the body to close and is rarely visible radiographically before age 18 years old Therefore, special views (e.g., the cephalic tilt view) or advanced imaging with CT may be necessary for the identification of posteriorly displaced sternoclavicular fractures ( Fig 111.10 ) Radiologic examination in these cases aims to identify any orthopedic injury as well as potentially lethal complications of trauma to the mediastinal structures that lie posteriorly, including the aorta and trachea Initial imaging for suspected AC joint injury should allow for comparison of the joints either through a single anteroposterior view, which includes both AC joints, or separate radiographs of each AC joint to allow for comparison Sensitivity for detecting injuries is increased if the x-ray is taken with the arm in internal rotation; however, stress views are no longer recommended Most clavicle shaft fractures and nondisplaced fractures of the lateral end of the clavicle in children are treated with nonoperative management due to the ability of pediatric bones to remodel Treatment of shaft fractures typically involves immobilization in either a sling and swathe or a simple sling for weeks and gradual return to daily activities depending on age and risk of repeat trauma Return to contact sports should be delayed until solid bony union occurs (typically between two to four months) The figure-of-eight splint, an alternative method of immobilization, can be more uncomfortable and cumbersome and has not been demonstrated to have superior outcomes For newborns and toddlers, the child can be put into a long-sleeved shirt with the distal sleeve of the injured side pinned to the shoulder area of the shirt of the contralateral side FIGURE 111.10 Three images of a patient with sternoclavicular dislocation A: Apparent normal anteroposterior (AP) view of the clavicle B: Serendipity view demonstrating asymmetry of the right sternoclavicular joint indicative of a posterior dislocation C: CT scan showing posterior sternoclavicular dislocation on the right (Reprinted with permission from Waters PM, Bae D, eds Pediatric Hand and Upper Limb Surgery: A Practical Guide Philadelphia, PA: Lippincott Williams & Wilkins; 2012.) Indications for consultation with an orthopedic surgeon include open fractures, impending open fractures secondary to skin tenting, sternoclavicular dislocation, any fracture to the medial one-third or 100% displaced fractures of the lateral one-third, neurovascular compromise, multitrauma patients, and floating shoulder injuries Relative indications for urgent orthopedic consultation include comminuted fractures, displacement ≥2 cm in the midshaft, and shortening ≥1.5 cm, particularly if the adolescent is of advanced skeletal age Management of AC joint injuries varies by severity Typically, types I to III are nonoperative and patients are treated with rest, ice, analgesics, and support or immobilization with a sling; however operative repair of type III separations may be indicated to improve functional outcomes in children and adolescents Types IV to VI are severe and require orthopedic evaluation and surgical treatment; emergent evaluation is required in the setting of neurovascular compromise Disposition The majority of children with clavicle fractures or injuries to the AC joint can be discharged home Fractures or injuries requiring operative intervention as described above should be seen by orthopedics for possible admission Shoulder Dislocation Goals of Treatment Traumatic dislocations of the shoulder usually result from an indirect force, which overcomes the supports provided by the muscles and ligaments The initial goal of treatment is to manage the pain and expedite reduction of the shoulder dislocation after radiographs have been obtained Postreduction radiographs should be obtained to confirm relocation and evaluate for fractures after reduction CLINICAL PEARLS AND PITFALLS Complications of shoulder dislocation include fracture of the humeral head (Hill–Sachs lesion), tearing of the anteroinferior glenoid labrum with or without associated bony injury (Bankart lesion), and neurovascular injuries (Fig 111.11 ) Due to its close association with the glenohumeral joint, the axillary nerve may be injured with shoulder dislocation, resulting in motor and sensory defects There is a high rate of recurrence or joint instability in young active patients 14 years and older Consequently, patients who plan to return to competitive contact sports may be candidates for surgical stabilization after a first-time instability event Recurrence rates are lower in patients with open relative to closed proximal humeral physis at the time of primary dislocation Current Evidence Anterior shoulder dislocation is the most common joint dislocation seen in the pediatric ED, and accounts for greater than 90% of shoulder dislocations Shoulder dislocation is rare in infants and children aged less than 10 years, but becomes increasingly common through adolescence following physeal closure In the skeletally immature child, fracture of the proximal humerus is more common than dislocation due to the anatomy of the physis Shoulder dislocations are associated with a 70% to 90% recurrence rate Intravenous sedation and analgesia has been the mainstay of pain control for shoulder reduction when indicated; however, adult literature supports the use of intra-articular injection of lidocaine as adjunctive or alternative approach to pain control Although no studies in strictly pediatric populations exist, consideration of intra-articular lidocaine may be worthwhile in skeletally mature adolescents given the added benefits of decreased procedure time and potentially reduced cost Clinical Considerations Clinical Recognition The patient with a shoulder dislocation usually presents with substantial pain, holding their injured arm supported by the uninjured arm There is often an obvious abnormality with loss of the usual rounded contour of the shoulder with the dislocation FIGURE 111.11 Hill–Sachs deformity with anterior humeral dislocation A: AP shoulder demonstrating an anteroinferior dislocation of the humerus with impaction between the inferior glenoid rim and the opposing humeral head (arrow ) The impaction produces the articular defect that has been referred to as the hatchet deformity (Hill–Sachs defect) B: Postreduction, AP shoulder After repositioning the humeral head within the glenoid fossa, the residual effect of compression of the articular surface is clearly identified (arrow ) (Reprinted with permission from Yochum TR, Rowe LJ, eds Yochum and Rowe’s Essentials of Skeletal Radiology 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Triage Considerations The patient should be given adequate pain medication, and the injured upper extremity should be placed in a sling This injury warrants an expedited triage for timely shoulder reduction ... sternoclavicular dislocation on the right (Reprinted with permission from Waters PM, Bae D, eds Pediatric Hand and Upper Limb Surgery: A Practical Guide Philadelphia, PA: Lippincott Williams... Current Evidence Anterior shoulder dislocation is the most common joint dislocation seen in the pediatric ED, and accounts for greater than 90% of shoulder dislocations Shoulder dislocation is... lidocaine as adjunctive or alternative approach to pain control Although no studies in strictly pediatric populations exist, consideration of intra-articular lidocaine may be worthwhile in skeletally