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

 

Pediatric Upper Extremity Trauma 

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1. Medial Epicondyle Fracture (Children)

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Key Anatomy

• Last ossification center to fuse in elbow
• Fusion age:
  • Boys: 16–19 years
  • Girls: 13–16 years

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Attachments

• Medial collateral ligament (MCL)

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Mechanism

• Valgus stress – avulsion injury
• Commonly associated with elbow dislocation

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Treatment

Non-operative (Most Cases)

• Minimal displacement
• Stable elbow

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Absolute Indication for Surgery

• Fragment entrapped in joint

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Relative Indications

• Displacement >10 mm
• Valgus instability
• High-demand athletes (e.g., throwers)

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2. Nursemaid’s Elbow (Pulled Elbow)

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Age Group

• 2–3 years

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Mechanism

• Sudden traction on a pronated forearm

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Clinical Features

• Arm held:
  • Pronated
  • Close to body
• Refusal to move limb
• X-ray:
  • Normal

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Treatment

• Reduction maneuver:
  • Supination – Flexion

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Key Sign

• “Click” felt over radial head
• Immediate return of function

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3. Radial Head & Neck Fractures (Children)

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Epidemiology

• Rare
• Typical age: ~9 years

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Mechanism

• Valgus force

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Types

• Non-displaced
• Angulated
• Displaced

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Fracture Location

• Physeal (Salter-Harris)
• Metaphyseal

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Important Rule

• Radial head must align with capitellum in ALL views

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Management

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Techniques

• Closed reduction:
  • Traction + supination + varus force
• K-wire joystick technique
• Metaizeau technique (intramedullary nail)

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Complications

• Stiffness
• Avascular necrosis
• Radioulnar synostosis
• Non-union (rare)

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4. Monteggia fracture-dislocation

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Definition

• Ulna fracture + radial head dislocation

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Key Clinical Rule

• Radial head must point to capitellum

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Most Common Type in Children

• Bado Type I:
  • Anterior radial head dislocation
  • Apex anterior ulna angulation

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Diagnosis Tip

• AP view may appear normal
• Lateral view is critical

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Treatment

First-line

• Closed reduction of ulna

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Position

• Elbow:
  • 90–100° flexion
• Forearm:
  • Supination

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Mechanism

• Relaxes biceps – reduces radial head

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If Unstable

• K-wire fixation
• Plate fixation

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Missed Injury

• Ulna osteotomy + lengthening
• Radial head reduces secondarily

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5. Both Bone Forearm Fractures

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Incidence

• Very common pediatric injury

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Acceptable Alignment

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Key Point

• Some shortening (overriding) is acceptable

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Rotation Assessment

AP View

• Radial styloid vs bicipital tuberosity

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Lateral View

• Ulnar styloid vs coronoid (180° apart)

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Treatment

Conservative

• Closed reduction + long arm cast

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Short Arm Cast

• For distal one-third fractures

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Cast Index

• Ratio = AP / ML diameter

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Normal

• < 0.8

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Clinical Significance

• 0.8 – high risk of redisplacement

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Surgical Indications

• Failed reduction
• Near skeletal maturity
• Unstable fractures

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Surgical Options

• Flexible nails (preferred)
• Plates and screws

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High-Yield Exam Pearls

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• Medial epicondyle entrapped – ORIF
• Nursemaid’s elbow – supination + flexion
• Radial head must align with capitellum ALWAYS
• Monteggia = ulna fracture + radial head dislocation
• Missed Monteggia – ulna osteotomy
• Cast index < 0.8
• Distal radius – high remodeling potential

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Critical Warning

• Avoid open reduction in radial neck fractures:
  • Higher complication rates

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Final Message

• Pediatric upper limb trauma requires:
  • Accurate anatomical understanding
  • Careful radiographic assessment
  • Preference for conservative treatment when possible

to ensure optimal functional outcomes