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Shoulder instability in children

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The current craze for sports leads to more and more young people to the sport, resulting in increasing incidents of trauma or accidents because of these excesses are subject budding athletes.
The concept of risk has to be imposed on officials in sports because the child knows and can pace yourself and recognize its limitations especially if it is engaged in a training program defined under competitive.
As in adults, the lesions of the shoulder with the waning of sport succeed either to a single violent trauma (macro-trauma which processing rules are no different from that of pediatric orthopedic surgery) either to use on a growing skeleton (micro-trauma), which brings the child to the consultation.
In children, the shoulder capsule insertion is along the bony margin of the glenoid and labrum. The humeral insertion is located on the anatomical neck at the level of the epiphyseal plate except where its inner side fastener descends along the metaphysis of about one centimeter (this anatomical peculiarity that, in case of detachment epiphyseal, metaphyseal a small fragment will be carried with the epiphysis - Salter II).
The upper humeral epiphysis develops from three cores of ossification (one for the head, one for the greater tuberosity and lesser tuberosity for the). The cranial ossification core generally appears between the 4th and the 6th month, one of the greater tuberosity in the 3rd year, the lesser tuberosity of the fifth year. The tuberosity nuclei quickly merge in the fifth-sixth year, and with the cephalic nucleus during the seventh year. The fusion of epiphysis to the diaphysis is made ??permanently to the 18th year.
The upper humeral epiphysis retroversion is of the order of 20 to 30 ┬░.
At the level of the scapula, the body and the spine of the scapula are ossified at birth. Glenoid develops from two cores of ossification. The upper core appears at the base of the coracoid to the 10th year, and merges to the 15th year, involved in the ossification of the upper part of the glenoid cavity and the base of the coracoid process. The lower core, shaped horseshoe appears at the bottom of the glenoid bet at the time of puberty, involved in the ossification of the lower 2/3 of the glenoid.
In the plane of the scapula, the version of the glenoid between 5 ┬░ and 10 ┬░ of retroversion anteversion.
The growth of the humerus is essentially in dependence on the upper end (80%); about 7cms at birth, it doubles in size between 0 and 3 years, reached 50% of its final size at age 5 and measures approximately 35 cms in adulthood (late-stage report Humerus / Stand Size is about 20%, the report humerus / Size sitting of 38%).
In general, a number of factors influence joint laxity (2): the structure of collagen, the shape of the joint, muscle tone which controls the movement, the tension of the skin surface facing each other, the importance of the local greasy panicle, the volume of peripheral muscle mass, a family nature of laxity.
The glenohumeral joint is the articulation of the human body which has the more degrees of mobility.
The children and adolescents may be at his shoulder a greater or lesser joint laxity without this necessarily leads to instability (6).
As at the knee laxity is defined as asymptomatic passive translation of the humeral head over the glenoid (with its attendant potential clinical signs anterior drawer, posterior sulcus) while instability is defined as a translation abnormal pain during active shoulder mobility.
Knowledge of static and dynamic factors controlling the stability of the shoulder allows a rational therapeutic management of patients with shoulder instability.
Unlike the acetabulum, glenoid bone does not provide inherent stability to the humeral head. Indeed, whatever the position of the shoulder, only 25 to 30% of the humeral head is in contact with the glenoid with ever constant overall retroversion of around thirty degrees.
Although the glenoid curvature radius four times that of the humeral head, the glenoid surface has a degree of concavity (18), greater concavity in the upper-lower level and in the antero-posterior plane. Indeed, although the glenoid subchondral bone is relatively flat, the cartilage surface is thicker at the periphery than at the center of the glenoid which contributes to the concavity of the articular surface.
This concavity of the glenoid surface is increased by the presence of the glenoid rim (labrum), preventing slippage of the humeral head out of the glenoid during rotational movements (the stability of a ball on the surface of a flat table provides little resistance against a pressure which dragged the ball on the table, the resistance of the ball against the pressure will be even greater than it is in a concave depression).
The glenoid labrum, further increasing the concavity of the glenoid surface, contributes to the stability of the glenohumeral joint by two mechanisms:
It increases the contact area between the humeral head and the glenoid.
Above all, it is the docking area of the glenohumeral ligaments
In cases of traumatic anterior instability, glenoid labrum is typically detached (Bankart lesion), which reduces the glenoid concavity, thereby facilitating dislocation or subluxation, not only because of ligament relaxation, but also because of the decrease in height of the glenoid concavity. L├ęs repetitive episodes erode articular cartilage thereby decreasing the concavity of the glenoid.
The anatomical repair of the Bankart lesion should restore not only the strong attachment of ligaments to the anterior glenoid but must also restore the concavity of the glenoid cavity (default re stapling techniques to the front edge of the scapular neck and not riding on the anterior glenoid).
In very rare cases, hypoplasia or dysplasia of the glenoid, or an orientation defect of the glenoid and / or humeral head can cause instability, (less than 1% of all instabilities of the shoulder). In this case, most of the time, the clinical picture is part of a framework of instability more or less voluntary (usually posterior instability or multidirectional).
The Hill-Sachs lesion (posterolateral impaction bone of the humeral head even more common as the number of dislocations is important) can play a role in the recurrence of instability accidents if it reaches a significant size (over 20 to 30% of the articular surface).
In children, before 12/14 years, it only manifests itself in the form of depression at the cartilage matrix of the head, not viewable on standard imaging.
The STRUCTURES capsuloligamentous
Glenohumeral capsule consists of two systems of collagen fibers:
beam substantially circular fiber orientation
beams of essentially radial orientation fibers.
These fiber bundles are oriented in the direction of maximum tensile stress, undergoing an interlacing system (cross-linking), suggesting a structural adaptation to shear stress from loads of varying directions during the combined movements of the shoulder, with capsular reinforcements for defining "ligament zones" of equal importance.
It follows from this adaptation capsular a cylindrical structure where it is possible to define three areas:
Very complex posterior end, makes radial and circular fibers intersecting.
Complex consists of the upper glenohumeral ligament superior, the coracohumeral ligament and the insertion of the rotator cuff muscles (anterior part of the infraspinatus, supraspinatus, long head of the biceps). This superior complex dominated by circular fibers, appears as a transmission belt between the subscapularis and infraspinatus muscle.
Anteroinferior complex made ??of the strongest parts of the capsule (predominant radial fibers) radiating spiral with glenohumeral ligaments middle and lower. The LGHI, the thicker, long and coiled stretches in the position of the armed horizontal arm (vulnerable position of anterior instability) thus being one of the predominant barriers to anterior shoulder instability.
This cylindrical design with ligament reinforcement of unequal importance of the glenohumeral capsule explains the concept of circular concept of the instability of the shoulder (23). This implies that in case of shoulder instability, it is necessary to have lesions on each side of the joint (anterior dislocation of the shoulder alters not only the earlier structures, but also the posterior structures).
This concept becomes important in multidirectional shoulder instability.
In unidirectional instability of the shoulder, post-traumatic stress in general, simply repair the only major structure concerned.
By against the capsular must consider this cylindrical structure reinforcement ligament: capsular plasties T (Neer, Warren etc ...) represent a concentric shortening capsuloligamentous structure, whereas the technique is only a Bankart unilateral shortening.
These are the shoulder girdle muscles that are responsible for the dynamic shoulder stability by dynamic compression mechanisms of the humeral head in the glenoid cavity.
The anatomy very suitable for rotator cuff muscles (subscapularis, supraspinatus, infraspinatus, teres minor and intraarticular portion of the biceps) that these muscles dynamically compress the humeral head in the glenoid concavity. The powerful cuff muscles that surround the shoulder (deltoid, pectoralis major, latissimus dorsi) contributes significantly to the shoulder compression mechanism in certain positions.
A concept of concavity compression (18) it adds the notion of scapulohumeral balance, the rotator cuff and other muscles of the shoulder girdle to work so that the resultant of the compression forces in the lead closer possible to the center of the glenoid, within a stability range subtended by the glenoid concavity.
The periarticular muscles thus contribute to the stability of the shoulder lining the glenoid on the resultant force through the joint, while leading the movement that led slowly to the tensioning of the capsular ligament structures whose role appears in the extreme positions.
In cases of physiological laxity, this can lead to the creation of strong angle exceeding the tolerance of scapulothoracic balance, resulting in instability (the capsular ligamentous structures, due to their hyper elasticity, are longer sufficient to restore the compression mechanism).
A capsular retendant the lower and posterior hammock can be quite justified.
Muscle dynamic imbalance (neurological shoulder) can lead to instability inducing a resultant of forces which deviate excessively from the central axis glenoid, or being unable to position this axis due to abnormal orientation of the glenoid.
This is why it is necessary to differentiate under voluntary instabilities (21) those that are initiated by a muscle control of those that are initiated by an end position of the arm.
The subject is positional instability is usually psychologically balanced, and if conservative treatment fails, can benefit from surgical treatment of capsular.
In contrast the subject is able, in a given position by the simple muscle control, to dislocate his shoulder and cut, essentially is a psychological treatment associated with a rehabilitation program and should not benefit surgical treatment given the unacceptably high risk of recurrence.
The instability of the shoulder can occur as a result of macro-trauma ( "TUBS" Anglo-Saxon). Instability occurs after a significant traumatic episode. It is usually Unidirectional (usually anterior inferior). The pathological lesion is usually an avulsion of the bead and the capsular ligament complex of the anterior inferior edge of the glenoid (Bankart lesion). A surgery (Surgery) is the rule to restore the stability of the shoulder.
In contrast, instability may be secondary to repetitive movements that gradually stretch the tissue elements static stabilizers of the shoulder ( "AMBRII" Anglo-Saxon). Instability is Atraumatic, often multi-directional type or Bilateral. Treatment is dominated by rehabilitation, to restore an optimal neuromuscular control. If surgery is needed, it must involve a retention interval cuff and Inferior capsular ligament complex.
The shoulder dislocations in children under 12 years are extremely rare (2.5 to 4, 7% of all shoulder dislocations - ROWE, WAGNER).
Although traumatic anterior dislocation remains quite rare, the child is no exception to the trend of recidivism (100% recurrence MARANS for a series of twenty children from 4 years 11 months to 16 years).
In many publications, the anterior dislocation of recidivism appears relatively independent of the type originally proposed treatment in the first episode in subjects under 20 years with occurrence of recurrence in 25-100% of cases according to the literature, most time in the first two years (over 50% for Hovelius -15- on a prospective study on 10 years of decline, more than 80% for Arciero -1- in a population at "risk" despite an initial capital treatment of 3 to 4 weeks followed by intensive rehabilitation of secondary muscle building continued for several weeks).
At that age, non-traumatic dislocations (AMBRII) seem much more common and it is only during the transition from childhood to adolescence the rate of post-traumatic instability (TUBS) increases at the expense of atraumatic instability (although one wonders if a number of instabilities called atraumatic are not secondary to dislocation episode spontaneously reduced undiagnosed in childhood, especially in cases of physiological joint hypermobility).
Despite the scarcity of shoulder instability in children, the use of a classification as proposed by CURTIS, based on the cause of instability is a valuable support for the clinician with a view to taking therapeutic management. Thus we can distinguish the shoulder instability:
Traumatic Anterior
Atraumatic: Congenital
post infection
Tissue (pathological laxity)
Ehlers Danlos Syndrome On, Marfan.
Problem "emotional" or psychiatric
Only after determining these specific elements and knowledge of the pathological lesion therapeutic indication will be given, as well as:
- The concept of functional laxity acquired by overwork (especially throwing sports).
- Anterior instability may be associated with a lower and / or posterior laxity.
- Ignorance of the multidirectional laxity is the cause of the most common failure.
The radio-clinical approach of a child with shoulder instability is not different from that of an adult, the discoveries of circumstances that may occur in three different tables:
Either the waning of a dislocation episode not spontaneously reduced.
Either the waning of an array of shoulder trouble in daily activities or sports with a concept known instability.
Either the waning of a known voluntary instability, parents bringing children by "fear of the future."
Before an anterior dislocation, one finds the same signs as in adults, dominated by pain and functional impairment, arm in abduction and external rotation. It is always advised to seek neurovascular complications, including damage to the axillary nerve or signs of rough brachial plexus. Before any reduction maneuver, it is necessary to perform radiographs that eliminates fracture epiphyseal separation.
Posterior dislocation of the shoulder is as rare if not more in children than in adults. We must think about before a post-traumatic shoulder pain for the loss of external rotation, slurring the pit thorny, abnormal protrusion of the coracoid process forward.
The radiographs enables the diagnosis, knowing give full importance to the face of clich├ę too often considered normal to asymmetric joint space, a pear-shaped appearance of the upper end of the humerus, fixed internal rotation. Axillary profile remains the most reliable, always feasible in the absence of humeral fracture, Bloom-Obata profile is rarely necessary.
The implementation of the emergency profile, recently reported by Busson and Judet (3), allows in all cases the diagnosis of shoulder dislocation regardless of its direction.
Whatever the direction of the dislocation, the reduction is performed under general anesthesia in children, followed by a holding phase of 4 to 6 weeks and a rehabilitation program and high specific strength training, even if the risk of secondary recurrence remains significant (1, 12, 17).
The epidemiological and clinical examination survey assume significance in order to classify the instability before considering treatment.
The examination will trace the history of the shoulder, seeking the source of instability (initial traumatic episode or not), the state of the contralateral shoulder, a family notion of instability of shoulder or context of joint hypermobility (Ehlers Danlos syndrome, Marfan syndrome).
Under the usual instability, especially after the child can reproduce a "jerk test" spontaneous at his shoulder with the arm horizontal adduction and internal rotation (sub-dislocated shoulder), reducing by bringing the arms in the coronal plane, sometimes perception of an audible click during reduction (positional instability).
In contrast, under the voluntary instability, by the simple muscle contraction, the child is capable of sub-dislocate his shoulder which is reduced by the simple muscle relaxation, without requiring the setting position luxante arm.
The search for general signs of hypermobility is part of the review of the unstable shoulder hyper-extensibility at the metacarpophalangeal joint of the index or the third finger on the wrist and thumb metacarpo-phalangeal , hyper-extensibility at the elbow etc ...
The laxity testing at shoulder level imply a relaxation of the capsular ligament apparatus.
Anteroposterior drawer ( "drawer test")
This research on a seated patient, relaxed shoulder, elbow bent, forearm resting on the thigh. The examiner, placed behind the patient, surrounds the humeral head with one hand while the other hand stabilizes the shoulder acromioclavicular level, then prints the anterior humeral head translation movements and later enjoying the trip the head, the occurrence of apprehension reaction or not the child, hanging or cracking raising the possibility of damage to the bead.
Furrow Test ( "sulcus sign")
Always in the same examination position, the examiner pulls of downward force to the lower part of the arm; the appearance of a groove at the lower edge of the acromion more or less marked sign laxity below the shoulder level.
"Push-Pull Test"
This research on a patient lying, shoulder resting in a vacuum on the side of the examination table, arm in 90 ┬░ of abduction in the scapular plane (30 ┬░ flexion). The examiner pulls up at the wrist ( "pull") while the other hand holds the arm down ( "push"). It occurs on a subject released a posterior translation of the greater or lesser humeral head (up to 50% in normal subjects).
In this case, examination signs assume the power of the capsular ligament apparatus, capable of withstanding anteroposterior translation forces.
Apprehension test ( "Crank Test")
On a subject sitting, the examiner grabbing the wrist bears the arm abducted 90 ┬░ or more, and external rotation with one hand, while on the other, the stabilizing shoulder acromioclavicular level, thumb exerts a forward translational force on the humeral head.
As part of the anterior instability, the patient experiences apprehension during this maneuver even opposed.
"Jerk Test"
Always in the same examination position, the examiner leads in one hand the arm in horizontal adduction and internal rotation using a rearward thrust, while the other hand stabilizes the scapula. In case of posterior shoulder instability, there may be a "jerk" when suddenly the humeral head out of the glenoid concavity of the back that is reduced when returning to the starting position.
"Fulcrum test" and "test relocation"
Lying on a subject, shoulder sitting outside the edge of the examination table, the examiner moves the arm in abduction external rotation with one hand while the other hand grasping the posterior surface of the upper end of the arm exerts a biasing force toward the front gradually as the arm is brought in abduction and external rotation. The patient feels apprehensive or oppose it ( "fulcrum test"), fear disappears when the drive force applied by the other hand is carried down ( "relocation test").
Clinical examination of the unstable shoulder ends with the assessment of the strength of the various periarticular shoulder muscles with isometric testing of the biceps, supraspinatus, infraspinatus, subscapularis, deltoid, pectoralis major, latissimus dorsi.
Not to mention the effects of obstetric brachial plexus or a hemi or monoplegia infant brain, looking for neurological signs should not be forgotten, not so much of the axillary nerve in this context recurrent dislocation that subscapularis nerve particular, with the assessment of the relief of different areas of the shoulder (ie request an electromyogram in case of diagnostic doubt).
The evidence provided by medical imaging in the context of post-traumatic instabilities are similar to those we research in adults, reservation made ??of the greater or lesser importance to the cartilage function matrix of age the child.
The standard radiographs, comparative, includes the classic clich├ęs face 3 rotations, looking in particular a notch at the humeral head (Hill-Sachs lesion), absent for 12 years, and the Bernageau profile research lesions in the anterior-inferior edge of the glenoid, absent before 14-15 years.
Using a CT arthrography may be useful in the absence of secondary bone disease, to better analyze the anatomic lesions (to the extent that the child is big enough to support such a review without using a method invasive analgesia). This also allows to study the different orientations of the bony elements of the joint (humeral retroversion, abnormal orientation or hypoplasia of the glenoid).
Very often, the results of medical imaging AMBRII remains normal, apart from stress clich├ęs materializing towards instability (tensile face of a lower plate visualizing instability, lateral view in sub-luxante position).
Whatever type of shoulder instability, the therapeutic management can always start with a rehabilitation phase, especially as the child is younger.
It aims to give an optimal neuromuscular control the rotator cuff muscles, deltoid, pectoralis major and fixers of the scapula. This program uses simple muscle strengthening exercises, early in shoulder stability postions (eg avoiding the work of anterior elevation in the plane of the scapula in internal rotation of the arm in the case of posterior instability). Gradually, as the coordination and confidence get better, work is done in less stable positions with repetitive exercises bringing gradually shoulder to reprogram themselves to confront the activities of daily life and sports ( 20 to 80% good results, depending on the context or not traumatic instability).
Leaving aside partisan positions School and convictions of others, we can adopt a reasonable attitude by child's age or adolescent to treat and according to the lesions found:
Before 14-15 years, given the ossification of the glenoid, it is better to move towards techniques capsuloligamentous r├ęinsertions:
distension capsuloligamentous anteroinferior: capsulorraphie anteroinferior according Altschek.
avulsion of the bead and LGHI: anatomical reintegration avoiding anchors based rehabilitation equipment (metal or not)
From 14-15 years:
same attitude vis-à-vis ligament injury capsulo without bone lesions than in younger patients.
in case of fracture of the anterior inferior edge of the glenoid and lesions of Hill Sachs, coracoid bone block in position flush technique Paw, particularly since there is an impaction injury Hill Sachs at the humeral head.
Exceptionally traumatic, it remains accessible after failure of rehabilitation, primary repair.
In this post-traumatic context, the lesions are usually mirrored those that we encounter in post-traumatic anterior instability, namely an avulsion of the bead and the capsule. The diagnosis must be irrefutable with an undeniable initial traumatic episode and an isolated posterior drawer with a jerk positive test well reproducing the gene experienced by the patient.
In the absence of abnormality orientation or development of the glenoid, it makes sense to move towards gestures capsuloligamentous r├ęinsertions meet the anatomical principles repair the bead defined in anterior instability.
Before considering any surgery, it is essential to appreciate all directions of instability and find anatomical factors that could explain this instability they are static origin (including orientation of the glenoid) or dynamic origin (muscle balance, neurological deficit ...).
This is a rule of multidirectional instability predominantly anterior, integrating often in a context of constitutional hypermobility.
It is in this context that capsulorraphies concentrically retension the capsular ligament cylinder distended their place (technique Altchek), with or without a closure of the rotator interval after failure of conservative treatment.
Prior initiation of a rehabilitation program extended from four to six months remains essential, as well as evaluation of the child's psychological profile or young person in his family, especially in the context of voluntary instabilities so as to recognize a true "mental tic" that is not within the course of surgery (24).
The decision of a radical treatment is also no need for character, for despite these repeated episodes of normal or voluntary dislocations, this does not lead, it seems, of secondary disorders of bone development of the glenoid nor omo-brachial degenerative alteration, even late in the (adult age (17).
That is why the surgical decision should only concern cases of painful instability usual with generally abnormal static factors (orientation defect of the glenoid or hypoplasia, humeral torsion disorders).
The surgical procedure requires not only a gesture of retension capsular ligament, but also a gesture bone (osteoplasty of the glenoid, iliac bone block or levied at the expense of the spine of the scapula on a pedicle flap of posterior deltoid or rotator humeral) with favorable results (19).
If we take the classification Curtis, different surgical indications developed above relate only to shoulder instability of the child and traumatic and atraumatic teenager.
As part of shoulder instability of tissue origin (Ehler Danlos syndrome OF) surgical decision should be taken with even more reluctance. When working, gestures capsuloligamentous retension are insufficient and must be associated with bone sometimes combined anterior and posterior gestures.
In the context of neurological shoulder (plexus palsy brachial sequelae, cerebral infantile monoplegia sequels), to be considered in the indication of the importance of neurological damage, the degree of tissue shrinkage different muscles of periarticular shoulder that may require specific actions lengthening or tenotomy perfect for a reduction of a dislocation or habitual inveterate.
You should know detect neurological deficits rough, and request an EMG if diagnostic doubt, before asking the indication for surgical treatment whatsoever.
The instability of the shoulder in children remains a rare disease.
Its management, as usually in pediatric orthopedics, requires not only knowledge of the mechanical problem but also given more extensive medical different etiological settings where it may occur.
There are the same rules as those applied to treatment in adults, including for the last fifteen years a better biomechanical and histological knowledge. Surgically, everything is not just the Latarjet and Bankart and of course, one must know the potential residual growth of the shoulder to treat.
1 Arciero RA, WHELER JH, RYAN JB, JT Mc BRIDE Arthroscopic Repair VS non-operative treatment for acute initial anterior dislocation. Am J Sports Med 1994, 22, 589-594
2 Altchek DW, WARREN RF, SKYHAR MJ, G. ORTIZ T-plasty modification of the Bankart procedure for multidirectional instability Of the anterior and inferior kinds. J. Bone Joint Surg Am 1991, 73, 105-112
3 BIRD HA, BA Joint BARTON hyperlaxity and Its long-term effect on the seal.Soc Health 1993, December, 327-329
BUSSON J., JUDET Or No new shoulder profile feasible in emergency J. Traumatol. Sports 1999, 16, 46-49
5 CURTIS RJJ, DAMERON TBJr, ROCKWOOD CAJr Fractures and dislocations of the shoulder in children CAJr In ROCKWOOD, Wilkins KE and KING RE (eds) Fractures in Children, Philadelphia, JB LIPPINCOTT 1991, 829-919
6 Dim├ęglio A. Growth in orthopedics
7 ELBAUM R., PARENT H., R. Zeller, Seringe RLglenohumeral uxation traumatic in children and adolescents About 9 cases Orthopaedica Acta Belgica, Vol 60, ??1994, No. 2, 204 -.. 209
8 EMERY RJH, Mullaji AB Glenohumeral Joint Instability in Normal Adolescents The Journal of Bone and Joint Surgery, Vol 73 B, 1991, No. 3, 406-408
9 ENDO S. and Col. Traumatic Anterior Dislocation of the Shoulder in a Child Orthop Trauma Surg a CTA, Vol 112, 1993, No. 4, 201-202
WS 10 FORSTER, FORD TB DREZ D.Jr Isolated Posterior Shoulder Dislocation in a Child. A Case Report.. Am J Sports Med, Vol 13, 1983, No. 3, 198 -. 200
11 GOHLKE F., J. EULERT structure of the capsule of the glenohumeral joint: orientation of collagen fiber bundles and applications to biomechanics instability teaching Papers SOFCOT No. 49 Chronic instability of the Shoulder U nder the direction of M.MANSAT French Scientific Expansion, PARIS 1994, 15-25.
12 Hecks CC Anterior Dislocation of the Joint Glenohumeral a Child in The Journal of Trauma, Vol 21, 1981, 174-175
HENRY 13 JH, GENUNG January atural History of gleno-humeral dislocation Am J Sports Med 1982, 10, 135-137
14 Hoffer MM, PHILIPPS GJ Closed Reduction and Tendon Transfer for Treatment of Dislocation of the Joint Glenohumeral Plexus Birth Palsy Secundary to J. Bone Joint Surg Am Flight 80 A, No. 7, 997-1001
15 HOVELIUS L. Anterior Dislocation of the Shoulder in Teen Agers and Young Adults Five Years J. Prognosis Bone Joint Surg Am Flight 69 A, 1987, No. 3, 393-399

Doctor Serge HERMAN, Doctor Nicolas LEFEVRE, Doctor Yoann BOHU. - 9 f├ęvrier 2011.

Conflicts of interest: the author or authors have no conflicts of interest concerning the data published in this article.


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