Children and adolescents are not “mini-adults” and must be treated with special consideration when performing arthroscopy on the shoulder. With more and more sports injuries, the use of arthroscopic examination and treatment in this age group is on the rise. In this review article, two pediatric orthopedic surgeons provide surgeons with guidance on the principles of shoulder arthroscopy in children and teens.
Discussion of equipment, patient positioning, and portal placements is provided. Details on surgical technique are given for specific conditions such as the septic (infected) shoulder, brachial plexus palsy, labral injuries, shoulder instability, and rotator cuff pathology. Arthroscopic images with various camera placements and different diagnoses are also provided with descriptions of arthroscopic findings.
Special attention is given to young patients who have special needs because of medical conditions including hemophilia, cystic fibrosis, Down syndrome, Marfan syndrome, muscular dystrophy, seizure disorder, and other neurologic conditions. The authors provide a useful table of concerns that must be addressed when planning arthroscopic evaluation and/or treatment.
For example, intubation (insertion of a tube into the trachea to assist breathing) may be difficult with children who have neurologic conditions. Children with autism may need to be sedated ahead of time in order to improve cooperation. Children with any deformities or heart problems must be monitored closely during and after any surgery. Likewise, anyone with a seizure or bleeding disorder will need extra attention.
As for surgical techniques, the authors describe the size of arthroscope they recommend using for each procedure. Placement must be individualized for each patient since anatomy varies from child to child. The basic arthroscopic skills learned during training may not always apply to this age group.
When scopes are placed through the anterior (front) of the shoulder, soft tissue structures must be released in a particular order in order (as described) in order to preserve and protect them. The surgeon must also be careful to avoid damaging the physis (growth plate) or joint in any child or teen who has not completed skeletal growth yet.
The authors advise using traction “sparingly” in order to prevent stress to the growth plate. Steroids, local anesthetics, and implants or suture anchors should not come in contact with the physis. Any drilling across the plate must be done with the smallest drill bit possible.
There are many advantages of arthroscopic surgery. Arthroscopic examination gives the surgeon the opportunity to carefully and thoroughly examine the shoulder. As a result, damage or injury to the shoulder structures that might have gone undetected is identified and treated.
With smaller incisions possible, there is less pain and stiffness following arthroscopic procedures (compared with open incision surgeries). And studies show that with arthroscopic stabilization of a chronically dislocating shoulder, there are fewer recurrences of dislocation after arthroscopic surgery compared with nonsurgical treatment.
The authors conclude by reminding surgeons that the use of shoulder arthroscopy in the pediatric population is a valuable tool that must be used carefully and judiciously. In all aspects of treatment (evaluation, preoperative and postoperative care, and the surgery itself), this age group must be treated individually and not automatically regarded as adults in small bodies. This is an important concept as more and more children are developing sports-related shoulder injuries previously only seen in the adult population.