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

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

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

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

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?

Case #1

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!

“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%)

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

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?

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)

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

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

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)

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)

Name that Salter Injury

Salter Harris Type II

Name that Salter Injury

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

Name that Salter Injury

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

Name that Salter Injury

Salter Harris Type IV

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

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

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

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

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

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

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

“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%)

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

Evaluate the radiograph

See the lines? What is abnormal?

What is abnormal?

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

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

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

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?

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?

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

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?

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

Snuffbox tenderness

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

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

Boxer’s Fracture Normal Rotational Deformity

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

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

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