FEATURE

Pediatric Upper-Extremity Fractures

Rajan Arora, MD; Utkarsh Fichadia, MD; Earl Hartwig, MD; and Nirupama Kannikeswaran, MD

Abstract
Upper-extremity fractures account for
more than half of childhood bony injuries.
The frequency of injury increases with
increasing mobility. The most common
mechanism is a fall on an outstretched
hand while playing. Optimal management
requires knowledge of the normal anatomy
and variants unique to pediatric bones.
The physician needs to maintain a high
level of suspicion for growth plate injuries
because if unrecognized, these may result
in growth arrest. Although the vast major-
ity of pediatric upper-extremity fractures
will heal rapidly with minimal intervention,
physicians should be aware of the compli-
cations that can arise from these injuries.

Rajan Arora, MD, is a Pediatric Emergency

Medicine Fellow, Carman and Ann Adam Depart-
ment of Pediatrics, Childrens Hospital of Michi-
gan. Utkarsh Fichadia, MD, is a Pediatric Emer-
gency Medicine Fellow, Carman and Ann Adam
Department of Pediatrics, Childrens Hospital of
Michigan. Earl Hartwig, MD, is Associate Profes-
sor of Pediatrics and Emergency Medicine, Car-
man and Ann Adam Department of Pediatrics,
Childrens Hospital of Michigan. Nirupama Kan-
nikeswaran, MD, is Associate Professor of Pediat-
rics and Emergency Medicine, Carman and Ann
Adam Department of Pediatrics, Childrens Hos-
pital of Michigan.
Address correspondence to: Rajan Arora, MD,
Carman and Ann Adam Department of Pediat-
rics, Division of Emergency Medicine, Childrens
Hospital of Michigan, 3901 Beaubien Boulevard,
Detroit, MI 48201; email: rarora@dmc.org.
Disclosure: The authors have no relevant fi-
Shutterstock

nancial relationships to disclose.

doi: 10.3928/00904481-20140417-12

196 | Healio.com/Pediatrics PEDIATRIC ANNALS 43:5 | MAY 2014


C
hildhood injuries account for
more than 10 million annual
visits and are the second lead-
ing cause for visits to primary care of-
fices and the emergency department.1,2
Fractures make up around 10% to 25%
of these musculoskeletal injuries. Almost
two-thirds of all boys and nearly half of
all girls will have had sustained a fracture
by 15 years of age, with a peak incidence
for fractures of age 14 years for boys and
11 years for girls.3,4 In children, fractures
tend to occur more frequently in the up-
per extremity in comparison to the lower
extremity.5 The distal radius is the most
frequently fractured bone. This, along
with fracture of metacarpals and phalan-
ges, accounts for 50% of all fractures.3,6
With children and adolescents ever-
increasing participation in sports, it is
likely that primary care physicians will
increasingly encounter patients with
upper-extremity injuries. This article
discusses the commonly encountered
upper-extremity fractures in children.
Common mechanisms of injury, fracture
type and classification, possible compli-
cations, and current principles of their
management are reviewed.
KEY ASPECTS OF PEDIATRIC BONE
The skeletal anatomy of a child varies
considerably from that of an adult in sev-
eral important ways. The pediatric bone
is less dense, more porous, and has a
lower mineral content. Being more elas-
tic and pliable, it can undergo a greater
degree of deformation before breaking.
Hence, both greenstick and torus frac-
tures are seen almost exclusively in the
pediatric population. Increased porosity
prevents fracture propagation, thereby
resulting in a lower incidence of com-
minuted fractures in children. However,
since the tensile strength of pediatric
bone is lower than that of the ligaments,
fractures are more common than sprains.
The two key attributes of imma-
ture skeleton are presence of growth
plate and thick periosteum. The growth
PEDIATRIC ANNALS 43:5 | MAY 2014
FEATURE
A B
Figure 1. (A) Buckle fracture of the distal radius. (B) Plastic deformation of the ulna. (C) Greenstick frac-
ture of the radius. (D) Salter II fracture of the distal radius.
plates are located at the ends of the
long bones and are responsible for con-
tinued longitudinal growth. In younger
children, fractures closer to a growth
plate have great remodeling potential,
as the physis of a bent bone will grow
eccentrically to help restore alignment
over time. Depending upon age, re-
modeling can correct varying degrees
of displacement and angulation but
not axial malrotation. The periosteum
in children is much thicker, stronger,
and has a greater osteogenic potential.
It provides stability, acts as a restraint
to displacement, preserves the vascular
supply, maintains reduction, and allows
for faster fracture healing.
CLASSIFICATION OF PEDIATRIC
FRACTURES
Pediatric fractures can be broadly
classified into five types: plastic de-
formation, buckle fracture, greenstick
fracture, complete fracture, and phy-
seal injury (Figure 1). Plastic deforma-
tion is essentially unique to children
and most commonly involves the ulna.
Plastic deformity occurs from longitu-
dinal stress and results in bowing of the
bones, with a completely intact perios-
teum. No fracture line is visible radio-
graphically. Buckle or torus fracture,
also a primary childhood injury, results
from axial loading on an extremity and
Images courtesy of Rajan Arora, MD.
C D
occurs at the junction of the metaphysis
and diaphysis. Acute angulation of the
cortex is noted as opposed to the usual
curved surface, resembling the torus or
base of a classical Greek pillar. This is
best seen on the antero-posterior view
and not on the lateral view of a radio-
graph. Greenstick fractures are incom-
plete fractures that result from a bend-
ing force perpendicular to the shaft of a
long bone, much like a green twig when
it is bent. The side under the force re-
mains intact but gets bent, whereas the
cortex opposite the bending force frac-
tures completely. Complete fractures
are those that propagate completely
through a bone. They can be spiral,
oblique, or transverse fractures.
The physis, also known as the
growth plate, is an area unique to pe-
diatric bone. The physis is the transition
zone at the end of the long bones in the
body between the metaphysis and the
epiphysis. Physeal fractures make up
15% to 25% of the pediatric fractures,
with a peak incidence in the adolescent
age group.7 The distal radial physis is
the most frequently injured physis.8
Growth plate injury should be suspected
if point tenderness is noted over a phy-
sis regardless of presence or absence of
radiographic findings. Depending upon
the pattern, the physeal injuries are usu-
ally classified into five categories by the
Healio.com/Pediatrics | 197
 FEATURE

TABLE 1.
obese and overweight children tend to
fall more during daily activities as a
Sensorimotor Assessment of Common Upper-Limb Nerves result of difficulty with balance. Envi-
Nerve Sensory Motor ronmental modifications have not been
Radial Dorsum of first web space Thumbs-up sign
shown to lower the risk of fractures in
obese children, and the only reduction in
Ulnar Volar aspect of little finger Make a star
fracture risk was achieved by attaining a
(Spread fingers wide)
healthy body weight.13
Median Volar aspect of index finger Make a fist with thumb flexion
The role of vitamin D in maintaining
Anterior Interosseus No sensory function OK sign (Making a circle with the
patients bone health, as well as fracture
thumb and index finger)
healing and prevention of future frac-
tures, is well known. In a recent study
TABLE 2. by James et al.,14 hypovitaminosis D was
common among children with upper-
Common Upper-Extremity Splints and Their Indications
extremity fractures. In their study cohort
Splint Indications of 181 patients, 64% had low vitamin D
Volar/Dorsal Soft tissue injuries to hand and wrist, carpal bone fractures (excluding levels, with African-American children
scaphoid/trapezium), and distal radius buckle fracture. being more likely to have an insufficient
Thumb Spica Scaphoid, non-displaced first metacarpal, and stable thumb fracture. or deficient level.
Radial Gutter Non-displaced/non-rotated fractures of second and third metacarpal or Repetitive stress may result in frac-
corresponding proximal/middle phalangeal shaft fractures. tures due to overuse and fatigue of the
Ulnar Gutter Non-displaced/non-rotated fractures of fourth and fifth metacarpal or surrounding musculature. Though less
corresponding proximal/middle phalangeal shaft fractures. prevalent than lower-extremity stress
Sugar Tong Acute distal radial and ulnar fractures. fractures, upper-extremity stress frac-
Long Arm Distal humeral, proximal/midshaft forearm fractures, and non-buckle tures are now being more frequently
Posterior wrist fractures. recognized. Common examples include
Aluminum Distal phalangeal fractures. Little Leaguer shoulder and gym-
U-Shaped Splint nast wrist, which are a chronic Salter-
Buddy Taping Stable, non-displaced, non-angulated shaft fractures of the proximal or Harris type I injury to the physis of the
middle phalanx. proximal humerus and distal radius,
respectively. Pediatricians should offer
nutritional counseling and discuss the
Salter and Harris classification system.9 but it is important to recognize physeal importance of appropriate training and
Type I injuries extend through the phy- fractures as any damage to the growth conditioning prior to and during sports
sis. Type II fractures extend through the plate can result in progressive angular participation to avoid these fractures.
physis and exit through the metaphysis. deformity, limb-length discrepancy, or
They are the most common and repre- joint incongruity. INITIAL ASSESSMENT
sent approximately 50% of all growth- Accurate diagnosis of musculoskel-
plate fractures in children.10 Type III RISK FACTORS etal injuries in children warrants a sys-
begins in the physis and exits through In otherwise healthy children, skel- tematic approach. A detailed history,
the epiphysis intra-articularly. Type IV etal fragility is often attributed to low comprehensive physical examination,
injury traverses through the physis, me- peak bone mass. Several independent and a good understanding of sport bio-
taphysis, and epiphysis. Type V involves risk factors like genetic constitution, mechanics are vital adjuncts in mak-
crush injury to the physis and carries birth weight, poor nutrition, and low ing the correct diagnosis and planning
the worst prognosis. Salter-Harris III to socio-economic status may influence appropriate management. A pertinent
V fractures have a higher incidence of fracture risk in children. Whiting11 and history should include mechanism of
growth disturbance, as the likelihood of Goulding et al.12 showed that obesity injury, direction and magnitude of the
growth arrest is directly related to the in childhood and adolescence reduces force, prior injuries, or any associated
severity of physeal injury. Usually the bone mineral density with an increased symptoms. All splints and bandages
growth plate repairs well and rapidly propensity for fractures. Furthermore, must be removed to ensure a thorough

198 | Healio.com/Pediatrics PEDIATRIC ANNALS 43:5 | MAY 2014


examination of the injured extremity.
Ensure appropriate analgesia, as it will
make the child comfortable and comply
with the examination. It is imperative to
examine the entire limb as well as assess
the joint above and below the injury for
range of motion, stability, or concomi-
tant injuries.
While performing an upper-extrem-
ity examination, attention should be
paid to the clavicle, scapula, and shoul-
der. One should assess for any swelling,
deformity, open wound, area of maxi-
mal tenderness, and active and passive
range of motion. Finally, it is important
to assess the distal neurovascular status
of the limb. In younger children, motor
and sensory assessment can be done by
asking them to copy simple movements
and touching areas reliably supplied by
each nerve (Table 1). Plain radiographs
are the mainstay of the diagnosis. Frac-
tures should be described in terms of
location, displacement, separation,
shortening, and presence of angular
or rotational deformities. Further im-
aging, such as computed tomography
(CT) scans, may be necessary to plan
operative intervention for intra-articu-
lar displacements. A bone scan or mag-
netic resonance imaging (MRI) may be
needed occasionally to confirm the di-
agnosis of a stress fracture.
BASIC PRINCIPLES OF FRACTURE
MANAGEMENT IN CHILDREN
Bone healing in children is usually
rapid and inversely related to the age of
the patient. Further, greater remodeling
potential and abundant callus formation
lessens the likelihood of long-term com-
plications in childhood fractures. There-
fore, conservative treatment including
pain control, immobilization in a splint
or cast, and return of activity in accor-
dance with the patients symptoms suf-
fices in the majority of common upper-
extremity fractures.
Splinting may be accomplished us-
ing plaster, pre-padded casting material,
PEDIATRIC ANNALS 43:5 | MAY 2014
FEATURE
A B
Figure 2. (A) Midshaft clavicle fracture with overriding. (B) Healing clavicle fracture with surrounding callous.
or prefabricated and over-the-counter
splints. In general, six to 10 sheets of
plaster material over appropriate pad-
ding especially over bony promi-
nences are recommended for upper-
extremity injuries. Splints should be
non-circumferential, somewhat loose,
and applied in a position of function.
Commonly used upper-extremity splints
and their indications are listed in Table
2. Although some angulation is accept-
able depending upon patients age, the
fracture should not be malaligned or
malrotated. In most cases, 15 to 20 de-
grees of volar/dorsal angulation in the
sagittal plane in a skeletally immature
child is deemed acceptable.15,16 Marked
bowing should usually be corrected
by completing the fracture and restor-
ing alignment. For displaced fractures,
closed reduction and immobilization in
a cast can be achieved under procedural
sedation. Open fracture warrants broad-
spectrum antibiotics and tetanus vacci-
nation. Immediate orthopedic evaluation
is indicated for fractures that are unsta-
ble, open, or associated with neurovas-
cular compromise.
CLAVICLE FRACTURES
Clavicle fractures are the most com-
mon of all pediatric fractures. They may
be seen in newborns as a result of birth
trauma, or in children and adolescents
following a fall on an outstretched hand
(FOOSH) or shoulder, or a direct blow
to the bone. An overwhelming majority
(80% to 85%) occur in the middle one-
third of the bone (Figure 2). In younger
children, these fractures are typically
greenstick and may go unnoticed until
a large callus forms.17 In older children,
the fracture is usually displaced and as-
sociated with lowering of the affected
shoulder, point tenderness, swelling,
obvious deformity, and/or ecchymosis
at the fracture site. Shoulder movements
across different planes usually exac-
erbate the pain. X-rays with dedicated
clavicle views can accurately diagnose
most clavicle fractures. However, one
should be aware that clavicle views are
different from routine shoulder films.
The majority of clavicle fractures will
heal uneventfully and are managed using
a simple sling for 2 to 3 weeks, primar-
ily for pain control. When compared to
a figure-of-eight splint, a sling is more
comfortable, less cumbersome to put
on, causes fewer skin problems, and has
similar outcomes. Indications for opera-
tive intervention include open fractures,
complicated comminuted fractures, and
fractures with neurovascular compro-
mise or greater than 100% displacement
(width of the clavicle) where skin is tent-
ed or its integrity is threatened.18 Parents
should be informed that a callus bump at
the fracture site is part of the natural heal-
ing process and will become less distinct
as the bone remodels over the next 6 to 12
months. Complications, though rare, may
include brachial plexus injury, pneumo-
thorax, and airway compromise. Healing
usually happens over 6 to 18 weeks, with
average return to non-contact sports in 4
to 6 weeks followed by return to contact
sports when there is no pain over the frac-
ture site, full pain-free range of move-
ments, and normal strength.
Healio.com/Pediatrics | 199
 FEATURE
A B C is pathognomonic of abuse (Figure 3B).
Figure 3. (A) Displaced fracture through the neck of humerus. (B) Humerus shaft fracture with overrid-
ing. (C) Pathologic proximal humerus fracture through a bone cyst.
TABLE 3. TABLE 4.
Ossification Centers of the Gartlands Classification of
Pediatric Elbow Supracondylar Fractures
Age of
Appearance Type I Non-displaced.
Ossification Center (years)
C = Capitellum 1 most common.
Type II Partially displaced with
R = Radial Head 3
intact posterior cortex.
I = Internal (Medial) 5
Epicondyle
T = Trochlea 7
Type III Completely displaced with
O = Olecranon 9 no contact between frac-
tured segments.
E = External (Lateral) 11
Epicondyle
Adapted from Beatty and Kasser22 and Green23 Adapted from Gartland24
HUMERUS FRACTURES be subtle or absent and may include
Proximal humerus fractures are a swelling, bruising, and/or an obvious
common injury in children that peaks deformity in more severe injuries. Injury
during adolescence secondary to in- to the axillary nerve should be excluded
creased sports participation. It compris- by carefully assessing deltoid function
es of both physeal and metaphyseal frac- and sensation over the lateral aspect of
tures (Figure 3A). The most common the proximal humerus. Standard shoul-
mechanism of injury is a FOOSH or a der radiographs are diagnostic. These
hit directly at the proximal humerus. Al- fractures carry an excellent prognosis
though less common than clavicle frac- as a result of the abundant remodeling
tures, this type of fracture may be seen in potential of the proximal humerus. Most
neonates secondary to birth trauma. The can be managed by immobilization with
patient usually presents with pain local- a simple sling, or a coaptation splint for
ized to the proximal humerus and/or the more severely displaced fractures,
anterior shoulder or, in newborn cases, for approximately 3 to 4 weeks. Surgi-
pseudoparalysis. Physical findings could cal intervention is required for associ-
200 | Healio.com/Pediatrics
ated neurovascular injuries, open, and/
or intra-articular fractures, or severely
angulated fractures in older children and
adolescents. Complications are quiet
rare and include axillary nerve/brachial
plexus injury (typically neuropraxia),
avascular necrosis, and malunion.
Humeral metaphysial/shaft fractures
in the absence of significant trauma (eg,
motor vehicle accident, fall from height)
should raise the suspicion of abuse, al-
though neither age nor fracture pattern
Physicians should also consider patho-
logic fracture, as the humerus is a com-
mon site for bone cysts and other benign
lesions (Figure 3C).19 These fractures
also have an enormous remodeling po-
tential; hence, the majority are treated
with immobilization in a coaptation
splint for 3 to 4 weeks and rarely require
surgical intervention. Complications are
rare, with radial nerve injury being the
ELBOW FRACTURES
Elbow fractures in children are quite
common and represent approximately
10% to 12% of all pediatric fractures.20,21
Unlike fractures of the clavicle or proxi-
mal humerus, elbow fractures are more
likely to require precise, often surgical,
reduction.
Diagnosis of pediatric elbow frac-
tures can be challenging, as this requires
distinguishing normal ossification cen-
ters from fractures in a radiograph. Ap-
plying the mnemonic CRITOE, which
refers to the sequence of appearance
of six secondary ossification centers at
the elbow (Table 3), can help pediatric
providers with this.22,23 However, one
should be aware that these ages are ap-
proximations, and these injuries often
occur somewhat earlier in girls.
Supracondylar Fractures
Supracondylar fractures account for
60% to 80% of all pediatric elbow frac-
tures.5 They occur primarily during the
PEDIATRIC ANNALS 43:5 | MAY 2014
 FEATURE

first decade of life, with a peak incidence

at around 5 to 7 years of age. The most
common mechanism is a FOOSH injury
with hyperextension of the elbow (eg,
a fall off the monkey bars). The child
usually presents with a swollen painful
elbow and limited range of motion and
may have an obvious deformity. Signifi-
cant ecchymosis is considered a risk fac-
tor for forearm compartment syndrome.
A B C
Due to its potential to injure the brachial
artery, as well as the radial, median, and/ Figure 4. (A) Type I supracondylar fracture showing anterior fat pad (sail sign) and posterior fad pad sign
with normal anatomic alignment of anterior humeral line (black line). (B) Type II posteriorly displaced
or ulnar nerve, a thorough neurovascu- supracondylar fracture with large effusion. (C) Type 3 supracondylar fracture with severe and complete
lar assessment should be performed in displacement of the distal segment.
all patients with a suspected or known
elbow fracture. Standard elbow radio-
graphs, including an anteroposterior
(AP) view in extension and a lateral
view at 90-degree flexion, are sufficient
in making the diagnosis. On a lateral
radiograph, the classic figure-of-eight
appearance of the distal humerus and
the anterior humeral line should always
be assessed. In a normal elbow, a line
drawn along the anterior cortex of the
A B C D
humerus should bisect the middle third
of the capitellum, whereas in the case of Figure 5. (A) Transverse fracture through lateral condyle and epicondyle with displaced capitellum. (B)
Fracture of the medial epicondyle. (C) Fracture of the radial head. (D) Avulsion fracture of the olecranon.
a supracondylar fracture, the capitellum
is generally displaced posterior to this
line. In absence of a clear fracture line, clude neurovascular injuries, compart- tellum (Figure 5A). Treatment is usu-
subtle signs like presence of a posterior ment syndrome, Volkmanns ischemic ally surgical. The articular nature of the
fat pad or a large, triangular sail-shaped contractures (contracture deformities of fracture and often delayed diagnosis re-
anterior fat pad are indicative of an intra- the fingers, hand, and wrists), and cubi- sult in a high incidence of malunion and
articular joint effusion with an associat- tus varus (angular gunstock deformity). nonunion with this injury.
ed fracture. Supracondylar fractures are
classified on the basis of the degree of OTHER ELBOW FRACTURES Medial Epicondyle
displacement of the fractured distal frag- Lateral condyle Medial epicondyle is the third most
ment (Figure 4, Table 4).24 The lateral condyle is the second common pediatric elbow fracture. It is
Type I non-displaced supracondylar most common elbow fracture and results usually seen in children between the
fractures can be treated in a long-arm from a FOOSH mechanism. Examina- ages of 9 and 14 years and frequently
cast for approximately 3 to 4 weeks. tion findings reveal a swollen elbow, encountered in baseball pitchers. The
Type II and Type III fractures are mostly possible localized lateral tenderness, and mechanism of injury is a valgus stress,
managed surgically with closed reduc- decreased range of movement. The frac- and about half of cases are associated
tion and percutaneous pin fixation. In ture may not always be appreciated on with dislocation of elbow. Examina-
case of suspected vascular compromise, initial radiographs, as it occurs through tion findings include a swelling and
the patient should be taken immediately an area that may be only partially ossi- tenderness over the medial epicondyle
to the operating room for fracture reduc- fied. Radiographic findings may include and weakness in the flexor-pronator
tion. Supracondylar fracture carries one the presence of a posteriorly displaced muscle group. Imaging for epicondylar
of the highest complication rates of any metaphysial fragment or disruption of fractures includes AP and lateral radio-
pediatric fracture.25 Complications in- the radial head alignment with the capi- graphs (Figure 5B). Non-displaced and

PEDIATRIC ANNALS 43:5 | MAY 2014 Healio.com/Pediatrics | 201


A B
Figure 6. (A) Transverse fracture of the radial metadiaphysis. (B) Fracture of both bones of the forearm.
(C) Monteggia fracture characterized by proximal ulnar fracture with radial head dislocation. (D) Gale-
azzi fracture depicted by distal radial fracture with disrupted distal radio-ulnar joint.
A B
Figure 7. (A) Fracture through waist of the scaph-
oid bone. (B) Fracture through shaft of the 5th
metacarpal (boxers fracture).
stress fractures are treated conservative-
ly in a long arm posterior splint or cast
for 3 weeks. Displacement of greater
than 3 mm to 5 mm or presence of intra-
articular loose bodies require surgical
fixation.26 The most common compli-
cations are stiffness, ulnar nerve injury,
and symptomatic non-union.
RADIAL HEAD/NECK FRACTURES
Children usually sustain radial neck
fractures, whereas fractures of the ra-
dial head occur primarily in adults. Most
fractures result from a FOOSH mecha-
nism with the elbow in extension and
valgus. Upon examination, there may
be local tenderness over the radial head
with pain accentuation on pronation/
supination of the forearm. At times, pa-
tients may present with referred pain at
the wrist. Most cases are Salter-Harris
type II fractures and are revealed on
standard elbow radiographs (Figure
6C). At times, radiographic findings can
202 | Healio.com/Pediatrics
FEATURE
C D
be subtle and only demonstrate the pres-
ence of a posterior fat pad sign. Undis-
placed fractures, or those with less than
30-degree angulation, are managed in a
long arm posterior splint or cast. Dis-
placed or more angulated fractures are
treated surgically. Complications in-
clude decreased range of motion, avas-
cular necrosis of the radial head, and
posterior interosseous nerve injury.
due to direct blow, as in the case of a
OLECRANON FRACTURES
Olecranon fractures occur rarely in
children. If present, they are commonly
associated with other elbow injuries.
The common mechanism is a fall onto
the elbow or a direct blow to the olec-
ranon process. Examination may reveal
swelling and tenderness over the olecra-
non process, and the patient will resist
extension at the elbow. If nondisplaced,
these fractures can be treated in a long
arm cast; however, operative interven-
tion is required for displaced fractures.
FOREARM FRACTURES
Childhood forearm fractures repre-
sent 40% to 50% of all fractures in chil-
dren.27,28 They may occur at the proxi-
mal end or in the middle of the forearm,
but the majority (75%) are located near
the wrist at the distal end of the bone
(Figure 6A).29 Distal injuries vary great-
ly in severity and complexity, with age
determining the pattern and the location
of the fracture. In children younger than
10 years of age, buckle and greenstick
fractures occur most frequently, whereas
growth plate and complete fractures are
more likely in patients older than 10
years of age and adolescents, respec-
tively. Fractures of both bones of the
forearm are mostly distal in location,
as well (Figure 6B). Imaging may re-
veal plastic deformation, greenstick, or
complete injuries with varying degrees
of displacement. Fracture dislocations
of the forearm can also happen, in which
there is a fracture with shortening of one
of the two bones with dislocation of the
other bone. Monteggia fracture compris-
es radial head dislocation plus proximal
ulna fracture or plastic deformation of
the ulna without obvious fracture (Fig-
ure 6C). Galeazzi fracture is a relatively
rare injury characterized by fracture of
the distal radial shaft with disruption of
the distal radioulnar joint (Figure 6D).
Forearm fractures typically result
from a FOOSH injury or, occasionally,
both-bone forearm fracture. Physical
exam may reveal swelling, tenderness,
and decreased motion, and gross defor-
mity may or may not be present. While
evaluating forearm fractures, if only one
bone appears to be fractured, the clini-
cian should check the proximal and
distal joints for injury. Although rare,
compartment syndrome should be ruled
out in both-bone forearm fractures. Plain
radiographs of the forearm can provide
the diagnosis.
Treatment depends on the type of
fracture and the degree of displacement.
Most pediatric forearm fractures can be
treated without surgery. Buckle fractures
may simply need the support of a splint
or cast for 2 to 3 weeks until they heal.
Closed reduction and immobilization
for 6 to 12 weeks in a long arm cast is
needed for greenstick fracture with more
than 10 degrees of angulation, both-
bone fracture in children younger than
age 10 years, fracture dislocations, distal
radius fractures, and Salter-Harris type I
PEDIATRIC ANNALS 43:5 | MAY 2014

and II injuries. There is great potential
for remodeling, and outcomes are quite
good.30 Surgical indications include
open fractures, Salter-Harris type III and
IV fractures of the distal radial physis,
failed or unstable reductions, associated
vascular injuries, and fractures in skel-
etally mature individuals.
WRIST AND HAND FRACTURES
Carpal bones are predominately car-
tilaginous until late childhood. There-
fore, mechanisms that would produce
bony wrist injuries in adults would pro-
duce fracture of the forearm in young
children. Acute injuries to the wrist
usually result from a FOOSH or blunt
trauma. The scaphoid bone is the most
common carpal bone to be fractured
(Figure 7A). Clinically, there is radial-
sided wrist pain and swelling, with ten-
derness that is often localized to the an-
atomic snuffbox. Scaphoid fractures can
be difficult to diagnose on plain films,
with reported sensitivities between 70%
and 86%.31 Hence in an acute setting,
any suspected scaphoid injury should
be managed with a splint. CT or MRI
may be needed to make the diagnosis of
subtle or stress fractures. Treatment and
prognosis is dependent on the location
of the fracture. Distal and middle one-
third scaphoid fractures are often non-
displaced and treated with a short arm
thumb spica cast for 4 to 8 weeks. Since
they have a good vascular supply, dis-
tal and middle third scaphoid fractures
heal well without complications. Proxi-
mal or displaced scaphoid fractures of-
ten require surgery as they have a more
precarious blood supply and, hence, a
higher incidence of nonunion.
Hand injuries in children are common
but seldom complicated. Metacarpal
fractures are the second most common
type of upper extremity fracture. They
can result from a direct blow or trauma
to a clenched fist, such as punching a
wall. The most common site of injury is
neck of the fifth metacarpal, known as
PEDIATRIC ANNALS 43:5 | MAY 2014
FEATURE
a boxers fracture (Figure 7B). The
phalanges too are frequently fractured,
with distal phalanx being the most com-
mon. The usual mechanism of injury to
the distal phalanx is a crush or axial load
injury.32 Often there is associated finger-
tip or nail bed injury. The assessment
for hand injury should include finger
alignment, as any rotational deformity
is unacceptable. The radiographs should
be thoroughly examined for rotation,
shortening, and angulation.33 Pediatric
hand injuries are mostly managed non-
operatively. Non-displaced metacarpal
fractures can be immobilized in a radial
or ulnar gutter splint. Most phalangeal
fractures can be treated with splinting
or buddy taping for 3 to 4 weeks. Anti-
biotic therapy should be prescribed for
distal phalangeal fractures with associ-
ated nail trauma, as they are technically
open fractures. Fractures associated with
open injury, rotational deformity, unac-
ceptable angulation, and intraarticular
displacement require surgical manage-
ment.
CONCLUSION
Upper-extremity fractures occur fre-
quently in the pediatric and adolescent
patient population. It is important for
the primary care physician to be cogni-
zant of the key skeletal differences and
unique fracture patterns in children, as
they can directly impact patient man-
agement and outcome. A thorough, sys-
tematic approach will enable providers
to accurately identify these injuries,
institute the initial treatment, and offer
appropriate anticipatory guidance for a
positive outcome.
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Classified Marketplace

Be part of a wonderful Pediatric Hospitalist program

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Center Pediatric
Pediatric Hospitalists'
Hospitalists' seeks
seeks BC/BE
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Peds Hospitalist
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place for the past 2 years and extremely supported by our community physicians.
place for the past 2 years and extremely supported by our community physicians.
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flexible
exible schedule*
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Yuma Regional Medical
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Center (YRMC),
(YRMC), aa 406
406 bed
bed top-in-technology
top-in-technology facility,
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includes aa 22-bed
22-bed pediatric
pediatric unit
unit and
and aa 15-bed
15-bed level
level
IIEQ Neonatal ICU to help care for the pediatric patients within our community of 200,000 residents.
IIEQ Neonatal ICU to help care for the pediatric patients within our community of 200,000 residents.
This
This position
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provide limited
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Sub-specialty support
support is
is
available through
available through aa combination
combination of
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local physicians,
physicians, as
as well
well as
as through
through affi
affiliated
liated tertiary
tertiary care
care centers.
centers.

Further, YRMC
Further, YRMC has
has recently
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an integrated
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health record
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Yuma, Arizona
Yuma, Arizona isis located
located just
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over 22
hours
hours drive-
drive- either
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offers
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friendly, year around recreational opportunities in one of the sunniest cities across the
friendly, year around recreational opportunities in one of the sunniest cities across the US. US.

II welcome
welcome all
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Pam Orendorff
Pam Orendorff, Physician Relations
, Physician Relations Supervisor
Supervisor
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204 | Healio.com/Pediatrics PEDIATRIC ANNALS 43:5 | MAY 2014