Traumatic Upper Extremity Injuries in Children A focused review
of common upper extremity injuries seen in the ED Sujit Iyer, M.D.
Dell Childrens Medical Center of Central Texas Slide 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
Slide 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 Slide 4 Spectrum of
Fractures Depending on how much longitudinal force is applied, you
will see different fractures in pediatrics Slide 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? Slide
6 Case #1 Slide 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! Slide 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%) Slide 9 Radius and Ulna Fractures 2 nd 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 Slide 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? Slide 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) Slide 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 Slide 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 Slide 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) Slide 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) Slide 16 Name that Salter Injury Slide 17 Salter
Harris Type II Slide 18 Name that Salter Injury Slide 19 Salter
Harris Type I Green: Widening of physes (subtle) Blue: Sclerosis in
adjacent metaphyses Slide 20 Name that Salter Injury Slide 21
Salter Harris Type III Green: Widening of physes Red: linear
fracture through epiphyses Slide 22 Name that Salter Injury Slide
23 Salter Harris Type IV Slide 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 Slide
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 Slide 26 Bowing Fracture Numerous microfractures on
concave side of bent bone May need reduction if bend is >20
degrees Slide 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 Slide 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 Slide 29
Scaphoid fractures Physical exam: Tenderness at anatomic snuff box
Pain with longitudinal compression Radiographs May be normal Middle
1/3 rd most commonly injured Suspicious or nondisplaced: thumb
spica splint with follow up Displaced: OR Slide 30 Monkey Bars
Waltzmann ML, et al. Pediatrics, 1999 2 year retrospective study at
Boston Childrens 61% of injuries were fractures 90% of fractures
were upper extremity fx 40% of upper extremity fx were
supracondylar fractures Slide 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%) Slide 32 Normal elbow Anterior humeral line middle
or post 1/3 rd 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 Slide 33 Evaluate the
radiograph Slide 34 See the lines? What is abnormal? Slide 35 What
is abnormal? Slide 36 Fat pads Fat pad is a response to distension
of joint capsule In setting of trauma, can be a sign of occult
fracture Slide 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 Slide 38
Supracondylar fracture Blue abnormal anterior humeral line, Yellow
posterior fat pad and anterior fat pad displaced, Red transverse
supracondylar fracture Slide 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? Slide 40 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? Slide 41 Quick guide to distal upper extremity nerve exam
NerveMotor ExamSensory Innervation RadialWrist extensionDorsal web
space between thumb and index finger UlnarWrist flexion and
adduction, finger spread Ulnar aspect palm and dorsum of hand.
Little finger and ulnar aspect of ring finger MedianWrist 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 InterosseusFlexion distal
phalanx of index finger, flexion distal phalanx of thumb (OK sign)
None Slide 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? Slide 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 Slide 44 Snuffbox tenderness Slide 45 Case 15 year old
presents after a fight Swelling shown on right hand Suspected Dx?
How do you test this injury? Slide 46 Boxers fracture Fx 4 th or 5
th metacarpal neck with volar displacement Must check for
rotational deformity Hx: Striking with a closed fist ? Reduction if
angulation more than 40 0 60 0 Slide 47 Boxers Fracture Normal
Rotational Deformity Slide 48 Boxers Fractures Acceptable
angulation by digit-controversial 5 th : 40 0 4 th : 30 0 3 rd : 20
0 2 nd : 10 0 Orthopedic referral/follow up indicated for all cases
45 0 Slide 49 Metacarpal and Phalanx Fractures Majority can be
managed in ED Metacarpal and proximal phalanx Thumb: Spica splint 2
nd -3 rd digit: Metacarpal splint 4 th or 5 th digit: Ulnar gutter
splint Middle and Distal phalanges: finger splint Orthopedic or
Hand Surgery referral Significant displacement Rotational deformity
Intrarticular injuries Slide 50 Youre not done! To receive full
credit for this module please copy the link below (or click it)
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