1. Traumatic Upper Extremity Injuries in Children
A focused review of common upper extremity injuries seen in the ED
Sujit Iyer, M.D.
Dell Children’s Medical Center of Central Texas

2. Goals
Understand the most common upper extremity injuries seen in the ED
Understand how to methodically read a pediatric elbow radiograph
Understand the purpose of splinting with upper extremity injuries

3. Pediatric Fractures
Presence of physis (growth plate) and secondary ossification centers
More plastic and porous – can bend before breaks
Faster healing than adults – remodeling can correct many injuries; but growth plate injuries deserve special consideration for risk of growth disruption or arrest
mid-shaft femur fracture
4 months later, after remodeling

4. Spectrum of Fractures
Depending on how much longitudinal force is applied, you will see different fractures in pediatrics

5. Case #1
A 6 yo female presents via EMS after a witnessed fall off monkey bars. Her father states that the child broke her fall by landing on an outstretched hand. The patient is complaining of severe right arm pain. On exam there is an obvious deformity of the right wrist.
What are the most appropriate immediate steps In evaluation of this child?
What are the most likely injuries from this mechanism?

6. Case #1

7. Immediate Management For EVERY patient with a traumatic injury:
Vascular
Neurological Assessment
Pain Control
Medication & immobilization
Examine Overlying skin (open or closed fracture?)
Radiographs
Ortho Referral
Act NO DIFFERENT if patient is a transfer!

8. “FOOSH” Fall On Out-Stretched Hand Common fractures Forearm and Wrist
Distal radius and ulna
Scaphoid
Elbow
Supracondylar (>60%)
Lateral Condylar (10-20%)
Medial Condylar (10%)

9. Radius and Ulna Fractures
2nd most common fractures of childhood
Distal injuries (75%)
Midshaft
Check skin for puncture wounds (open fx)
Isolated fracture of one bone are rare – check wrist and elbow views if you see only one bone broken
See Galeazzi and Monteggia

10. Galeazzi fractures
Fracture of distal radius with disruption of radio-ulnar joint
Can also have separation of ulnar physis
Can cause anterior interosseus nerve palsy (Do you know how to check for this?

11. Distal forearm fractures
Distal injuries
Close to physis
Excellent remodeling
Fracture types
Buckle or torus (low energy mechanism)
Salter Harris fractures (I-V)
Galeazzi fracture (see previous)

12. Buckle fracture (Torus)
Excellent remodeling potential
Some RCT have shown equal healing with removable splint vs. short arm cast (previous standard)
Plint AC, Pediatrics, 2006

13. Salter Harris Fracture
Physis is weakest part of growing skeleton. Ligaments 2-5X stronger than physis
Higher the classification, greater risk of physeal arrest and joint incongruity
Why? More likely to injure vascular supply of physis

14. Salter Harris Fracture Types
Imagine bone as long bone, with epiphyses at the base. Helpful (?) mneomonic:
I – S – straight through
II – A – above physis line
III – L – below the physis line
IV – T – through the physis line
V – R – crushed injury (uncommon)

15. Salter Harris Fractures
Type I – excellent healing, may be normal xr with only pain at growth plate
Type II – most common, good prognosis
Type III – through epiphyses, and extends into the joint, greater chance for blood supply disruption ( needs surgery)
Type IV – through all 3 elements, also Intrarticular – risk for growth arrest (surgery)
Type V – Crush, usually axial load injury – rare (good, because often diagnoses only in retrospect after there is growth arrest)

16. Name that Salter Injury

17. Salter Harris Type II

18. Name that Salter Injury

19. Salter Harris Type I
Green: Widening of physes (subtle) Blue: Sclerosis in adjacent metaphyses

20. Name that Salter Injury

21. Salter Harris Type III Green: Widening of physes
Red: linear fracture through epiphyses

22. Name that Salter Injury

23. Salter Harris Type IV

24. Midshaft Radius and Ulna Fractures
Injuries seen:
Complete fx
Greenstick fx
Plastic (bowing)
Assess for nerve injury and compartment syndrome
Motor and sensation
Pain with extension of digits, paresthesias, pallor

25. Can you assess the nerves of the forearm and hand?
Go over quick motor function
Two point sensation discrimination (can see this if there is digital nerve injury from a hand injury)
Make sure pain is well controlled
Focus on nerves commonly injured with forearm and elbow fractures

26. Bowing Fracture Numerous microfractures on concave side of bent bone
May need reduction if bend is >20 degrees

27. Reduction or OR?
Diaphyseal fx – limits of acceptable angulation are more stringent than distal fractures – closed reduction often possible
Indications for OR:
Open fracture
Arterial injury
Irreducible fracture
Failed reduction
Skeletal maturity

28. What about the hand?
Hand bones (carpus) almost all cartilage until late childhood and adolescence – young kids rarely have injuries – will break forearm
Scaphoid most common carpal bone injured (like adults)
Usually adolescent with FOOSH

29. Scaphoid fractures Physical exam: Radiographs
Tenderness at anatomic snuff box
Pain with longitudinal compression
Radiographs
May be normal
Middle 1/3rd most commonly injured
Suspicious or nondisplaced: thumb spica splint with follow up
Displaced: OR

30. Monkey Bars Waltzmann ML, et al. Pediatrics, 1999
2 year retrospective study at Boston Children’s
61% of injuries were fractures
90% of fractures were upper extremity fx
40% of upper extremity fx were supracondylar fractures

31. “FOOSH” Fall On Out-Stretched Hand Common fractures Forearm and Wrist
Distal radius and ulna
Scaphoid
Elbow
Supracondylar (>60%)
Lateral Condylar (10-20%)
Medial Condylar (10%)

32. Normal elbow
Anterior humeral line – middle or post 1/3rd of capitellum
Fat pad – posterior fat pad visualization indicates an effusion
Radiocapitellar line – bisects radial shaft and through capitellum
Hourglass sign – can be disrupted with fracture or poor quality lateral
Anterior humeral line: tangential to anterior cortex passes through medial or posterior 1/3rd of capitellum – not useful if less < 2 yo – capitellum is all cartilage
Radiocapitellar line – should pass through capitellum in all views, suspect radial head dislocation if not

33. Evaluate the radiograph

34. See the lines? What is abnormal?

35. What is abnormal?

36. Fat pads Fat pad is a response to distension of joint capsule
In setting of trauma, can be a sign of occult fracture

37. Supracondylar fractures
Presentation:
Most common elbow fracture, third most common limb fracture in kids
Exam focuses on pulses and neuro exam
Pain or pain with passive extension of fingers – concerning sign of ischemia

38. Supracondylar fracture
Blue – abnormal anterior humeral line, Yellow – posterior fat pad and anterior fat pad displaced,
Red – transverse supracondylar fracture

39. Supracondylar Fracture
Immediate Complications:
Compartment syndrome – higher risk with ipsilateral forearm fracture
Forearm pain, pain with passive extension, paralysis of finger extension, paresthesias – all worrisome
Neurologic – usually transient
Radial, medial and ulnar palsies can all occur
Do you know how to check nerve function in the upper extremity?

40. Patient is trying to lift their wrist up. What nerve is being tested?
Do you know?
What nerve is being tested on the left, and then not working in the picture on the right?
Patient is trying to lift their wrist up. What nerve is being tested?
What nerves are responsible for sensation in the purple, red and yellow areas?

41. Quick guide to distal upper extremity nerve exam
Motor Exam
Sensory Innervation
Radial
Wrist extension
Dorsal web space – between thumb and index finger
Ulnar
Wrist flexion and adduction, finger spread
Ulnar aspect palm and dorsum of hand. Little finger and ulnar aspect of ring finger
Median
Wrist flexion and abduction, flexion of fingers at PIP, Opposition of thumb to base of pinky
Radial aspect palm of hand. Thumb, index, middle radial aspect ring finger
Anterior Interosseus
Flexion distal phalanx of index finger, flexion distal phalanx of thumb (OK sign)
None

42. Case 14 year old with one month of wrist pain after skateboard injury.
Has negative XR one month ago
Still with pain.
XR shown. Ignore the arrow.
Diagnosis?

43. Scaphoid fracture Usually only in older population (late adolescent)
Can have nonunion
Splint if high suspicion by exam even with negative XR:
+ PE findings for scaphoid injury:
Snuffbox tenderness
Pain with longitudinal compression
Pain with supination of wrist against resistance

44. Snuffbox tenderness

45. Case 15 year old presents after a fight Swelling shown on right hand
Suspected Dx?
How do you test this injury?

46. Boxer’s fracture Fx 4th or 5th metacarpal neck with volar displacement
Must check for rotational deformity
Hx: Striking with a closed fist
? Reduction if angulation more than 400
600

47. Boxer’s Fracture
Normal
Rotational Deformity

48. Boxer’s Fractures Acceptable angulation by digit-controversial
5th: 400
4th: 300
3rd: 200
2nd: 100
Orthopedic referral/follow up indicated for all cases
450

49. Metacarpal and Phalanx Fractures
Majority can be managed in ED
Metacarpal and proximal phalanx
Thumb: Spica splint
2nd-3rd digit: Metacarpal splint
4th or 5th digit: Ulnar gutter splint
Middle and Distal phalanges: finger splint
Orthopedic or Hand Surgery referral
Significant displacement
Rotational deformity
Intrarticular injuries

50. You’re not done!
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