Normal anatomy of the pediatric

shoulder

J. Herman Kan, M.D.

Section chief, musculoskeletal radiology
Edward B. Singleton Department of Pediatric Radiology
Texas Childrens Hospital

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Outline
1. Normal physeal and apophyseal anatomy of the
shoulder

2. Normal red marrow changes

3. Glenoid version

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 Normal shoulder ossification centers

5 month old 18 month old

13 year old

5 year old
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Common physis of the coracoid and
glenoid

3 year old boy

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 Coracoid process physis
coracoid physis fuses by 13-16 years (similar to the
acromion)

10 year old boy

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Normal physis is smooth
and undular whereas
acute fractures are
sharply defined

Normal coracoid physis

coracoid fracture

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 Coracoid has an additional physis at
the short head biceps origin

13 yo

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Coracoid process apophysis
Short head biceps origin

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 Coracoclavicular apophyseal
ossification center Associated with the
coracoclavicular and
13 year old boy coracoacromial ligament
insertions

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 Subcoracoid ossification center
10 year old boy

May appear at
approximately 8-10
years of age; fuses
by 16-17 years

Associated with long

head biceps tendon
origin

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 Subcoracoid ossification center
14 year old boy

May appear at
approximately 8-10
years of age; fuses
by 16-17 years

Associated with long

head biceps tendon
origin

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 Subcoracoid ossification center

14 year old boy 12 year old girl

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Normal ossification of the glenoid
13 yo
Glenoid secondary
ossification centers
appear early in the
second decade, and fully
ossifies and fuses by 18
years of age1

Should not be confused

with labral or Bankart
injuries

1 Zember et al 2015 Page 12

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Glenoid apophysis

14 year old boy

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Glenoid apophysis can normally be
fragmented and irregular
7 year old girl

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 AC joint and acromion
Acromion ossification center appears by 14-16 years, and fuses by 18-
25 years

Therefore, avoid measurements to determine AC joint separation

14 year old boy 12 year old girl

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Os acromiale
When the acromial ossification center does not
fuse by 18-25 years of age

Therefore, in pediatric patients avoid using this

term, even when there is stress reaction present
within the acromion

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Stress reaction (apophysitis) of the
acromial ossification center
16 yo boy

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Summary of shoulder girdle
apophysis
Coracoid physis

Coracoid apophysis associated with

short head biceps tendon

Coracoid apophysis associated with

the coracoclavicular ligaments

Subcoracoid secondary ossification

center

Acromion

Glenoid apophysis

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Summary of shoulder girdle
apophysis
Coracoid physis

Coracoid apophysis associated with

short head biceps tendon

Coracoid apophysis associated with

the coracoclavicular ligaments

Subcoracoid secondary ossification

center

Acromion

Glenoid apophysis

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Summary of shoulder girdle
apophysis
Coracoid physis

Coracoid apophysis associated

with short head biceps tendon

Coracoid apophysis associated with

the coracoclavicular ligaments

Subcoracoid secondary ossification

center

Acromion

Glenoid apophysis

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Summary of shoulder girdle
apophysis
Coracoid physis

Coracoid apophysis associated with

short head biceps tendon

Coracoid apophysis associated

with the coracoclavicular
ligaments

Subcoracoid secondary ossification

center

Acromion

Glenoid apophysis

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Summary of shoulder girdle
apophysis
Coracoid physis

Coracoid apophysis associated with

short head biceps tendon

Coracoid apophysis associated with

the coracoclavicular ligaments

Subcoracoid secondary
ossification center

Acromion

Glenoid apophysis

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Summary of shoulder girdle
apophysis
Coracoid physis

Coracoid apophysis associated with

short head biceps tendon

Coracoid apophysis associated with

the coracoclavicular ligaments

Subcoracoid secondary ossification

center

Glenoid apophysis

Acromion

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Summary of shoulder girdle
apophysis
Coracoid physis

Coracoid apophysis associated with

short head biceps tendon

Coracoid apophysis associated with

the coracoclavicular ligaments

Subcoracoid secondary ossification

center

Glenoid apophysis

Acromion

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Proximal humerus
Two ossification centers that appear between 2-4
months of age

They fuse by 3 years of age

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Proximal humeral epiphysis and
physis
Two separate lines on AP radiographs, and should
not be confused with a proximal humeral fracture

Fusion begins at age 14, with the posterolatareal

growth closing by 17 years of age

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 Normal proximal humeral
development
5 month old 18 month old

5 year old 13 year old

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 Do not confuse the undular physis
for a proximal humeral fracture

14 year old 10 year old

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Shoulder red and yellow marrow
conversion
1. Epiphysis

18 month old

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Shoulder red and yellow marrow
conversion
1. Epiphysis

2. Diaphysis
4 year old

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Shoulder red and yellow marrow
conversion
1. Epiphysis 5 year old

2. Diaphysis

3. Metaphysis

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Marrow changes in axial skeletal
equivalents follow similar changes

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Normal metaphyseal
marrow Osteomyelitis

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Metaphyseal vertical stripe
Subperiosteal signal related to axial bone growth

Disappears when the physis closes

Should not be confused with periostitis

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 Metaphyseal vertical stripe
10 yo

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 Metaphyseal vertical stripe
10 yo 13 yo

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 Metaphyseal vertical stripe
10 yo 13 yo

17 yo

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Normal Periostitis
metaphyseal related to
vertical stripe osteomyelitis

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 Glenoid version
The glenoid is normally retroverted by
approximately 6 degrees by 2 years of age. By 10
years of age, the glenoid is retroverted by 2
degrees
5 month old 7 year old

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Significance of glenoid version?
Determines posterior shoulder stability

Not to be confused with:

Primary glenoid dysplasia

25 year old

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Significance of glenoid version?
Determines posterior shoulder stability

Not to be confused with:

Primary glenoid dysplasia

25 year old

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45 deg
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Significance of glenoid version?
Determines posterior shoulder stability

Not to be confused with:

Primary glenoid dysplasia
Secondary glenoid dysplasia from brachial plexus birth
trauma
8 month old

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Significance of glenoid version?
Determines posterior shoulder stability

Not to be confused with:

Primary glenoid dysplasia
Secondary glenoid dysplasia from brachial plexus birth
trauma
8 month old

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40 deg
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Take away points
Understand normal apophyseal anatomy and
development to avoid calling fractures

Normal marrow conversion and metaphyseal

vertical stripe (not to be confused with periostitis)

Understand normal glenoid version to avoid

missing primary glenoid dysplasia and subtle
sequelae related to brachial plexus birth injuries

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