Overview of Paediatric Upper Extremity Trauma

Courtesy: Amr Abdelgawad, Maimonaides Medical Centre, NY, USA

Pediatric Upper Extremity Trauma

Clavicle Fracture

Key anatomy
- First bone to ossify during fetal development.
- Medial clavicular epiphysis is the last epiphysis to fuse at 20 to 25 years.
Management
- Children younger than 12 years are treated nonoperatively in almost all cases.
- Adolescents 15 years and older may require surgery for displaced comminuted fractures or polytrauma.
Important point
- Apparent acromioclavicular joint dislocation in children is usually a physeal injury with an intact periosteal sleeve that remodels well.
Sternoclavicular Joint Injury

Key concept
- Children younger than 20 years usually sustain a Salter Harris physeal injury rather than a true sternoclavicular dislocation.
Posterior displacement
- Observe if there are no symptoms of tracheal or esophageal compression.
- Urgent reduction is required if mediastinal compression is present.
Proximal Humerus Fracture

Key anatomy
- Approximately 80 percent of humeral growth occurs through the proximal physis.
- Excellent remodeling potential.
Treatment
- Children younger than 10 years are usually treated with a sling even if the fracture is displaced.
- Children older than 12 years with significant displacement usually require closed reduction and percutaneous pinning.
Common injury pattern
- Usually Salter Harris Type I or II.
Humeral Shaft Fracture

Treatment
- Most fractures are treated nonoperatively.
- Coaptation splint, brace, or sling is commonly used.
Radial nerve palsy
- Usually managed nonoperatively.
Important point
- Spiral humeral shaft fracture in an infant should raise suspicion of nonaccidental injury.
Supracondylar Humerus Fracture

Gartland classification
- Type I: Nondisplaced.
- Type II: Angulated.
- Type III: Completely displaced.
- Type IV: Complete periosteal disruption.
Nerve injuries
- Anterior interosseous nerve injury is the most common overall.
- Ulnar nerve injury is commonly associated with flexion type fractures.
Treatment
- Type I: Cast immobilization.
- Type II: Operate if hyperextension exceeds 20 degrees or medial comminution is present.
- Type III and IV: Closed reduction and percutaneous pinning.
Pin configuration
- Lateral pins are preferred.
- Cross pins provide greater stability but increase the risk of ulnar nerve injury.
Complication
- Malunion may produce cubitus varus with internal rotation and hyperextension.
- Cubitus varus is usually a cosmetic deformity.
Pulseless Hand

Cold, pale hand
- Emergency closed reduction and percutaneous pinning.
- Explore the artery if ischemia persists.
Pink, pulseless hand
- Urgent closed reduction and percutaneous pinning.
- Observe if the hand remains pink after reduction.
Pulseless white hand after reduction
- Suggests arterial entrapment.
- Immediate vascular exploration is required.
Transphyseal Distal Humerus Fracture

Features
- Usually occurs in children younger than 2 years.
- May mimic elbow dislocation.
- Associated with birth trauma or child abuse.
Treatment
- Closed reduction and percutaneous pinning.
Lateral Condyle Fracture

Treatment
- Displacement greater than 2 mm requires open reduction and internal fixation.
- Nondisplaced fractures are treated with a cast and weekly radiographic follow up.
Best radiographic view
- Internal oblique view.
Complication
- Nonunion may lead to cubitus valgus and tardy ulnar nerve palsy.
Lateral Condyle Nonunion

Pathophysiology
- Continued medial growth produces progressive valgus deformity.
Treatment
- Open reduction, internal fixation, and bone grafting.
Exam Pearls
- Clavicle is the first bone to ossify.
- Proximal humerus has excellent remodeling potential.
- Radial nerve palsy after humeral shaft fracture is usually treated nonoperatively.
- Supracondylar fracture is the most common pediatric elbow fracture.
- Lateral condyle fractures displaced more than 2 mm require open reduction and internal fixation.
- Transphyseal distal humerus fractures occur in children younger than 2 years.