500 cases. 4Rowe C.R. Anterior dislocations of the shoulder: prognosis and treatment.Surg Clin North Am. 1963; 43: 1609-1614Crossref PubMed Scopus (42) Google Scholar This rarity is further accentuated by the limited number of case reports on isolated anterior 5Endo S. Kasai T. Fujii N. Yamada Y. Takakuwa T. Nakae H. et al.Traumatic anterior dislocation of the shoulder in a child.Arch Orthop Trauma Surg. 1993; 112: 201-202Crossref PubMed Scopus (9) Google Scholar, 6Heck C.C. Anterior dislocation of the glenohumeral joint in a child.J Trauma. 1981; 21: 174-175Crossref PubMed Google Scholar, 7Maso G. Pala E. Berizzi A. Ruggieri P. A rare case of anterior shoulder dislocation in 1-year- and 10-month-old toddler: case report and literature review.Arch Orthop Trauma Surg. 2021; 141: 831-835https://doi.org/10.1007/s00402-020-03536-xCrossref PubMed Scopus (0) Google Scholar, 8Seybold D. Schildhauer T.A. Muhr G. Rare anterior shoulder dislocation in a toddler.Arch Orthop Trauma Surg. 2009; 129: 295-298https://doi.org/10.1007/s00402-007-0546-xCrossref PubMed Scopus (4) Google Scholar and posterior dislocations 1Alogayyel N.S. Aldawodi M.D. Ahmed B. Jawadi A.H. Posterior shoulder dislocation in a 10 year old child: Case report.Ann Med Surg (Lond). 2018; 33: 32-35https://doi.org/10.1016/j.amsu.2018.08.005Crossref PubMed Scopus (1) Google Scholar,2Foster W.S. Ford T.B. Drez Jr., D. Isolated posterior shoulder dislocation in a child. A case report.Am J Sports Med. 1985; 13: 198-200Crossref PubMed Scopus (15) Google Scholar,9Park R. Wood K.S. Case report: pediatric posterior shoulder dislocation.JSES Rev Rep Tech. 2021; 1: 130-134https://doi.org/10.1016/j.xrrt.2020.12.003Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar within the pediatric population. The predominant guidance for managing these dislocations in young children is often extrapolated from studies on adolescents due to this scarcity of direct evidence. 4Rowe C.R. Anterior dislocations of the shoulder: prognosis and treatment.Surg Clin North Am. 1963; 43: 1609-1614Crossref PubMed Scopus (42) Google Scholar,10Cordischi K. Li X. Busconi B. Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patients aged 10 to 13 years.Orthopedics. 2009; 32https://doi.org/10.3928/01477447-20090728-34Crossref PubMed Scopus (39) Google Scholar, 11Lampert C. Baumgartner G. Slongo T. Kohler G. Horst M. Traumatic shoulder dislocation in children and adolescents.Eur J Trauma. 2003; 6: 375-378https://doi.org/10.1007/s00068-003-1218-3Crossref Scopus (24) Google Scholar, 12Lawton R.L. Choudhury S. Mansat P. Cofield R.H. Stans A.A. Pediatric shoulder instability: presentation, findings, treatment, and outcomes.J Pediatr Orthop. 2002; 22 (No doi): 52-61Crossref PubMed Google Scholar, 13Marans H. Angel K. Schemitsch E. Wedge J. The fate of traumatic anterior dislocation of the shoulder in children.J Bone Jt. Surg Am. 1992; 74: 1242-1244Crossref PubMed Google Scholar, 14Postacchini F. Gumina S. Cinotti G. Anterior shoulder dislocation in adolescents.J Shoulder Elbow Surg. 2000; 9: 470-474Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 15Wagner Jr., K.T. Lyne E.D. Adolescent traumatic dislocations of the shoulder with open epiphyses.J Pediatr Orthop. 1983; 3: 61-62Crossref PubMed Google Scholar, 16Li X. Ma R. Nielsen N.M. Gulotta L.V. Dines J.S. Owens B.D. Management of shoulder instability in the skeletally immature patient.J Am Acad Orthop Surg. 2013; 21: 529-537https://doi.org/10.5435/JAAOS-21-09-529Crossref PubMed Scopus (23) Google Scholar A significant concern following initial shoulder dislocation in children is the potential for recurrence, with age identified as a critical prognostic factor. The range of reported recurrence rates is broad, from as low as 0% to as high as 100% in skeletally immature patients. 10Cordischi K. Li X. Busconi B. Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patients aged 10 to 13 years.Orthopedics. 2009; 32https://doi.org/10.3928/01477447-20090728-34Crossref PubMed Scopus (39) Google Scholar,13Marans H. Angel K. Schemitsch E. Wedge J. The fate of traumatic anterior dislocation of the shoulder in children.J Bone Jt. Surg Am. 1992; 74: 1242-1244Crossref PubMed Google Scholar, 14Postacchini F. Gumina S. Cinotti G. Anterior shoulder dislocation in adolescents.J Shoulder Elbow Surg. 2000; 9: 470-474Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar, 15Wagner Jr., K.T. Lyne E.D. Adolescent traumatic dislocations of the shoulder with open epiphyses.J Pediatr Orthop. 1983; 3: 61-62Crossref PubMed Google Scholar Row (1963) observed a 100% recurrence in a small cohort of eight children under 10 years old with initial dislocations. 4Rowe C.R. Anterior dislocations of the shoulder: prognosis and treatment.Surg Clin North Am. 1963; 43: 1609-1614Crossref PubMed Scopus (42) Google Scholar Similarly, Marans et al reported a 100% recurrence among four skeletally immature patients under the age of 10 out of a total of 21 cases .13Marans H. Angel K. Schemitsch E. Wedge J. The fate of traumatic anterior dislocation of the shoulder in children.J Bone Jt. Surg Am. 1992; 74: 1242-1244Crossref PubMed Google Scholar Postacchini et al identified a recurrence rate of 86% (24 out of 28 cases) in patients aged 12 to 17 years14Postacchini F. Gumina S. Cinotti G. Anterior shoulder dislocation in adolescents.J Shoulder Elbow Surg. 2000; 9: 470-474Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar, while Wagner and Lyne found an 80% recurrence rate (8 out of 10 cases) in patients aged 12 to 16 years, including one patient with bilateral dislocations. 15Wagner Jr., K.T. Lyne E.D. Adolescent traumatic dislocations of the shoulder with open epiphyses.J Pediatr Orthop. 1983; 3: 61-62Crossref PubMed Google Scholar In contrast, Cordischi et al reported a significantly lower recurrence rate of 21% (3 out of 14 cases) in patients aged between 10.9 and 13.1 years, with none of the patients exhibiting Bankart lesions, all of whom received conservative treatment. 10Cordischi K. Li X. Busconi B. Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patients aged 10 to 13 years.Orthopedics. 2009; 32https://doi.org/10.3928/01477447-20090728-34Crossref PubMed Scopus (39) Google Scholar Lampert's multicenter retrospective study also presented a 0% recurrence rate among 12 followed children aged less than 14 years. 11Lampert C. Baumgartner G. Slongo T. Kohler G. Horst M. Traumatic shoulder dislocation in children and adolescents.Eur J Trauma. 2003; 6: 375-378https://doi.org/10.1007/s00068-003-1218-3Crossref Scopus (24) Google Scholar Lawton et al echoed these findings, noting a lower recurrence rate in children under 10 years compared to adolescents. 12Lawton R.L. Choudhury S. Mansat P. Cofield R.H. Stans A.A. Pediatric shoulder instability: presentation, findings, treatment, and outcomes.J Pediatr Orthop. 2002; 22 (No doi): 52-61Crossref PubMed Google Scholar Case reports regarding shoulder dislocation in young children have underscored the efficacy of conservative treatment, highlighting the quick recovery and positive functional outcomes without recurrence or pathologic findings on follow-up imaging. 3Longo U.G. Salvatore G. Locher J. Ruzzini L. Candela V. Berton A. et al.Epidemiology of paediatric shoulder dislocation: a nationwide study in Italy from 2001 to 2014.Int J Environ Res Public Health. 2020; 17: 2834https://doi.org/10.3390/ijerph17082834Crossref PubMed Scopus (17) Google Scholar,5Endo S. Kasai T. Fujii N. Yamada Y. Takakuwa T. Nakae H. et al.Traumatic anterior dislocation of the shoulder in a child.Arch Orthop Trauma Surg. 1993; 112: 201-202Crossref PubMed Scopus (9) Google Scholar, 6Heck C.C. Anterior dislocation of the glenohumeral joint in a child.J Trauma. 1981; 21: 174-175Crossref PubMed Google Scholar, 7Maso G. Pala E. Berizzi A. Ruggieri P. A rare case of anterior shoulder dislocation in 1-year- and 10-month-old toddler: case report and literature review.Arch Orthop Trauma Surg. 2021; 141: 831-835https://doi.org/10.1007/s00402-020-03536-xCrossref PubMed Scopus (0) Google Scholar, 8Seybold D. Schildhauer T.A. Muhr G. Rare anterior shoulder dislocation in a toddler.Arch Orthop Trauma Surg. 2009; 129: 295-298https://doi.org/10.1007/s00402-007-0546-xCrossref PubMed Scopus (4) Google Scholar These findings suggest that despite the high recurrence rates and subsequent surgical stabilization recommendations in adolescents, conservative treatment remains preferable in children under 10 years of age. This preference is reinforced by the notion that primary traumatic shoulder dislocation in young children may represent a distinct pathoanatomical condition, potentially due to greater capsular and labral elasticity at this age, as well as a more lateral capsular insertion on the glenoid, contributing to a smaller anteroinferior recess and increased tension upon healing, which could act to prevent future dislocations. 8Seybold D. Schildhauer T.A. Muhr G. Rare anterior shoulder dislocation in a toddler.Arch Orthop Trauma Surg. 2009; 129: 295-298https://doi.org/10.1007/s00402-007-0546-xCrossref PubMed Scopus (4) Google Scholar,14Postacchini F. Gumina S. Cinotti G. Anterior shoulder dislocation in adolescents.J Shoulder Elbow Surg. 2000; 9: 470-474Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar,17Deitch J. Mehlman C.T. Foad S.L. Obbehat A. Mallory M. Traumatic anterior shoulder dislocation in adolescents.Am J Sports Med. 2003; 31: 758-763https://doi.org/10.1177/03635465030310052001Crossref PubMed Scopus (120) Google Scholar,18Rockwood CA. The Shoulder; Elsevier Health Sciences: Amsterdam, The Netherlands, 2009; Volume 1. ISBN 9781416034278Google Scholar Shoulder dislocations in young patients often also associate with additional injuries, including epiphyseal separations (Salter and Harris type 1), epiphyseal fractures (Salter and Harris types 2 and 3), and proximal humeral metaphyseal fractures. 19Gupta R. Singh A. Singh K.K. Vohra R. Fracture of proximal humerus with dislocation of glenohumeral joint in a 3 year old child: A case report.J Orthop Case Rep. 2013; 3 (No doi): 26-28PubMed Google Scholar, 20Ikram M.A. Premdas V.B. Alias M.S.B. Traumatic shoulder fracture-dislocation in a child: An innovative method of closed reduction.Trauma. 2021; 23: 64-69https://doi.org/10.1177/1460408620936606Crossref Scopus (1) Google Scholar, 21Isik M. Subasi M. Cebesoy O. Koca I. Pamukcu U. Traumatic shoulder fracture-dislocation in a 7-year-old child: a case report.J Med Case Rep. 2013; 7: 156https://doi.org/10.1186/1752-1947-7-156Crossref PubMed Scopus (17) Google Scholar In the case we report, the patient sustained a shoulder dislocation in conjunction with a clavicle fracture. The favorable outcome following conservative management in this case reinforces the effectiveness of such an approach for managing shoulder dislocations in children younger than ten years. Our findings, in conjunction with a review of existing literature, suggest that conservative management remains a viable and effective treatment pathway even for those with additional considerations such as ADHD, which may complicate adherence to typical post-injury protocols. In line with previous case reports, the absence of Hill-Sachs and Bankart lesions in our pediatric patient suggests that conservative treatment is a viable option for managing shoulder dislocation in children. This case, along with others reported in the literature 4Rowe C.R. Anterior dislocations of the shoulder: prognosis and treatment.Surg Clin North Am. 1963; 43: 1609-1614Crossref PubMed Scopus (42) Google Scholar,7Maso G. Pala E. Berizzi A. Ruggieri P. A rare case of anterior shoulder dislocation in 1-year- and 10-month-old toddler: case report and literature review.Arch Orthop Trauma Surg. 2021; 141: 831-835https://doi.org/10.1007/s00402-020-03536-xCrossref PubMed Scopus (0) Google Scholar,14Postacchini F. Gumina S. Cinotti G. Anterior shoulder dislocation in adolescents.J Shoulder Elbow Surg. 2000; 9: 470-474Abstract Full Text Full Text PDF PubMed Scopus (136) Google Scholar,16Li X. Ma R. Nielsen N.M. Gulotta L.V. Dines J.S. Owens B.D. Management of shoulder instability in the skeletally immature patient.J Am Acad Orthop Surg. 2013; 21: 529-537https://doi.org/10.5435/JAAOS-21-09-529Crossref PubMed Scopus (23) Google Scholar,21Isik M. Subasi M. Cebesoy O. Koca I. Pamukcu U. Traumatic shoulder fracture-dislocation in a 7-year-old child: a case report.J Med Case Rep. 2013; 7: 156https://doi.org/10.1186/1752-1947-7-156Crossref PubMed Scopus (17) Google Scholar, demonstrates that such an approach can lead to rapid recovery and positive clinical outcomes. These results contrast with the higher recurrence rates and the need for surgical stabilization often seen in adolescents. Therefore, our findings support the consideration of conservative management for shoulder dislocations in young children.