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Common upper limb injuries in childhood
ORTHOPAEDICS V: PAEDIATRICS
Common upper limb injuries in childhood
Paediatric fracture patterns Axial force
Bending force
David Rowland Emily Baird
Abstract
Plastic deformation of ulna
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.
Greenstick fracture of radius
Buckle (torus) fracture radius
Keywords Children; fracture; orthopaedic; paediatric; upper limb Figure 1
It is essential at this point to identify limb-threatening injuries, including vascular injury, compartment syndrome and open fractures. An assessment of the distal nerve function can be difficult in young children, as they 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 2 and Figure 2).
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. Children’s bones are more malleable than those of adults. The periosteum is thicker and the physes are open. They may therefore suffer fracture patterns not seen in adults such as buckle (torus) or greenstick fractures, plastic deformation and injuries affecting the physes (Figure 1). The majority of fractures affecting a child’s 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 significant and will be discussed in relation to specific fractures. No discussion of children’s 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 clavicle Aetiology Most are caused by a fall onto the outstretched arm or onto the shoulder. Midshaft clavicle fractures account for 10e15% of children’s upper limb fractures.
Examination sequence Look Feel Move
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. A ‘look, feel, move’ sequence can be followed (Table 1) and the diagnosis is confirmed with radiographs.
Table 1
Simple examination of the nerves of the upper limb
David Rowland MA FRCS(Orth) is a Consultant in Children’s Orthopaedics at The Royal Hospital for Sick Children in Glasgow, Glasgow, UK. Conflicts of interest: none declared. Emily Baird MBChB FRCS(Tr & Orth) MFSTEd is a Specialty Registrar on the West of Scotland Training Rotation, UK. Conflicts of interest: none declared.
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Discolouration, deformity, swelling, wounds Warmth, pulses, capillary refill, tenderness, crepitation Active e if the child is cooperative Passive e except when there is an obvious extremity fracture or dislocation, as further soft tissue injury may be inflicted unnecessarily
Nerve
Motor
Sensory
Median Radial Ulnar Anterior interosseous
‘ROCK’ ‘PAPER’ ‘SCISSORS’ ‘OK’
Pulp of index finger First dorsal web space Pulp of little finger Anterior interosseous nerve has no sensory function
Table 2
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ORTHOPAEDICS V: PAEDIATRICS
Figure 2 Simple motor testing of the nerves of the upper limb using ‘rock (a), paper (b), scissors (c), OK (d)’. ‘ROCK’ tests the median nerve. ‘PAPER’ tests the radial nerve. ‘SCISSORS’ tests the ulnar nerve. ‘OK’ tests the anterior interosseous nerve. (Images courtesy of A Marsh and J Huntley.)
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.
Diagnosis There may be tenderness to palpation. Sensation in the chevron area should be assessed to exclude injury to the axillary nerve. Treatment Most may be managed non-operatively with a collar and cuff for comfort for the first week or two, then gentle mobilization 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.
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. 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 difficult. A CT may be more useful.
Fractures of the humeral shaft
Fractures of the proximal humerus (Figure 3)
Aetiology These account for 1e3% of children’s fractures and may be caused by twisting or a direct blow.
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 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.
Figure 3 (a) Pre- and (b) postoperative radiographs of a displaced humeral fracture, treated with intramedullary nailing.
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Treatment Non-operative management is the mainstay. A collar and cuff may be sufficient 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. Immobilization is required for approximately 4 weeks. Surgical indications are few but include open fractures, polytrauma or excessively unstable injuries. Elastic nailing is increasingly popular, but plating or external fixation are alternatives. Radial nerve injuries are usually neurapraxias and are not routinely explored at initial presentation.
Age of appearance of ossific centres around the elbow on radiographs
Elbow injuries Anatomy Assessment of the radiographs of a child’s elbow is made difficult by the numerous ossific centres (Figure 4). The order of their development can be remembered by the acronym ‘CRITOE’ (Table 3). Radiographs of the opposite elbow may provide a useful comparison. 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 5).
Ossification centre
First appearance on radiographs (years)
C Capitellum R Radial head I Internal (medial) epicondyle T Trochlea O Olecranon E External (lateral) epicondyle
0.5e2 2e4 4e6 6e8 8e10 10e12
Table 3
Treatment Prompt reduction should be performed and an above elbow backslab applied. Neurology should be reassessed after reduction. Radiographs should confirm 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.
Elbow dislocation (Figure 6)
Complications Neurological injuries are often neurapraxias and usually recover well. Elbow instability and myositis ossificans are rare but stiffness is not uncommon.
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 confirm the dislocation but should also be inspected for fractures of the radial head, humeral epicondyles and coronoid process of the ulna.
Distal humeral physeal separation Aetiology This is produced by the same mechanisms as other elbow injuries, however there is suggestion in the literature that this fracture could represent non-accidental injury, as most are seen in very young children. It may be a result of birth trauma and may be mistaken for a brachial plexus injury if not investigated appropriately.
Ossification centres around the elbow
Normal anatomical alignment in the elbow Humerus
Olecranon External (lateral) epicondyle
Internal (medial) epicondyle
Anterior humeral line Radio capitellar line
Trochlea
Capitellum
Capitellum
Radius
Radial head
Ulna Figure 4
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Figure 5
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Supracondylar fractures of the humerus (Figure 7) Aetiology These are the most common fractures around the elbow in children (approximately 75%). 95% are of the extension-type following hyperextension of the elbow. Flexion types are caused by a fall onto a flexed 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. The Wilkins modification of Gartland’s classification of extension-type injuries is used (Table 4). Treatment Type I fractures may be treated in a plaster for 3 weeks but should have another radiograph to confirm that the position has not changed at 1 week. Type IIA fractures with angulation of less than 5e10 may be treated in a cast flexed beyond 90 at the elbow. Imaging in the plaster should show adequate positioning. If not, the patient should be taken to theatre for manipulation with or without K wires. Type IIB and type III fractures should be reduced and stabilized with K wires and protected in an above elbow cast. About 95% 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 refill return the fracture is stabilised with wires. If the pulse is present before reduction but disappears after, the fixation 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.
Figure 6 Elbow dislocation in a 12-year-old. Note the incarcerated medial epicondyle fragment.
Diagnosis X-rays show that the proximal radius and ulna maintain anatomical relationship to each other, but are displaced posterior and medially in relation to distal humerus. This is in contrast to elbow dislocation, where the proximal radius and ulna usually displace posterolaterally. In the youngest cases the distal humerus may not have ossified sufficiently to be seen on plain radiographs. Ultrasound or MRI may help confirm the diagnosis. Treatment These injuries are treated in the same way as supracondylar fractures of the humerus with reduction and stabilisation with plaster with or without percutaneous wires.
Complications Volkmann’s ischaemic contracture is a disastrous contracture of the wrist and fingers caused by scarring of the muscles in the forearm following 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 significant deformities.
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. Diagnosis The child is reluctant to move the elbow and is tender over the radial head. Radiographs may not demonstrate the unossified radial head but can help rule out other fractures. Treatment Pressure is applied over the radial head with the forearm supinated. As the elbow is flexed, a palpable clunk suggests reduction of the radial head. Full function usually returns soon after.
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Fractures of the lateral mass of the humerus Aetiology These are usually caused by a fall onto the outstretched hand.
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Figure 7 (a and b) Pre- and (c and d) postoperative radiographs of wiring of a supracondylar fracture of the humerus.
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 ossified.
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 metalwork is removed once the fracture has healed.
Classification of extension-type supracondylar fractures of the humerus Classification
Fracture type
I IIA
Undisplaced Some continuity between the fragments with angulation but no rotation Some continuity between the fragments but rotation þ/e angulation No continuity between fragments
IIB III
Complications Non-union is uncommon in children’s fractures but is occasionally seen with this fracture. Displaced fractures must be stabilized and it is recommended that radiographic evidence of union is obtained before the fixation 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 significant.
Table 4
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Medial epicondyle fractures
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 first. 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.
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 fixation.
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.
Olecranon fractures Aetiology The most common cause of this rare injury is a fall onto the elbow.
Fractures of the shaft of the radius and ulna
Diagnosis The patient may be swollen and tender over the olecranon process and sore on resisted elbow extension.
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 only one is injured, the joints between it and its partner should be assessed carefully.
Treatment Undisplaced fractures can be treated in plaster for 4 weeks. Displaced fractures are managed with open reduction and a tension band technique.
Diagnosis There may be tenderness, deformity and reduced motion. Imaging may reveal plastic deformation, greenstick or complete injuries.
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.
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.
Diagnosis There may be local tenderness and a reduced range of rotation in the forearm.
Figure 8 (a) Pre- and (b) postoperative radiographs of a Monteggia lesion with plastic deformation of the ulna.
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Diagnosis There may be tenderness over the ulna and at the radiocapitellar joint or prominence of the radial head at the elbow.
Unstable fractures should be stabilised. Intramedullary elastic nails have proven more popular than plates. Stabilised fractures need not be immobilised for such a long period and the cast can be removed after 2e3 weeks if comfort allows.
Monteggia injuries (Figure 8)
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.
Aetiology A fracture of the ulna is associated with dislocation of the radial head.
Complications Late subluxation or dislocation of the radial head can restrict elbow flexion and rotation.
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.
Figure 9 (a and b) Pre- and (c and d) postoperative radiographs of wiring of a displaced distal radial fracture.
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Galeazzi lesion
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).
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.
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 1 week to ensure that there has been no displacement.
Fractures of the distal radius and ulna (Figure 9) Aetiology Two-thirds of forearm fractures occur around the wrist. A fall onto the outstretched hand is the most common cause but forced dorsiflexion or volar flexion injuries may have the same result.
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 1 week.
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. 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.
Conclusion There is a wide range of upper limb injuries in children. While many will heal without difficulty and will model with time, there is a proportion which will require intervention as described above. Examination of the injured child is always difficult but should always be thorough, as should documentation of the findings. The examiner must have a high index of suspicion for neurovascular compromise and be alert to the warning signs of non-accidental injury. A
FURTHER READING Beaty JH, Kasser JR, eds. Rockwood & Wilkins’ fractures in children. 7th ed. Lippincott, 2009. Section 2 Upper Extremity. Benson M, Fixsen J, Macnicol M, Parsch K, eds. Children’s Orthopaedics and fractures. 3rd ed. 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. Tachdjian’s Paediatric Orthopaedics. 4th ed, vol. 3. Saunders, 2007; 2423e572 [chapter 42] Upper extremity injuries.
Complications Malunion may restrict forearm rotation so close follow-up is required to ensure that reduction is not lost. 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.
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Common upper limb injuries in childhood
Paediatric fracture patterns Axial force
Bending force
David Rowland Emily Baird
Abstract
Plastic deformation of ulna
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.
Greenstick fracture of radius
Buckle (torus) fracture radius
Keywords Children; fracture; orthopaedic; paediatric; upper limb Figure 1
It is essential at this point to identify limb-threatening injuries, including vascular injury, compartment syndrome and open fractures. An assessment of the distal nerve function can be difficult in young children, as they 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 2 and Figure 2).
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. Children’s bones are more malleable than those of adults. The periosteum is thicker and the physes are open. They may therefore suffer fracture patterns not seen in adults such as buckle (torus) or greenstick fractures, plastic deformation and injuries affecting the physes (Figure 1). The majority of fractures affecting a child’s 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 significant and will be discussed in relation to specific fractures. No discussion of children’s 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 clavicle Aetiology Most are caused by a fall onto the outstretched arm or onto the shoulder. Midshaft clavicle fractures account for 10e15% of children’s upper limb fractures.
Examination sequence Look Feel Move
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. A ‘look, feel, move’ sequence can be followed (Table 1) and the diagnosis is confirmed with radiographs.
Table 1
Simple examination of the nerves of the upper limb
David Rowland MA FRCS(Orth) is a Consultant in Children’s Orthopaedics at The Royal Hospital for Sick Children in Glasgow, Glasgow, UK. Conflicts of interest: none declared. Emily Baird MBChB FRCS(Tr & Orth) MFSTEd is a Specialty Registrar on the West of Scotland Training Rotation, UK. Conflicts of interest: none declared.
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Discolouration, deformity, swelling, wounds Warmth, pulses, capillary refill, tenderness, crepitation Active e if the child is cooperative Passive e except when there is an obvious extremity fracture or dislocation, as further soft tissue injury may be inflicted unnecessarily
Nerve
Motor
Sensory
Median Radial Ulnar Anterior interosseous
‘ROCK’ ‘PAPER’ ‘SCISSORS’ ‘OK’
Pulp of index finger First dorsal web space Pulp of little finger Anterior interosseous nerve has no sensory function
Table 2
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ORTHOPAEDICS V: PAEDIATRICS
Figure 2 Simple motor testing of the nerves of the upper limb using ‘rock (a), paper (b), scissors (c), OK (d)’. ‘ROCK’ tests the median nerve. ‘PAPER’ tests the radial nerve. ‘SCISSORS’ tests the ulnar nerve. ‘OK’ tests the anterior interosseous nerve. (Images courtesy of A Marsh and J Huntley.)
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.
Diagnosis There may be tenderness to palpation. Sensation in the chevron area should be assessed to exclude injury to the axillary nerve. Treatment Most may be managed non-operatively with a collar and cuff for comfort for the first week or two, then gentle mobilization 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.
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. 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 difficult. A CT may be more useful.
Fractures of the humeral shaft
Fractures of the proximal humerus (Figure 3)
Aetiology These account for 1e3% of children’s fractures and may be caused by twisting or a direct blow.
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 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.
Figure 3 (a) Pre- and (b) postoperative radiographs of a displaced humeral fracture, treated with intramedullary nailing.
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Treatment Non-operative management is the mainstay. A collar and cuff may be sufficient 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. Immobilization is required for approximately 4 weeks. Surgical indications are few but include open fractures, polytrauma or excessively unstable injuries. Elastic nailing is increasingly popular, but plating or external fixation are alternatives. Radial nerve injuries are usually neurapraxias and are not routinely explored at initial presentation.
Age of appearance of ossific centres around the elbow on radiographs
Elbow injuries Anatomy Assessment of the radiographs of a child’s elbow is made difficult by the numerous ossific centres (Figure 4). The order of their development can be remembered by the acronym ‘CRITOE’ (Table 3). Radiographs of the opposite elbow may provide a useful comparison. 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 5).
Ossification centre
First appearance on radiographs (years)
C Capitellum R Radial head I Internal (medial) epicondyle T Trochlea O Olecranon E External (lateral) epicondyle
0.5e2 2e4 4e6 6e8 8e10 10e12
Table 3
Treatment Prompt reduction should be performed and an above elbow backslab applied. Neurology should be reassessed after reduction. Radiographs should confirm 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.
Elbow dislocation (Figure 6)
Complications Neurological injuries are often neurapraxias and usually recover well. Elbow instability and myositis ossificans are rare but stiffness is not uncommon.
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 confirm the dislocation but should also be inspected for fractures of the radial head, humeral epicondyles and coronoid process of the ulna.
Distal humeral physeal separation Aetiology This is produced by the same mechanisms as other elbow injuries, however there is suggestion in the literature that this fracture could represent non-accidental injury, as most are seen in very young children. It may be a result of birth trauma and may be mistaken for a brachial plexus injury if not investigated appropriately.
Ossification centres around the elbow
Normal anatomical alignment in the elbow Humerus
Olecranon External (lateral) epicondyle
Internal (medial) epicondyle
Anterior humeral line Radio capitellar line
Trochlea
Capitellum
Capitellum
Radius
Radial head
Ulna Figure 4
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Figure 5
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ORTHOPAEDICS V: PAEDIATRICS
Supracondylar fractures of the humerus (Figure 7) Aetiology These are the most common fractures around the elbow in children (approximately 75%). 95% are of the extension-type following hyperextension of the elbow. Flexion types are caused by a fall onto a flexed 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. The Wilkins modification of Gartland’s classification of extension-type injuries is used (Table 4). Treatment Type I fractures may be treated in a plaster for 3 weeks but should have another radiograph to confirm that the position has not changed at 1 week. Type IIA fractures with angulation of less than 5e10 may be treated in a cast flexed beyond 90 at the elbow. Imaging in the plaster should show adequate positioning. If not, the patient should be taken to theatre for manipulation with or without K wires. Type IIB and type III fractures should be reduced and stabilized with K wires and protected in an above elbow cast. About 95% 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 refill return the fracture is stabilised with wires. If the pulse is present before reduction but disappears after, the fixation 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.
Figure 6 Elbow dislocation in a 12-year-old. Note the incarcerated medial epicondyle fragment.
Diagnosis X-rays show that the proximal radius and ulna maintain anatomical relationship to each other, but are displaced posterior and medially in relation to distal humerus. This is in contrast to elbow dislocation, where the proximal radius and ulna usually displace posterolaterally. In the youngest cases the distal humerus may not have ossified sufficiently to be seen on plain radiographs. Ultrasound or MRI may help confirm the diagnosis. Treatment These injuries are treated in the same way as supracondylar fractures of the humerus with reduction and stabilisation with plaster with or without percutaneous wires.
Complications Volkmann’s ischaemic contracture is a disastrous contracture of the wrist and fingers caused by scarring of the muscles in the forearm following 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 significant deformities.
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. Diagnosis The child is reluctant to move the elbow and is tender over the radial head. Radiographs may not demonstrate the unossified radial head but can help rule out other fractures. Treatment Pressure is applied over the radial head with the forearm supinated. As the elbow is flexed, a palpable clunk suggests reduction of the radial head. Full function usually returns soon after.
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Fractures of the lateral mass of the humerus Aetiology These are usually caused by a fall onto the outstretched hand.
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Figure 7 (a and b) Pre- and (c and d) postoperative radiographs of wiring of a supracondylar fracture of the humerus.
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 ossified.
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 metalwork is removed once the fracture has healed.
Classification of extension-type supracondylar fractures of the humerus Classification
Fracture type
I IIA
Undisplaced Some continuity between the fragments with angulation but no rotation Some continuity between the fragments but rotation þ/e angulation No continuity between fragments
IIB III
Complications Non-union is uncommon in children’s fractures but is occasionally seen with this fracture. Displaced fractures must be stabilized and it is recommended that radiographic evidence of union is obtained before the fixation 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 significant.
Table 4
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Medial epicondyle fractures
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 first. 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.
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 fixation.
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.
Olecranon fractures Aetiology The most common cause of this rare injury is a fall onto the elbow.
Fractures of the shaft of the radius and ulna
Diagnosis The patient may be swollen and tender over the olecranon process and sore on resisted elbow extension.
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 only one is injured, the joints between it and its partner should be assessed carefully.
Treatment Undisplaced fractures can be treated in plaster for 4 weeks. Displaced fractures are managed with open reduction and a tension band technique.
Diagnosis There may be tenderness, deformity and reduced motion. Imaging may reveal plastic deformation, greenstick or complete injuries.
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.
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.
Diagnosis There may be local tenderness and a reduced range of rotation in the forearm.
Figure 8 (a) Pre- and (b) postoperative radiographs of a Monteggia lesion with plastic deformation of the ulna.
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Diagnosis There may be tenderness over the ulna and at the radiocapitellar joint or prominence of the radial head at the elbow.
Unstable fractures should be stabilised. Intramedullary elastic nails have proven more popular than plates. Stabilised fractures need not be immobilised for such a long period and the cast can be removed after 2e3 weeks if comfort allows.
Monteggia injuries (Figure 8)
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.
Aetiology A fracture of the ulna is associated with dislocation of the radial head.
Complications Late subluxation or dislocation of the radial head can restrict elbow flexion and rotation.
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.
Figure 9 (a and b) Pre- and (c and d) postoperative radiographs of wiring of a displaced distal radial fracture.
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Galeazzi lesion
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).
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.
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 1 week to ensure that there has been no displacement.
Fractures of the distal radius and ulna (Figure 9) Aetiology Two-thirds of forearm fractures occur around the wrist. A fall onto the outstretched hand is the most common cause but forced dorsiflexion or volar flexion injuries may have the same result.
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 1 week.
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. 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.
Conclusion There is a wide range of upper limb injuries in children. While many will heal without difficulty and will model with time, there is a proportion which will require intervention as described above. Examination of the injured child is always difficult but should always be thorough, as should documentation of the findings. The examiner must have a high index of suspicion for neurovascular compromise and be alert to the warning signs of non-accidental injury. A
FURTHER READING Beaty JH, Kasser JR, eds. Rockwood & Wilkins’ fractures in children. 7th ed. Lippincott, 2009. Section 2 Upper Extremity. Benson M, Fixsen J, Macnicol M, Parsch K, eds. Children’s Orthopaedics and fractures. 3rd ed. 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. Tachdjian’s Paediatric Orthopaedics. 4th ed, vol. 3. Saunders, 2007; 2423e572 [chapter 42] Upper extremity injuries.
Complications Malunion may restrict forearm rotation so close follow-up is required to ensure that reduction is not lost. 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.
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