Skip to main content
Log in

Contemporary imaging of the pediatric shoulder: pearls and pitfalls

  • Review
  • Published:
Pediatric Radiology Aims and scope Submit manuscript

Abstract

In skeletally immature patients, the presence of growth plates and articular cartilage of the shoulder can create a predisposition for unique injuries not observed in adults. Furthermore, increasing participation in sports by children and adolescents appears to be leading to a corresponding increase in the number of sports-related injuries. The importance of radiologists being familiar with pediatric shoulder imaging and its associated injuries is therefore growing. In this article, we review the normal development and maturation pattern of ossification centers of the shoulder from the early gestational period through adolescence. Brachial plexus birth palsy, physeal injuries, shoulder dislocation, and internal impingement are discussed within the context of the child’s age and the mechanism of injury to guide radiologists to a correct diagnosis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19

Similar content being viewed by others

References

  1. National Federation of State High School Associations (2020) High school sports participation increases for 29th consecutive year. NFSH website. https://nfhs.org/articles/high-school-sports-participation-increases-for-29th-consecutive-year/. Accessed 4 Dec 2020

  2. Gottschalk AW, Andrish JT (2011) Epidemiology of sports injury in pediatric athletes. Sports Med Arthrosc Rev 19:2–6

    Article  PubMed  Google Scholar 

  3. Nguyen JC, Sheehan SE, Davis KW, Gill KG (2017) Sports and the growing musculoskeletal system: sports imaging series. Radiology 284:25–42

    Article  PubMed  Google Scholar 

  4. O’Dell MC, Jaramillo D, Bancroft L et al (2016) Imaging of sports-related injuries of the lower extremity in pediatric patients. Radiographics 36:1807–1827

    Article  PubMed  Google Scholar 

  5. Jaramillo D, Laor T, Zaleske DJ (1993) Indirect trauma to the growth plate: results of MR imaging after epiphyseal and metaphyseal injury in rabbits. Radiology 187:171–178

    Article  CAS  PubMed  Google Scholar 

  6. Arnaiz J, Piedra T, de Lucas EM et al (2011) Imaging findings of lower limb apophysitis. AJR Am J Roentgenol 196:W316–W325

    Article  PubMed  Google Scholar 

  7. Baumgart M, Wiśniewski M, Grzonkowska M et al (2016) Morphometric study of the two fused primary ossification centers of the clavicle in the human fetus. Surg Radiol Anat 38:937–945

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ogata S, Uhthoff HK (1990) The early development and ossification of the human clavicle — an embryologic study. Acta Orthop Scand 61:330–334

    Article  CAS  PubMed  Google Scholar 

  9. Yoon SH, Yoo HJ, Yoo R-E et al (2016) Ossification of the medial clavicular epiphysis on chest radiographs: utility and diagnostic accuracy in identifying Korean adolescents and young adults under the age of majority. J Korean Med Sci 31:1538–1545

    Article  PubMed  PubMed Central  Google Scholar 

  10. Calixto LF, Penagos R, Jaramillo L et al (2015) A histological study of postnatal development of clavicle articular ends. Univ Sci 20:361

    Article  Google Scholar 

  11. Zember JS, Rosenberg ZS, Kwong S et al (2015) Normal skeletal maturation and imaging pitfalls in the pediatric shoulder. Radiographics 35:1108–1122

    Article  PubMed  Google Scholar 

  12. Kothary S, Rosenberg ZS, Poncinelli LL, Kwong S (2014) Skeletal development of the glenoid and glenoid–coracoid interface in the pediatric population: MRI features. Skelet Radiol 43:1281–1288

    Article  Google Scholar 

  13. Zember J, Vega P, Rossi I, Rosenberg ZS (2019) Normal development imaging pitfalls and injuries in the pediatric shoulder. Pediatr Radiol 49:1617–1628

    Article  PubMed  Google Scholar 

  14. Zawin JK, Jaramillo D (1993) Conversion of bone marrow in the humerus, sternum, and clavicle: changes with age on MR images. Radiology 188:159–164

    Article  CAS  PubMed  Google Scholar 

  15. Vande Berg BC, Malghem J, Lecouvet FE, Maldague B (1998) Magnetic resonance imaging of normal bone marrow. Eur Radiol 8:1327–1334

    Article  CAS  PubMed  Google Scholar 

  16. Steens SCA, Pondaag W, Malessy MJA, Verbist BM (2011) Obstetric brachial plexus lesions: CT myelography. Radiology 259:508–515

    Article  PubMed  Google Scholar 

  17. Joseph JR, DiPietro MA, Somashekar D et al (2014) Ultrasonography for neonatal brachial plexus palsy. J Neurosurg Pediatr 14:527–531

    Article  PubMed  Google Scholar 

  18. Vuillermin C, Bauer AS (2016) Boston Children’s Hospital approach to brachial plexus birth palsy. J Pediatr Orthop B 25:296–304

    Article  PubMed  Google Scholar 

  19. Tse R, Nixon JN, Iyer RS et al (2014) The diagnostic value of CT myelography, MR myelography, and both in neonatal brachial plexus palsy. AJNR Am J Neuroradiol 35:1425–1432

    Article  CAS  PubMed  Google Scholar 

  20. Menashe SJ, Tse R, Nixon JN et al (2015) Brachial plexus birth palsy: multimodality imaging of spine and shoulder abnormalities in children. AJR Am J Roentgenol 204:W199–W206

    Article  PubMed  Google Scholar 

  21. Stein J, Laor T, Carr P et al (2017) The effect of scapular position on magnetic resonance imaging measurements of glenohumeral dysplasia caused by neonatal brachial plexus palsy. J Hand Surg Am 42:1030.e1–1030.e11

    Article  Google Scholar 

  22. Iorio ML, Menashe SJ, Iyer RS et al (2015) Glenohumeral dysplasia following neonatal brachial plexus palsy: presentation and predictive features during infancy. J Hand Surg Am 40:2345–2351.e1

    Article  PubMed  Google Scholar 

  23. Pöyhiä TH, Lamminen AE, Peltonen JI et al (2010) Brachial plexus birth injury: US screening for glenohumeral joint instability. Radiology 254:253–260

    Article  PubMed  Google Scholar 

  24. Waters PM, Smith GR, Jaramillo D (1998) Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 80:668–677

    Article  CAS  PubMed  Google Scholar 

  25. Donohue KW, Little KJ, Gaughan JP et al (2017) Comparison of ultrasound and MRI for the diagnosis of glenohumeral dysplasia in brachial plexus birth palsy. J Bone Joint Surg Am 99:123–132

    Article  PubMed  Google Scholar 

  26. van de Bunt F, Pearl ML, Lee EK et al (2017) Analysis of normal and dysplastic glenohumeral morphology at magnetic resonance imaging in children with neonatal brachial plexus palsy. Pediatr Radiol 47:1337–1344

    Article  PubMed  PubMed Central  Google Scholar 

  27. Pöyhiä TH, Nietosvaara YA, Remes VM et al (2005) MRI of rotator cuff muscle atrophy in relation to glenohumeral joint incongruence in brachial plexus birth injury. Pediatr Radiol 35:402–409

    Article  PubMed  Google Scholar 

  28. Kozin SH, Boardman MJ, Chafetz RS et al (2010) Arthroscopic treatment of internal rotation contracture and glenohumeral dysplasia in children with brachial plexus birth palsy. J Shoulder Elb Surg 19:102–110

    Article  Google Scholar 

  29. Bishop JY, Flatow EL (2005) Pediatric shoulder trauma. Clin Orthop Relat Res 2005:41–48

    Article  Google Scholar 

  30. Delgado J, Jaramillo D, Chauvin NA (2016) Imaging the injured pediatric athlete: upper extremity. Radiographics 36:1672–1687

    Article  PubMed  Google Scholar 

  31. Dobbs MB, Luhmann SL, Gordon JE et al (2003) Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 23:208–215

    Article  PubMed  Google Scholar 

  32. Varghese J, Teng M, Huang M, Balsam D (2017) Birth injuries to growth plates: a sheep in wolves’ clothing. J Clin Ultrasound 45:511–514

    Article  PubMed  Google Scholar 

  33. DiPaola M, Marchetto P (2009) Coracoid process fracture with acromioclavicular joint separation in an American football player: a case report and literature review. Am J Orthop 38:37–39

    PubMed  Google Scholar 

  34. Ogawa K, Yoshida A, Takahashi M, Ui M (1997) Fractures of the coracoid process. J Bone Joint Surg Br 79:17–19

    Article  CAS  PubMed  Google Scholar 

  35. May MM, Bishop JY (2013) Shoulder injuries in young athletes. Pediatr Radiol 43:135–140

    Article  Google Scholar 

  36. Salter R, Harris W (1963) Injuries involving the epiphyseal plate. J Bone Joint Surg 45:587–622

    Article  Google Scholar 

  37. Dotter WE (1953) Little Leaguer’s shoulder: a fracture of the proximal epiphysial cartilage of the humerus due to baseball pitching. Guthrie Clin Bull 23:68–72

    CAS  PubMed  Google Scholar 

  38. Obembe OO, Gaskin CM, Taffoni MJ, Anderson MW (2007) Little Leaguer’s shoulder (proximal humeral epiphysiolysis): MRI findings in four boys. Pediatr Radiol 37:885–889

    Article  PubMed  Google Scholar 

  39. Martin RP, Parsons DL (1997) Avascular necrosis of the proximal humeral epiphysis after physeal fracture. A case report. J Bone Joint Surg Am 79:760–762

    Article  CAS  PubMed  Google Scholar 

  40. Cordischi K, Li X, Busconi B (2009) Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patients aged 10 to 13 years. Orthopedics 32:686–690

    Google Scholar 

  41. Taylor DC, Arciero RA (1997) Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 25:306–311

    Article  CAS  PubMed  Google Scholar 

  42. Norlin R (1993) Intraarticular pathology in acute, first-time anterior shoulder dislocation: an arthroscopic study. Arthroscopy 9:546–549

    Article  CAS  PubMed  Google Scholar 

  43. Baker CL, Uribe JW, Whitman C (1990) Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 18:25–28

    Article  CAS  PubMed  Google Scholar 

  44. Hovelius L (1987) Anterior dislocation of the shoulder in teen-agers and young adults. Five-year prognosis. J Bone Joint Surg Am 69:393–399

    Article  CAS  PubMed  Google Scholar 

  45. Rowe CR (1956) Prognosis in dislocations of the shoulder. J Bone Joint Surg Am 38-A:957–977

    Article  CAS  PubMed  Google Scholar 

  46. Bencardino JT, Gyftopoulos S, Palmer WE (2013) Imaging in anterior glenohumeral instability. Radiology 269:323–337

    Article  PubMed  Google Scholar 

  47. Burkhart SS, Beer JFD (2000) Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 16:677–694

    Article  CAS  PubMed  Google Scholar 

  48. Gyftopoulos S, Yemin A, Bencardino J (2013) Engaging Hill-Sachs lesion: is there an association between this lesion and findings on MRI? AJR Am J Roentgenol 201:W633–W638

    Article  PubMed  Google Scholar 

  49. Yamamoto N, Itoi E, Abe H et al (2007) Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elb Surg 16:649–656

    Article  Google Scholar 

  50. Cho SH, Cho NS, Rhee YG (2011) Preoperative analysis of the Hill-Sachs lesion in anterior shoulder instability: how to predict engagement of the lesion. Am J Sports Med 39:2389–2395

    Article  PubMed  Google Scholar 

  51. Saliken DJ, Bornes TD, Bouliane MJ et al (2015) Imaging methods for quantifying glenoid and Hill-Sachs bone loss in traumatic instability of the shoulder: a scoping review. BMC Musculoskelet Disord 16:164

    Article  PubMed  PubMed Central  Google Scholar 

  52. Bois AJ, Fening SD, Polster J et al (2012) Quantifying glenoid bone loss in anterior shoulder instability: reliability and accuracy of 2-dimensional and 3-dimensional computed tomography measurement techniques. Am J Sports Med 40:2569–2577

    Article  PubMed  Google Scholar 

  53. Ghodadra N, Gupta A, Romeo AA et al (2010) Normalization of glenohumeral articular contact pressures after Latarjet or iliac crest bone-grafting. J Bone Joint Surg Am 92:1478–1489

    Article  PubMed  Google Scholar 

  54. Di Giacomo G, Itoi E, Burkhart SS (2014) Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy 30:90–98

    Article  PubMed  Google Scholar 

  55. Maio M, Sarmento M, Moura N, Cartucho A (2019) How to measure a Hill–Sachs lesion: a systematic review. EFORT Open Rev 4:151–157

    Article  PubMed  PubMed Central  Google Scholar 

  56. Purchase RJ, Wolf EM, Hobgood ER et al (2008) Hill-Sachs “remplissage”: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 24:723–726

    Article  PubMed  Google Scholar 

  57. Hughes JL, Kruk P, Bastrom TP, Edmonds EW (2019) Magnetic resonance imaging predictors of shoulder instability in adolescents. Pediatr Radiol 49:365–371

    Article  PubMed  Google Scholar 

  58. Marshall KW, Marshall DL, Busch MT (2010) Shoulder pain in the adolescent athlete: a multidisciplinary diagnostic approach from the medical, surgical, and imaging perspectives. Pediatr Radiol 40:453–460

    Article  PubMed  Google Scholar 

  59. Braun S, Kokmeyer D, Millett PJ (2009) Shoulder injuries in the throwing athlete. J Bone Joint Surg Am 91:966–978

    Article  PubMed  Google Scholar 

  60. Lin DJ, Wong TT, Kazam JK (2018) Shoulder injuries in the overhead-throwing athlete: epidemiology, mechanisms of injury, and imaging findings. Radiology 286:370–387

    Article  PubMed  Google Scholar 

  61. Wilk KE, Macrina LC, Fleisig GS et al (2011) Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med 39:329–335

    Article  PubMed  Google Scholar 

  62. Fessa CK, Peduto A, Linklater J, Tirman P (2015) Posterosuperior glenoid internal impingement of the shoulder in the overhead athlete: pathogenesis, clinical features and MR imaging findings. J Med Imaging Radiat Oncol 59:182–187

    Article  PubMed  Google Scholar 

  63. Jobe CM (1995) Posterior superior glenoid impingement: expanded spectrum. Arthroscopy 11:530–536

    Article  CAS  PubMed  Google Scholar 

  64. Giaroli EL, Major NM, Higgins LD (2005) MRI of internal impingement of the shoulder. AJR Am J Roentgenol 185:925–929

    Article  PubMed  Google Scholar 

  65. Rossi F (1998) Shoulder impingement syndromes. Eur J Radiol 27:S42–S48

    Article  PubMed  Google Scholar 

  66. Burkhart SS, Morgan CD, Kibler WB (2003) The disabled throwing shoulder: spectrum of pathology part I: pathoanatomy and biomechanics. Arthroscopy 19:404–420

    Article  PubMed  Google Scholar 

  67. Payne LZ, Altchek DW, Craig EV, Warren RF (1997) Arthroscopic treatment of partial rotator cuff tears in young athletes: a preliminary report. Am J Sports Med 25:299–305

    Article  CAS  PubMed  Google Scholar 

  68. Paley KJ, Jobe FW, Pink MM et al (2000) Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff. Arthroscopy 16:35–40

    Article  CAS  PubMed  Google Scholar 

  69. Gardner E, Gray DJ (1953) Prenatal development of the human shoulder and acromioclavicular joints. Am J Anat 92:219–276

    Article  CAS  PubMed  Google Scholar 

  70. Kothary P, Rosenberg ZS (2015) Skeletal developmental patterns in the acromial process and distal clavicle as observed by MRI. Skelet Radiol 44:207–215

    Article  Google Scholar 

  71. Winfeld M, Rosenberg ZS, Wang A, Bencardino J (2015) Differentiating os acromiale from normally developing acromial ossification centers using magnetic resonance imaging. Skelet Radiol 44:667–672

    Article  Google Scholar 

  72. Girdany BR, Golden R (1952) Centers of ossification of the skeleton. AJR Am J Roentgenol Radium Ther Nucl Med 68:922–924

    CAS  Google Scholar 

  73. Macalister A (1893) Notes on acromion. J Anat Physiol 27:244–251

    PubMed  PubMed Central  Google Scholar 

  74. Liberson F (1937) Os acromiale — a contested anomaly. J Bone Joint Surg 19:683–689

    Google Scholar 

  75. Johnston PS, Paxton ES, Gordon V et al (2013) Os acromiale: a review and an introduction of a new surgical technique for management. Orthop Clin North Am 44:635–644

    Article  PubMed  Google Scholar 

  76. Park JG, Lee JK, Phelps CT (1994) Os acromiale associated with rotator cuff impingement: MR imaging of the shoulder. Radiology 193:255–257

    Article  CAS  PubMed  Google Scholar 

  77. Flecker H (1932) Roentgenographic observations of the times of appearance of epiphyses and their fusion with the diaphyses. J Anat 67:118–164.3

    CAS  PubMed  PubMed Central  Google Scholar 

  78. Roedl JB, Morrison WB, Ciccotti MG, Zoga AC (2015) Acromial apophysiolysis: superior shoulder pain and acromial nonfusion in the young throwing athlete. Radiology. 274:201–209

    Article  PubMed  Google Scholar 

  79. Davlin CD, Fluker D (2003) Bilateral os acromiale in a division I basketball player. J Sports Sci Med 2:175–179

    PubMed  PubMed Central  Google Scholar 

  80. Warner JJP, Beim GM, Higgins L (1998) The treatment of symptomatic os acromiale. J Bone Joint Surg 80:1320–1326

    Article  CAS  PubMed  Google Scholar 

  81. Pagnani MJ, Mathis CE, Solman CG (2006) Painful os acromiale (or unfused acromial apophysis) in athletes. J Shoulder Elb Surg 15:432–435

    Article  Google Scholar 

  82. Moyes DA, Mawhinney D, Finch MB (2000) Acromial apophysitis. Rheumatology 39:1164–1165

    Article  CAS  PubMed  Google Scholar 

  83. Quinlan E, Bogar WC (2012) Acromial apophysitis in a 13-year-old adolescent boy: a common condition in an uncommon location. J Chiropr Med 11:104–108

    Article  PubMed  PubMed Central  Google Scholar 

  84. Smith J, Dahm DL, Newcomer-Aney KL (2008) Role of sonography in the evaluation of unstable os acromiale. J Ultrasound Med 27:1521–1526

    Article  PubMed  Google Scholar 

  85. Demetracopoulos CA, Kapadia NS, Herickhoff PK et al (2006) Surgical stabilization of os acromiale in a fast-pitch softball pitcher. Am J Sports Med 34:1855–1859

    Article  PubMed  Google Scholar 

  86. Sassmannshausen G, Wilson TC, Mair SD (2003) Operative stabilization of an unstable os acromiale in an adolescent football player. Orthopedics 26:509–511

    Article  PubMed  Google Scholar 

  87. Frizziero A, Benedetti MG, Creta D et al (2012) Painful os acromiale: conservative management in a young swimmer athlete. J Sports Sci Med 11:352–356

    PubMed  PubMed Central  Google Scholar 

  88. Bedi A, Rodeo SA (2009) Os acromiale as a cause for shoulder pain in a competitive swimmer: a case report. Sports Health 1:121–124

    Article  PubMed  PubMed Central  Google Scholar 

  89. Viner GC, He JK, Brabston EW et al (2020) Os acromiale: systematic review of surgical outcomes. J Shoulder Elb Surg 29:402–410

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Helen H. R. Kim.

Ethics declarations

Conflicts of interest

None

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

CME activity This article has been selected as the CME activity for the current month. Please visit the SPR website at www.pedrad.org on the Education page and follow the instructions to complete this CME activity.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kim, H.H.R., Ngo, AV., Maloney, E. et al. Contemporary imaging of the pediatric shoulder: pearls and pitfalls. Pediatr Radiol 51, 338–352 (2021). https://doi.org/10.1007/s00247-021-04963-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00247-021-04963-7

Keywords

Navigation