ORTHOPAEDICS V: PAEDIATRICS

Common upper limb injuries in childhood

David Rowland

Assessment of the distal nerve function and blood supply is essential. Young children will not understand complicated instructions. It is easier to assess their motor function by asking them to copy simple movements and to assess their sensation by touching areas reliably supplied by each nerve (Table 1). The diagnosis is conrmed with radiographs.

Abstract
Orthopaedic injuries of the upper limb in children are common. The majority may be managed by simple non-operative means, but others require surgical intervention. Common injuries in children will be discussed along with the principles of their management and the possible complications.

Fractures of the clavicle

Aetiology Most are caused by a fall onto the outstretched arm or onto the shoulder. Midshaft clavicle fractures account for 10e15% of childrens upper limb fractures. Diagnosis A swelling may be visible over the clavicle and the area of the fracture will be tender to palpation. Most of these fractures in children are of the greenstick type. Treatment The vast majority of clavicle shaft fractures will heal with no intervention. A prominent bump is usually seen, but will model over the next year. A broad arm sling is provided for comfort and may be discarded after 1e2 weeks. It is not usually necessary for these patients to be seen at the fracture clinic. Fractures through the lateral physis are uncommon. Most are treated non-operatively. Fractures through the medial physis are rare. Posterior displacement may compromise the airway and require surgical reduction. Diagnosis on radiographs is difcult. A computed tomography (CT) scan may be more useful.

Keywords Children; fracture; orthopaedic; paediatric; upper limb

Introduction
Fractures of the upper limb account for more than half of the bony injuries sustained in children. They are uncommon below the age of 18 months as infants are less likely to fall on their outstretched arms. The frequency of injury rises with increasing mobility. Childrens bones are more malleable than those of adults. The periosteum is thicker and the physes are open. They may therefore suffer from fracture patterns not seen in adults such as buckle (torus) or greenstick fractures, plastic deformation and injuries affecting the physes. The majority of fractures affecting a childs upper limb will heal rapidly and with minimal intervention. The modelling capabilities of growing bones can compensate for some degree of malunion so perfect anatomical reduction may not always be necessary. A proportion of these injuries will, however, require stabilisation. Complications are few but may be signicant and will be discussed in relation to specic fractures. No discussion of childrens fractures is complete without reference to non-accidental injury. Factors such as an inconsistent history, multiple injuries, and delayed presentation should raise the suspicions of the examining practitioner and initiate appropriate referral for further investigation.

Fractures of the proximal humerus (Figure 1)

Aetiology These injuries are more likely than dislocation of the glenohumeral joint in children. Even so they account for only 1% of upper limb fractures in this age group. Diagnosis There may be tenderness to palpation. Sensation in the chevron area should be assessed to exclude injury to the axillary nerve.

Clinical assessment
Injured children are usually reluctant to be examined. Appropriate analgesia will make the child more comfortable and more prone to comply with examination. Inspection may reveal deformities, bruising and wounds. The limb should be palpated to localise the area of maximal tenderness. The joints above and below the injury should be assessed for range of movement and stability.

Simple examination of the nerves of the upper limb

Nerve Motor Median Make a circle with thumb and forenger (OK sign). Lack of exion at the thumb interphalangeal joint implies anterior interosseous nerve injury Ulnar Make a star (spread ngers wide) Radial Thumbs up Table 1 Sensory Pulp of index nger

David Rowland MA FRCS(Orth) is a Consultant in Childrens Orthopaedics at The Royal Hospital for Sick Children in Glasgow, UK. Conicts of interest: none declared.

Pulp of little nger First dorsal web space

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Pre- and postoperative images of a displaced proximal humeral fracture treated with intramedullary nailing. Figure 1

Treatment Most may be managed non-operatively with a collar and cuff for comfort for the rst week or two, then gentle mobilisation as tolerated. If the diaphyseal fragment is prominent, having buttonholed through the deltoid for example, the fracture should be reduced by closed or open means. If unstable it may be stabilized with K wires or elastic nails.

increasingly popular, but plating or external xation are alternatives. Radial nerve injuries are usually neurapraxias and are not routinely explored at initial presentation.

Elbow injuries
Anatomy Assessment of the radiographs of a childs elbow is made difcult by the numerous ossic centres (Figure 2). The order of their development can be remembered by the acronym CRITOE (Table 2). Radiographs of the opposite elbow may provide a useful comparison.

Fractures of the humeral shaft

Aetiology These account for 1e3% of childrens fractures and may be caused by twisting or a direct blow. Diagnosis Clinical examination may identify tenderness, deformity or crepitus. The radial nerve should be assessed as it is easily injured where it passes through the spiral groove. Treatment Non-operative management is the mainstay. A collar and cuff may be sufcient but a U-slab may provide better control of the fracture. Body bandages or the wearing of the collar and cuff beneath clothes provide additional stability. Immobilisation is required for approximately 4 weeks. Surgical indications are few but include open fractures, polytrauma or excessively unstable injuries. Elastic nailing is

Age of appearance of ossic centres around the elbow on radiographs

Ossication centre C Capitellum R Radial head I Internal (medial) epicondyle T Trochlea O Olecranon E External (lateral) epicondyle Table 2 First appearance on radiographs (years) 1/2e2 2e4 4e6 6e8 8e10 10e12

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Ossification centres around the elbow

Lateral epicondyle

Medial epicondyle

Radial head

Capitellum

Trochlea Olecranon AP Lateral

Figure 2

The anterior humeral line should pass through the capitellum on the lateral view. A line along the long axis of the radius should also pass through the capitellum on antero-posterior (AP) and lateral views. (Figure 3)

Elbow dislocation (Figure 4)

Aetiology Most are caused by a fall onto the outstretched hand with the elbow extended. The injury is more common in adolescents. Diagnosis There is a clinical deformity and the elbow is swollen. The normal triangular relationship of the bony landmarks of the olecranon, medial and lateral epicondyles is disrupted. Radiographs will conrm
Figure 4 Elbow dislocation in a 12-year-old. Note the incarcerated medial epicondyle fragment.

the dislocation but should also be inspected for fractures of the radial head, humeral epicondyles and coronoid process of the ulna. Treatment Prompt reduction should be performed and an above elbow backslab applied. Neurology should be reassessed after reduction. Radiographs should conrm reduction and ensure that no fragments remain incarcerated in the joint. The elbow should be immobilized for 3 weeks before gentle range of movement exercises begin. Complications Neurological injuries are often neurapraxias and usually recover well. Elbow instability and myositis ossicans are rare, but stiffness is not uncommon.

Normal anatomical alignment in the elbow

Anterior humeral line

Humerus

Radial head

Pulled elbow
Aetiology The classic history is of a young child who refuses to use their arm after a traction injury. The radial head is pulled out of the annular ligament.

Capitellum

Radiocapitellar line

Figure 3

Diagnosis The child is reluctant to move the elbow and it is tender over the radial head. Radiographs may not demonstrate the unossied radial head but can rule out fractures.

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Treatment Pressure is applied over the radial head with the forearm supinated. As the elbow is extended a palpable clunk suggests reduction of the radial head. Full function usually returns soon after.

extension type following hyperextension of the elbow. Flexion types are caused by a fall onto a exed elbow. Diagnosis The elbow may be swollen and deformed. The triangular relationship between the epicondyles and olecranon is preserved. Any of the nerves around the elbow may be injured so a full examination must be performed. The brachial artery passes over the anterior aspect of the humerus and may be injured by the diaphyseal fragment so the distal circulation must be assessed.

Supracondylar fractures of the humerus (Figure 5)

Aetiology These are the most common fractures around the elbow in children (approximately 75%). Ninety-ve percent are of the

Pre- and postoperative wiring images of a supracondylar fracture of the humerus. Figure 5

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Classication of extension type supracondylar fractures of the humerus

Classication I IIA IIB III Table 3 Fracture type Undisplaced Some continuity between the fragments with angulation but no rotation Some continuity between the fragments but rotation angulation No continuity between fragments

Diagnosis The elbow is swollen and tender laterally. The fracture may not always be appreciated on initial radiographs as it occurs through an area which may be only partially ossied. Treatment Undisplaced fractures may be treated in a cast for 4 weeks, but with imaging at 1 and 2 weeks to ensure that there has been no displacement. Displacement should be treated by open reduction and stabilization with divergent K wires or an interfragmentary screw. Anatomical reduction of the joint surface should be obtained. The joint is immobilized in a cast for 4 weeks. The wires or screw are removed once fracture healing is assured. Complications Non-union is uncommon in childrens fractures, but is occasionally seen with this fracture. Displaced fractures must be stabilised and it is recommended that radiographic evidence of union is obtained before the xation is removed. Cubitus valgus deformity may occur as a consequence of nonunion or physeal injury on the lateral side. This may be associated with a tardy ulnar nerve palsy. The latter may be treated by transposition and the former by osteotomy but, as in cubitus varus correction, the risk of complications is signicant.

The Wilkins modication of Gartlands classication of extension type injuries is used (Table 3). Treatment Type I fractures may be treated in a plaster for 3 weeks, but should have another radiograph to conrm that the position has not changed at a week. Type IIA fractures with angulation of less than 5e10 may be treated in a cast exed beyond 90 at the elbow. Imaging in the plaster should show adequate positioning. If not, the patient should be taken to theatre for manipulation K wires. Type IIB and type III fractures should be reduced and stabilised with K wires and protected in an above elbow cast. Ninetyve percent will reduce with closed manipulation. The wires and cast are removed at 3 weeks. Most patients return to full movement within 6 weeks. They should avoid contact activities until then. Vascular compromise requires emergency management. The patient should be taken to theatre for reduction of the fracture. If the pulse and capillary rell return the fracture is stabilised with wires. If the pulse is present before reduction but disappears after, the xation should be removed and the fracture remanipulated. If the blood supply does not return after manipulation the vessel should be explored by a surgeon trained in vascular repair. Complications Volkmanns ischaemic contracture is a disastrous contracture of the wrist and ngers caused by scarring of the muscles in the forearm from compartment syndrome. Patients developing increasing pain or discomfort must be considered to have vascular compromise and should be managed appropriately. Most neurological injuries are neurapraxias and settle with time. Ulnar nerve symptoms which develop after insertion of a medial wire should prompt repositioning of the wire. Cubitus varus malunion is more common than cubitus valgus and produces the gunstock deformity. Surgical correction of this deformity is fraught with complications and is best reserved for only the most signicant deformities.

Medial epicondyle fractures

Aetiology These are frequently associated with dislocation of the elbow or a valgus stress. Diagnosis There is tenderness and swelling over the medial side of the elbow. Treatment Undisplaced fractures can be treated in a sling or cast for 3 weeks. Moderately displaced (5e10 mm) fractures with no instability may be managed non-operatively. Displaced fractures with symptomatic instability or neurological symptoms are treated by open reduction and internal xation.

Olecranon fractures
Aetiology The most common cause of this rare injury is a fall onto the elbow. Diagnosis The patient may be swollen and tender over the olecranon process and sore on resisted elbow extension. Treatment Undisplaced fractures can be treated in plaster for 4 weeks. Displaced fractures are managed with open reduction and a tension band technique.

Radial neck fractures

Aetiology A fall with valgus stress at the elbow can cause an angulated fracture of the radial neck. Fractures of the radial head itself are extremely uncommon in children.

Fractures of the lateral mass of the humerus (Figure 6)

Aetiology Usually caused by a fall onto the outstretched hand.

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Pre- and post-wiring images of a lateral mass fracture of the humerus. Figure 6

Diagnosis There may be local tenderness and a reduced range of rotation in the forearm. Treatment Angulation of less than 30 at the radial neck will correct with modelling. A sling or cast may be provided for comfort but early mobilization is preferable. Displaced or more angulated fractures are treated in theatre. Closed manipulation is attempted rst. If this is unsuccessful a percutaneous K wire may be used to manipulate the fracture. The wire is withdrawn after reduction. The Metaizeau technique of passing an intramedullary elastic nail from distal to proximal radius allows manipulation of the

fracture by rotation of the nail once it is engaged with the radial head. The nail is left in situ until the fracture has healed. A cast is applied for 3 weeks. Complications Some loss of forearm rotation may occur, particularly in more displaced fractures. There is a small risk of avascular necrosis, which may contribute to elbow stiffness.

Fractures of the shaft of the radius and ulna

Aetiology Forearm fractures account for two-thirds of upper limb fractures in children. They may be caused by direct trauma or a fall onto the outstretched hand. There may be injury to both bones, but if

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only one is injured the joints between it and its partner should be assessed carefully. Diagnosis There may be tenderness, deformity and reduced motion. Imaging may reveal plastic deformation, greenstick or complete injuries. Treatment Undisplaced injuries are managed in above elbow cast for 5e6 weeks with imaging at 1 and 2 weeks. Fractures with displacement or angulation more than 10 should be reduced. Closed reduction is possible in the majority. A well-moulded above elbow cast is applied in the position of maximum stability. Follow-up should be as above. Unstable fractures should be stabilised. Intramedullary elastic nails have proven more popular than plates. Stabilised fractures need not be immobilized for such a long period and the cast can be removed after 2e3 weeks if comfort allows. Complications Malunion can lead to reduced rotation so regular follow up in plaster should be performed. Synostosis is a rare complication, the treatment of which is rarely satisfactory.

Treatment Reduction of the ulnar fracture and manipulation of the radius acutely should reduce the dislocation. There should be a low threshold for stabilising the ulna. In delayed presentations an osteotomy of the ulna and soft tissue stabilisation of the radiocapitellar joint may be necessary. The arm should be immobilised for 4e5 weeks with radiographs at 1 and 2 weeks to ensure reduction is maintained. Complications Late subluxation or dislocation of the radial head can restrict elbow exion and rotation.

Galeazzi lesion
A fracture of the radius with dislocation of the distal radioulnar joint, this injury is the opposite of the Monteggia lesion. It is rare in children, but is managed by the same principles of reduction and stabilisation

Fractures of the distal radius and ulna (Figure 8)

Aetiology Two-thirds of forearm fractures occur around the wrist. A fall onto the outstretched hand is the most common cause, but forced dorsiexion or volar exion injuries may have the same result. Diagnosis There is tenderness over the wrist and may be a clinical deformity. Treatment Unicortical buckle fractures of the distal radius are common in younger children. They are stable injuries and can be treated in a wrist splint which the family may remove themselves at 4 weeks. The child need not be seen at the fracture clinic.

Monteggia injuries (Figure 7)

Aetiology A fracture of the ulna is associated with dislocation of the radial head. Diagnosis There may be tenderness over the ulna and at the radiocapitellar joint or prominence of the radial head at the elbow.

Pre- and postoperative manipulation images of a Monteggia lesion with plastic deformation of the ulna. Figure 7

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Pre- and postoperative wiring images of a displaced distal radial fracture. Figure 8

Greenstick fractures are less stable. Angulation greater than 15 should be reduced and a well-moulded cast applied. Radiographs should be taken at 1 and 2 weeks and the cast continued for 4 weeks. Displaced or angulated complete fractures should be similarly managed but may need to be stabilised with percutaneous

K wires. The wires are removed at 4 weeks. If the fracture is still tender a wrist splint can be provided for a further 2 weeks. Complications Malunion may restrict forearm rotation so close follow up is required to ensure that reduction is not lost.

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Nerve injuries are uncommon and usually represent neurapraxias which resolve spontaneously.

Fractures through the distal radial physis

Aetiology The distal radial physis is a weak point in the bone and displacement may occur here in response to trauma. Diagnosis The child is tender over the distal radius. There may be a clinical deformity. Radiographs show displacement through the physis often with a metaphyseal fragment attached (SaltereHarris type II) Treatment Undisplaced fractures are managed in a cast for 4 weeks. Displaced fractures should be reduced by closed manipulation and a moulded cast applied for 4 weeks with imaging at a week to ensure that there has been no displacement.

Complications Premature physeal closure may occur in a small proportion. It may lead to shortening or angulation of the radius relative to the ulna and may need treatment by osteotomy or shortening of the ulna. Redisplacement in plaster is uncommon, but a radiographic check of the position should be performed at a week. A

FURTHER READING Beaty JH, Kasser JR, eds. Rockwood & Wilkins fractures in children. 7th edn. Lippincott, 2009. Section 2 Upper Extremity. Benson M, Fixsen J, Macnicol M, Parsch K, eds. Childrens orthopaedics and fractures. 3rd edn. Springer, 2010: 715e50. Part V section 2, [chapters 43e45]. Dietz H-G, Schmittenbecher PP, Slongo T, Wilkins K. AO manual of fracture management e elastic stable intramedullary nailing (ESIN) in children. Thieme, 2006. Herring JA, ed. Tachdjians Paediatric Orthopaedics. 4th edn. Saunders, 2007; Vol 3: 2423e572. Upper extremity injuries, [chapter 42].

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