Paediatric Upper Limb Fractures

General principles

• Must consider growth plates
• Sprains uncommon
• Infants/toddlers – Femur and skull #
• Primary school – Elbow region
• Adolescents – Complex ankle fractures, transition to adult pattern and increasing ligamentous injuries

Salter-harris

• Salter-Harris type 2 is most common
• Types 3 and 4 are intra-articular as well as involving the physis and are therefore more worrying
• Most common Salter-Harris IV is lateral condyle of humerus
• Growth plate is injured in 1/3 of all bony injuries in children
  • Head of femur, head of radius prone to AVN
  • Distal radius/tibia/femur all tend to survive

NAI

• 1-2% of paediatric injury presentations, particularly in younger children
• All fractures in a child <12 months should be discussed with Paediatrician or Child Safety
• Suggestive fractures of NAI
  • Proximal humerus or humeral shaft fractures <3yo
  • Shearing or distraction mechanism
  • Corner or bucket-handle metaphyseal injuries
  • Femoral fractures in infants
  • Rib fractures
  • Complex skull fractures
  • Multiple fractures, especially different ages
• Suggestive presentations
  • Delayed
  • Different caregiver
  • Unwitnessed– Infants within view, toddlers within earshot…unless asleep
  • Recurrent fractures
  • Unexplained soft tissue markings
  • Unexplained anxiety
• Assessment
  • Draw diagram of injury history as described by witness
  • Examine child all over
  • Ascertain any previous injury history
  • Is developmental level congruent
  • Is history adequate

Clavicular fractures

• Midshaft clavicular fractures (80%)
  • At any age, fall onto shoulder or outstretched hand
  • Usually greenstick
  • Broad-arm sling to support limb for 2 weeks or until comfortable
  • No evidence for figure-of-8 bandage or brace
  • If age >12 and shortened >2cm, refer to orthopaedics
  • If <11yo and undisplaced, GP f/u
  • If displaced or >11yo, fracture clinic

• Lateral clavicular fracture (15%)
  • Broad-arm sling for 2 weeks or until comfortable
  • No evidence for figure-of-8
  • Fracture clinic f/u in 5-7 days
  • If displaced, refer to Orthopaedics

• Medial third clavicular fracture (5%)
  • If displaced refer to Orthopaedics
  • Consider sternoclavicular dislocation or physeal sleeve separation, neurovascular, pulmonary and cardiac injuries
• Lateral clavicular physeal fracture-separation
  • If posteriorly displaced, may required operative intervention
  • Otherwise place in sling and graduated exercises

• Who gets referred urgently?
  • Neurovascular compromise
  • Suspected underlying structural involvement
  • Open fractures
  • Severely comminuted or shortened >2cm in >12yo
  • Displaced medial third
  • Displaced lateral third
  • Pathological fractures

Shoulder dislocation

• Rare under 10 yo
• Best method is traction in prone position

Proximal Humeral fracture

• Proximal humerus
  • <5% of paediatric fractures
  • Prior to physeal closure (14-16yo), large displacement and angulation allowable
    • 5-12 yo: 60 degrees angulation and 50% displacement
    • >12 years: 30 degrees angulation and 30% displacement
  • Collar and cuff is usual treatment or shoulder immobiliser (no difference in outcome)
  • Infantile proximal injuries are usually physeal separations occuring in birth process and only visible on USS (proximal humeral epiphysis does not appear until 6mo)
  • Isolated greater tuberosity fractures with displacement are the exception and often require ORIF

• Who gets referred urgently?
  • >50% or 30% displacement (depending on age)
  • >60 or 30 degrees angulation (depending on age)
  • Pathological including through benign bone cyst
  • Associated brachial plexus
  • Vascular injury
  • Ipsilateral upper limb fractures
  • Multitrauma
• Does not have the same association with NAI as humeral shaft fractures

Humeral shaft fractures

• Midshaft humerus
  • Uncommon (2-5% of all paediatric fractures)
  • May be blunt or NAI
    • Spiral fractures in toddlers and younger are highly suspicious
    • Transverse and oblique due to direct trauma
  • Check and document radial nerve fx
    • At risk running in posterior radial groove at junction of middle and distal thirds
  • Will usually heal well due to weight of arm in collar and cuff
    • Acceptable axial alignment is within 10 degrees
    • Occasionally a hanging U-slab with collar and cuff is required
  • Follow-up in fracture clinic

• Who gets referred urgently?
  • Open fractures
  • Neurovascular compromise
  • Extreme swelling/compartment syndrome
  • Unable to achieve adequate reduction within 10 degrees
  • Pathological fracture
  • Suspicion of NAI
  • Multitrauma/associated fractures

Elbow injuries

• 75% supracondylar and 10% lateral epicondyle
• Missed or poorly treated injuries figure heavily in litigation
• Post-traumatic elbow effusion in childhood without an apparent fracture most commonly represents a minimally displaced supracondylar fracture
  • Must be immobilised in collar and cuff OR above elbow POP until fracture clinic review

Elbow X-ray

• Check for hourglass figure on distal humerus to confirm lateral
• Look for anterior fat pad
  • Small one is normal
• Look for posterior fat pad
  • 75% specific for fracture
• Check anterior humeral line
  • Should go through middle third of capitellum
• Check the radiocapitellar line
  • Line through midde of proximal radial shaft should bisect capitellum in lateral and AP views
• Look at radial head and neck angulation – often subtle
• Check cortex lines of distal humerus
• Check that ossification centres are appropriate
  • CRITOE (see next slides)

CRITOE

• Capitellum (1)
• Radial head (3)
• Internal epicondyle (5)
• Trochlear (7)
• Olecranon (9)
• External epicondyle (11)

Figure of 8 sign/hourglass

Anterior humeral line

Radio-capitellar line

Supracondylar fracture

• Typically primary school age with FOOSH with fracture through thin part of humerus above the growth plate
• Peak age 5-8 and most common elbow fracture in children
• Flexion-type (rare) with anterior displacement of distal fragment
• Extension-type (98%) with posterior displacement of distal fragment
• Urgent orthopaedic review if:
  • Absent radial pulse
  • Ischaemic hand
  • Severe swelling of forearm/elbow
  • Skin puckering or anterior bruising
  • Open injury
  • Neurological injury
• Deformed fractures should be placed in splint 30 degrees short of full extension prior to X-ray

Supracondylar fracture
 – Extension type

• Gartland type 1 – undisplaced
  • Fracture line between olecranon and coronoid fossae may be seen on AP view
  • Immobilise in above-elbow slab in 90 degrees flexion for 3 weeks
  • Wear under clothing
  • From as high as possible (axilla) to MCP joints
  • GP follow-up without repeat X-ray is suitable (RCH)

• Gartland type 2
  • Posterior angulation with probable intact posterior cortex
  • Check for associated varus/valgus deformity – NONE IS ALLOWED EVER
  • Use anterior humeral line to judge degree of posterior angulation
  • IIa (angulation only)
    • Above elbow slab at 90 degrees if able with f/u within 24 hours
  • IIb (angulation with rotation)
    • Gentle reduction by anterior push on distal fragment as elbow flexed to 90 degrees and admit under ortho
  • Consult orthopaedics and observe overnight with likely f/u in ortho in 1 week with repeat X-ray

• Gartland type 3 – Grossly displaced/rotated with no cortical contact
  • Check for open or neurovascular compromise
  • Brachial artery often involved – check radial pulse frequently (15% of cases have vascular injury)
  • Risk of compartment syndrome
  • If orthopaedics not available within 1 hour, traction and reduction under sedation to maximise radial pulse is indicated
  • Check median/radial nerves also
  • Splint in extension if grossly swollen

Supracondylar fracture

• 15% of displaced fractures have nerve injury
  • Mostly anterior interosseous branch of median nerve
    • Supplies deep muscles of forearm (FPL, lateral half of FDP and pronator quadratus)
  • Must test all nerves of forearm/hand
• Screening tests
  • Okay sign: Need visible flexion of DIP of index finger (FDP) and IP joint of thumb (FPL) to confirm anterior interosseous branch of median nerve intact
  • Benediction sign: Ask child to make fist but cannot flex thumb IP or index finger
  • Thumbs up: To fully extend thumb need intact EPL (radial nerve)
  • Starfish sign: To fully abduct all digits need intact ulnar nerve (DAB)
  • Cross fingers over one another: Again need intact ulnar nerve (DAB and PAD)
• Do not attribute failure to do these to pain alone

• Who needs urgent ortho consult:
  • Absence of radial pulse
  • Ischaemia of hand
  • Severe swelling in elbow/forearm
  • Skin puckering or anterior bruising
  • Open injury
  • Neurological injury
  • Associated same arm forearm/wrist injuries
  • Flexion supracondylar fractures
• If pulseless hand
  • If cool and pale need emergency OT for reduction and K wires +- vascular involvement
  • If warm and pink hand – urgent but not emergent

• Patients less than 3yo
  • Do not yet have capitellum ossification
  • Appears as dislocated elbow but is actually physeal separation of humerus (Salter-Harris type 1)
  • True elbow dislocation in this age group is very rare

• Intercondylar (T) fracture
  • Occurs in adolescents with axial impaction
  • Intra-articular separation of capitellum and trochlea and disruption of medial and lateral distal humeral columns
  • Operative

Lateral condylar fracture

• Lateral condyle
  • Second-most common elbow fracture in children (15-20% of elbow #)
  • 6-10yo (peak at 6yo)
  • Can frequently look benign clinically and get missed with poor outcomes
  • Varus force on supinated forearm, avulsing the condyle
  • Usually Salter-Harris type 4 but late appearance of trochlear and lateral epicondylar ossification centres, means often missed on X-ray (especially in younger children)
    • Ossification centre of lateral condyle arises at 18mo to 2 years
    • Ossification centre of lateral epicondyle arises at 11-13 years

• Milch type 1
  • Fracture line goes through capitellar ossification centre (laterally)
  • Salter-Harris IV equivalent
• Milch type 2  (most common)
  • Fracture line runs medial to the capitellar ossification centre
  • Salter-Harris II equivalent
• If uncorrected, leads to valgus deformity and delayed ulnar nerve palsy with arthritis

• Treatment
  • All require orthopaedic review
  • Any lateral condyle fracture with >2mm separation or any angulation is likely to require ORIF
  • All young children with major elbow swelling/deformity should all be assessed by orthopaedics as may require USS/MRI/arthrography
  • Place in splint of some description while awaiting orthopaedics
  • Undisplaced can be placed in above elbow backslab at 90 degree flexion and supported in sling with fracture clinic follow-up
  • Minimally displaced (<2mm) can either be placed in slab or pinned
• Infants
  • May suffer lateral humeral condyle separation as Salter-Harris type 1 fracture
  • Difficult to see radiologically but grossly swollen and tender laterally
  • History must explain varus force, NAI must be considered and USS may be required

Medial epicondylar fractures

• Medial epicondylar avulsion
  • 50% are associated with elbow dislocation
  • Medial condylar fracture are very rare (<1%) vs. medial epicondylar (5-10% of all elbow fractures in children)
  • Origin of common flexor tendon and ossifies at around age 6, fusing at age 14-17yo
  • Therefore, does not occur in children <5yo
  • This is an avulsion injury from common flexor origin
  • Will usually reunite with humerus if <5mm separation unless interposing tissue
  • Ulnar nerve injury is common
  • W.r.t. CRITOE, there should not be a trochlear ossification centre without one in the medial epicondyle and if seen, suggests an intra-articular medial epicondylar fracture segment
    • If closed reduction is performed of an elbow joint, always check post-reduction X-ray for trapped medial epicondyle fragment

• Treatment
  • <5mm displacement
    • Above elbow backslab 90 degrees flexion for 3 weeks. Fracture clinic f/u then collar and cuff for 3 weeks
  • 5-15mm displacement – Ortho referral
    • Closed vs. open depends on age, dominance and sporting ability
  • >15mm displacement (with elbow dislocation) – Ortho referral
• Who needs urgent ortho consult?
  • Displacement >15mm
  • Medial condyle fracture (i.e. intra-articular)
  • Associated with elbow dislocation
  • Entrapment of medial epicondyle fragment in joint

Medial condylar fractures

• Very rare
• Intra-articular and need urgent ORIF

Pulled elbow

• Pulled elbow
  • Above 6 months with disuse of one arm, held in semi-flexed and pronated position with hx of pulling
  • Should be point tender over radial head and no palpable elbow effusion (compared to other side)
  • Oval shape of radial head allows slight subluxation through annular ligament when forearm pulled in pronated position
  • Unusual if over 5 yo

• Reduction
  • Hyperpronation most likely to succeed and less painful
  • Oral or intranasal analgesia necessary prior
  • Hold thumb over radial head
  • If fails, consider repeating and/or full, firm supination and flexion technique
  • If still fails, repear history and exam + consider X-ray and/or USS
  • If no alternative diagnosis, put in sling in neutral position and review in 24-48 hours (most will spontaneously reduce)
  • Persistent dysfunction >48 hours requires orthopaedic review

Elbow dislocation

• From adolescence onwards
• Results from FOOSH with partially flexed elbow
• Younger children sustain supracondylar fractures
• Mostly posterior dislocations +- coronoid/radial neck/medial epicondyle #
• Median and ulnar nerves at risk
• Reduce in ED under sedation with gentle downwards pressure applied to supinated proximal forearm with extension of elbow to 135 degrees against distal humerus counter-traction
  • Full extension risks ulnar nerve injury
• Place in flexed above elbow POP and arrange orthopaedic follow-up

Olecranon fractures

• Olecranon fractures
  • Occur in older children in one of three patterns:
    • 1) Avulsion (flexion) fractures (ORIF)
    • 2) Extension fractures with intra-articular opening (may be stable in flexion)
    • 3) Comminuted from direct blow
  • Ossification centre appears around age 10 and may be fragmentary (easily confused)
  • Most common error is missed radial head dislocation (Monteggia variant), lateral condyle #, radial neck # or supracondylar #
    • Always assess radiocapitellar line
  • Treatment
    • Isolated/undisplaced – Above elbow backslab at 90 degrees flexion and # clinic
    • Displaced, unstable and combined – Above elbow backslab at 90 degrees and consult

Radial head fractures

• Rare in children. More often physis or radial neck (metaphysis)
• More common in older teenagers
• 35% have associated injuries: LCL, MCL, DRUJ disruption, interosseous membrane disruption, Coronoid/olecranon fracture, elbow dislocation, terrible triad (elbow dislocation, radial head fracture, coronoid fracture), carpal fractures
• Evaluate for mechanical blocks (may require elbow aspirate and local infiltration)
• Test collateral ligaments, wrist, interosseous membrane
• Management
  • Sling and early ROM for isolated minimally displaced fractures with no mechanical blocks
  • ORIF for rest

Radial neck fractures

• Associated injuries in 50% including medial epicondyle avulsion, olecranon fracture or proximal ulna or elbow dislocation
• May be subtle ‘torus’ breaking of the neck (best seen on lateral side on lateral view) to displaced fractures
• Localised tenderness should raise suspicion
• Posterior interosseous nerve (finger extension) injury must be sought
• Check interosseous membrane (radius pull test) and wrist for associated injuries
• Risk of forearm compartment syndrome

• Treatment
  • Isolated, <10 % translation, <30 degrees angulation and <10yo
    • Above elbow backslab at 90 degree flexion with sling and # clinic f/u
  • All other fractures require orthopaedic review (as you can see this includes every child >10yo as minimal remodelling capacity and any angulation may be significant
• Need to be seen in fracture clinic soon as healing occurs rapidly and closed reduction becomes difficult after 5 days. Many have missed injuries around the elbow

Monteggia fracture-dislocation

• Peaks age 4-10
• Dislocation of radial head (proximal radioulnar joint) with fracture of ulna
• Missed radio-capitellar disruption has SEVERE ramifications and is common!
  • If ulna fracture is present, always look for radial head dislocation
• Always X-ray elbow for wrist injuries
• Must assess radio-capitellar line AND normal straight posterior ulna border on lateral view
• Radial nerve is the most commonly injured (10-20%)
  • Usually a neurapraxia treated expectantly
  • May be posterior interosseous nerve injury (lies near radial head)

• Bado type 1 (70%)
  • Anterior displacement of radial head with angulated apex-volar ulnar shaft fracture
• Bado type 2 (5%)
  • Posterior displacement of radial head with angulated apex-dorsal ulnar shaft fracture
• Bado type 3 (25%)
  • Laterally displaced radial head with fracture of ulnar metaphysis
• Bado type 4 (rare)
  • Anterior dislocation of radial head with fracture of diaphysis of radius and ulna
• Monteggia equivalent
  • Proximal radial fracture/dislocation with bowing deformity of ulnar shaft must be sought (easily missed!)
• Aim of treatment is reduction of radial head and all require urgent orthopaedic review with reduction in OT for most
• Delayed diagnosis with complex management and poor outcomes is the most common complication!

Galeazzi fracture-dislocation

• Often missed and difficult to recognise (most often missed injury with distal radius #)
  • If distal radius fracture ALWAYS look at the DRUJ. REFER ALL SUSPECTED GALEAZZI
• Radial shaft distal third fracture with distal radioulnar disruption
• Volar – Volar displacement of ulna
• Dorsal – Dorsal displacement of ulna

• Always look at the ulnar styloid
  • If not pointing at the triquetrum in all views = subluxation/dislocation of DRUJ
• Mostly managed with closed reduction under fluoroscopy to assess stability of DRUJ
  • Adolescents generally need ORIF or K –wires to stabilise the DRUJ

Galeazzi equivalent

• Distal radius fracture with distal ulna physeal fracture without displacement of distal radioulnar joint
• Much more common in children than
  true galleazi

Midshaft radial and ulnar fracture

• Greenstick
  • Only convex side of cortex is broken
• Plastic deformation (bowing)
  • Usually require GA/orthopaedics due to prolonged corrective forces necessary
  • Bowing fractures often missed and mostly seen with ulna – check for straight posterior border on lateral view
• Complete fractures
  • Difficult to reduce, requiring internal fixation in 5-10%
• Single radial shaft fracture often associated with DRUG injury (Galleazi)
• Single ulnar shaft fracture often associated with proximal radial head dislocation (Monteggia)

• Reduction
  • Apex volar – pronate forearm, wrist traction and volar pressure
  • Apex dorsum – Supinate forearm, wrist traction and dorsal pressure
• Inherent instability makes 3-point moulding, straight ulnar border and interosseous moulding necessary
• Above elbow backslab required with interosseous moulding, 3-point moulding, mid-prone position, 90 degree elbow flexion
• Consider admitting overnight for observation to monitor for compartment syndrome

Proximal third radial shaft fractures

• Who needs reduction?
  • <10yo: >10 degrees angulation
  • >10yo: Anatomic reduction with internal fixation recommended for all
  • As girls mature earlier, acceptable angulation may be less for them
  • Up to 45 degrees rotation is acceptable, but get orthopaedic opinion as rotation is difficult to assess radiologically

Mid and distal third radial shaft fractures

• Who needs reduction?
  • <5yo: >20 degrees angulation
  • <10yo: >15 degrees angulation
  • >10yo: >10 degrees angulation
  • Any rotational deformity requires orthopaedic opinion (can have up to 45 degrees but difficult to quantify on X-ray)

Distal radial/ulnar fractures

• May be metaphyseal or epiphyseal
• Dorsal angulation in 80%
• Metaphyseal fractures have peak incidence in adolescent growth spurt due to weakening of metaphysis
• 13% incidence of other arm injuries
• Occur with proximal forearm fractures including Monteggia, supracondylar humeral fractures and hand fractures
• Minimally displaced complete metaphyseal fractures can resemble buckle fractures but management is very different
• Buckle injuries often misdiagnosed as wrist ’sprains’

Distal radial/ulnar metaphyseal fractures

• Simple torus (buckle) fractues
  • No periosteal or cortical breach. Occurs through compression injury
  • Can be placed in forearm splint or brace for 3 weeks. No F/U required.
  • Check cortices intact on AP and lateral
• Undisplaced greenstick or complete
  • A single cortex or periosteum breached (greenstick)
  • Inherent instability and potential for further deformation
  • Well-moulded, three-point fixated below-elbow plaster in neutral position and ortho follow-up
• Angulated or displaced greenstick fractures
  • Require reduction (see table)
  • 3-point moulding with slight wrist flexion (if dorsal apex angulation) or extension (if volar apex angulation)
  • Below elbow for older children but above-elbow in younger children

• Angulated or displaced isolated radial fractures
  • Closed reduction with immobilisation in below-elbow cast for 6 weeks with # clinic f/u
  • For young children, above elbow-cast preferred
• Fractures of radius and ulna with complete displacement and shortening
  • Reduction and above elbow cast
  • 10% will lose reduction. Must be followed-up closely
  • Speak to Orthopaedics

Distal radius/ulna fractures

• Who needs reduction of distal radius?
  • 0-5yo: >20 degrees angulation
  • 5-10yo: >15 degrees angulation
  • 10-15yo: >10 degrees angulation
  • Bayonet apposition (side-by-side vs. end-to-end)
    • Acceptable up to age 6 as long as angulation acceptable as per above
    • If 6-11yo ask ortho after attempted reduction
    • If >11yo, must have proper apposition
  • Coronal plane angulation is less well tolerated
  • As always, girls mature earlier and may have lower acceptable angulations at the same ages

Distal radius physeal fractures

• Salter-Harris injuries
• May be isolated or associated ulnar greenstick/physeal or styloid fractures
• Check median nerve fx
• Peaks at pre-adolescent growth spurt
• Uncommon under 5yo
• Salter-Harris I: Dx on focal tenderness. Minimal signs on X-ray. 
• When is reduction required?
  • Angulation >20 degrees (on lateral) needs reduction
  • Less acceptable if <2 years of bone growth remaining
  • More angulation allowed if <8yo
  • If presents >5 days, DO NOT reduce in ED. D/W ortho as causes physeal damage

Distal radial physeal fractures

• Management
  • Salter-Harris I and II – Undisplaced: Below elbow backslab or removable splint for 4 weeks and # clinic
  • Type I and II – Displaced: Closed reduction if angulation >20 degrees (see previous slide) and below elbow cast (above elbow in younger children) with three-point moulding and slight flexion (if dorsal apex) or slight extension (if volar apex)
  • Type III and IV – All: Splint and refer to ortho

Distal radial epiphyseal fractures

• Treat as for metaphyseal fractures
  • Manipulation and closed reduction
• Very low incidence of subsequent premature physeal closure
  • Risks include repeated/delayed manipulation, compressive injuries or distal physeal separation of ulna
  • Refer to fracture clinic for early review as manipulation of physis is contraindicated after 7 days
• Salter-Harris III injuries have moderate risk of growth disturbance
• Salter-Harris IV and V have high-risk of growth disturbance

Carpal injuries

• Very rare under 8yo due to flexibility of wrist and plastic properties of pre-ossified bone
• Scaphoid injuries are overdiagnosed
  • 65% of actual scaphoid fractures are distal pole with very low rares of non-union
  • Risk rises through adolescence
  • Scaphoid views suggested in older children if:
    • >10yo
    • High-velocity injury
    • Single-point tenderness and swelling over scaphoid dorsally and volar (more specific)
    • Pain to compression along first metacarpal ray
    • Kirk-Watson test positive (pain/clunk in scaphoid/scapholunar ligament on passive radial deviation of wrist)
• If suspected, place in scaphoid cast and refer to fracture clinic

Metacarpal fractures

• Must ensure no rotational deformity
• Isolated metacarpal fractures will not cause malrotation
• Isolated metacarpal neck fractures should be treated with buddy strapping

Phalangeal fractures

• Salter-Harris 2 at base of first phalanx may cause radial/ulnar angulation
  • Correct with traction
• May be subtle on X-ray
• All intra-articular, open or oblique (unstable) fractures need orthopaedic referral

Thumb fractures

• Forced thumb abduction can cause proximal thumb physis avulsion (Salter-Harris type 3 vs. adult-type UCL tear) or metaphyseal fracture of base of first metacarpal
• The SH3 injury needs orthopaedic referral as needs ORIF
• Metaphyseal fracture is allowed significant angulation and displacement if under 10 due to universal motion and remodelling capability
  • Place in scaphoid plaster and refer to fracture clinic

Last Updated on November 10, 2021 by Andrew Crofton