AAOS Comprehensive Orthopaedic Review
Section 3 - Pediatrics
Chapter 25. Pediatric Multiple Trauma and Upper Extremity Fractures
I. General Considerations
A. Skeletal differences between children and adults
1. Pediatric bone is more elastic, leading to unique fracture patterns, including torus (buckle) fractures and greenstick fractures.
2. The thicker periosteum generally remains intact on the side of the bone toward which the distal fragment is displaced.
a. This periosteal hinge serves to facilitate reduction.
b. Overly aggressive reduction attempts can disrupt the hinge and increase the difficulty of obtaining and maintaining a satisfactory reduction.
3. Open physes (growth plates) can allow remodeling and straightening of a malunited fracture; however, in the case of growth disturbance, ongoing growth can result in angular deformity, limb-length discrepancy, or both.
a. Remodeling occurs more rapidly and fully in the plane of joint motion (eg, sagittal malalignment at the wrist will remodel more successfully than will a coronal plane deformity).
b. In the upper extremity, the fastest growth is at the upper and lower ends of the extremity (ie, at the proximal humerus and distal radius and ulna), whereas in the lower extremity, most growth is in the middle (ie, at the distal femur and proximal tibia and fibula).
B. Growth plate (physeal) fractures—The most commonly used classification for growth plate fractures is the Salter-Harris classification (
1. Advantages—Ease of use and prognostic value.
2. One disadvantage of this classification is that Salter-Harris V fractures (which occur rarely) cannot be distinguished from Salter-Harris I fractures at initial presentation; the differentiation often is not made until a growth arrest has occurred.
II. Multiple Trauma
1. Trauma is the most common cause of death in children older than 1 year.
2. The most common causes are falls and motor vehicle accidents (MVAs).
a. Many injuries and deaths could be avoided by appropriate use of child seats and restraints.
b. Cervical spine injuries following an MVA are more common in children younger than 8 years because restraints often do not fit young children optimally.
B. Initial evaluation, resuscitation, and transport
1. Initial attention and care is directed to the life-threatening injuries.
a. Airway, breathing, and circulation (the ABCs) are addressed immediately.
b. Care from a trauma team is requisite to maximize the child's chance of survival.
c. Fluid resuscitation is essential; if venous access is difficult, an intraosseous infusion with a large-bore needle may be necessary.
d. Children often remain hemodynamically stable for significant periods of time following significant blood loss.
i. Hypovolemic shock eventually ensues if fluid resuscitation is inadequate.
ii. The "triad of death" (acidosis, hypothermia, and coagulopathy) may occur if hypovolemia persists.
2. Because of large head size in young children, a special transport board with an occipital cutout is necessary when transporting children younger than 6 years to the hospital, to prevent cervical spine flexion and potential iatrogenic cervical spinal cord injury.
[Figure 1. Salter-Harris classification of physeal fractures. Type I is characterized by a physeal separation; type II by a fracture that traverses the physis and exits through the metaphysis; type III by a fracture that traverses the physis before exiting through the epiphysis; type IV by a fracture that passes through the epiphysis, physis, and metaphysis; and type V by a crush injury to the physis.]
C. Secondary evaluation
1. Trauma rating systems
a. Although no single system is optimal for determining prognosis, several trauma rating scores frequently are used, including the Injury Severity Score, the Modified Injury Severity Score (MISS), and the Pediatric Trauma Score.
b. The Glasgow Coma Scale (GCS; see
Table 1), scored on a scale of 3 to 15 points, is the tool most commonly used for evaluating head injury.
i. GCS <8 at presentation in verbal children indicates a higher risk of mortality.
ii. GCS motor score 72 hours postinjury is predictive of permanent disability following traumatic brain injury.
2. Abdominal bruising often heralds abdominal visceral injuries and spine fractures.
3. Up to 10% of injuries are initially missed by the treating team because of head injury and/or severe pain in other locations.
D. Imaging studies
1. Plain radiographs suffice for most extremity fractures.
2. CT scans
a. Only about half of pelvic fractures identified on CT scan appear to be effected by AP pelvic radiographs.
b. CT also helps to delineate fracture patterns in spinal, calcaneal, or other intra-articular fractures.
3. Intravenous pyelography is used to assess for bladder or urethral injuries, which may occur with anterior pelvic fractures (especially straddle fractures).
E. Head and neck injuries
1. The two most important prognostic indicators of long-term neurologic recovery and function are oxygen saturation at the time of presentation and the GCS score 72 hours after injury.
2. Children can make remarkable recoveries following severe traumatic brain injury and must be treated as though such a recovery will occur.
3. Intracranial pressure (ICP) must be controlled in these patients to minimize ongoing brain damage. ICP can be controlled by elevating the head of the bed, hyperventilation (which lowers pCO2), limiting intravenous fluids, administration of diuretics, and appropriate pain control (including appropriate fracture immobilization before definitive treatment).
4. Musculoskeletal manifestations of head injuries
Spasticity begins within days to weeks; splinting helps prevent contractures.
Part-time positioning of the hip and knee in flexion can decrease the plantar flexor tone to help prevent equinus contracture.
[Table 1. Pediatric Glasgow Coma Scale]
Pharmacologic intervention with botulinum toxin A may be helpful acutely to control spasticity and facilitate rehabilitation.
Heterotopic ossification (HO), especially around the elbow, is more common following traumatic brain injury.
An increase in serum alkaline phosphatase may herald the onset of HO.
Treatment is generally with observation, although early administration of salicylates or nonsteroidal anti-inflammatory drugs decreases the likelihood of severe HO.
Fractures heal rapidly following traumatic brain injury, but the mechanism is not yet understood.
F. Abdominal visceral injuries
1. Abdominal bruising, swelling, and/or tenderness are worrisome clinical signs.
2. CT scans are the most reliable screening examinations for abdominal injuries.
G. Genitourinary injuries
1. Rare in most multiple-trauma patients but common in those with pelvic fractures
2. The risks are greatest with anterior pelvic fractures (especially straddle fractures).
H. Peripheral nerve injuries
1. Most commonly occur in association with closed fractures. Observation in such cases is warranted; electrodiagnostic studies should be obtained if there is no return of nerve function by 2 to 3 months.
2. If nerve function was intact preoperatively and absent postoperatively, nerve exploration is warranted.
3. In the case of an open fracture associated with nerve injury, surgical exploration is generally warranted.
I. Treatment of the patient with multiple injuries
1. Surgical fracture treatment is much more common in multiple-trauma patients.
2. Surgical fixation of fractures facilitates patient care and mobilization and decreases the risk of pressure sores from immobilization.
3. Open fractures are discussed below, in section III.
J. Complications in the patient with multiple injuries
1. Mortality rates can be as high as 20% following pediatric multiple trauma.
2. Long-term morbidity is present in one third to one half of children following multiple trauma.
a. Most of this long-term morbidity is due to head injuries and orthopaedic injuries.
b. The orthopaedic surgeon can minimize such late orthopaedic morbidity by assuming that the injured child will make a full recovery from the nonorthopaedic injuries.
3. Fat embolism syndrome is a rare but life-threatening complication.
a. The syndrome is heralded by an acute change in mental status, tachypnea, tachycardia, and hypoxemia.
b. Treatment is via intubation, mechanical ventilation, and intravenous hydration.
1. Pediatric patients often improve for 1 year or more following injury, with many making dramatic neurologic and functional gains.
2. Splinting and bracing are needed to prevent contractures and to enhance function.
III. Open Fractures
1. Open fractures are often high-energy injuries, and associated injuries are common.
2. Lawnmower injuries are another common cause of open fractures. These are often devastating injuries, with high rates of amputation and associated injuries of the head, neck, and upper extremities.
B. Initial evaluation and management
1. For high-energy injuries, initial evaluation and management is as discussed in section II, Multiple Trauma.
2. Thorough evaluation for other injuries is essential, because many children with open fractures have injuries to the head, abdomen, chest, or multiple extremities.
3. Tetanus status should be confirmed and updated; children with an unknown vaccination history or who have not had a booster within 5 years should receive a dose of tetanus toxoid.
4. Prompt administration of intravenous antibiotics is essential to minimize the risk of infection (
C. Classification—As in adults, the Gustilo-Anderson classification is used to grade open fractures (
1. Prompt administration of intravenous antibiotics appears to be the most important factor in preventing infection following open fractures.
2. Irrigation and debridement (I & D) must be performed in all open fractures.
[Table 2. Antibiotics Used in the Treatment of Pediatric Open Fractures]
[Table 3. Gustilo-Anderson Classification of Open Fractures]
a. Type I fractures generally need only a single I & D, whereas grade II and III injuries are generally treated with serial I & D every 48 to 72 hours until all remaining tissue appears clean and viable.
b. Recent studies have demonstrated that the risk of infection following open fractures is no higher if I & D is performed 8 to 24 hours postinjury than if it is performed within 8 hours of injury.
c. Because of better soft-tissue envelope and vascularity in children, tissue of apparently marginal viability may be left in the child at the time of initial debridement. Tissue viability will often declare itself by the time of re-exploration, 2 to 3 days later.
d. Because of enhanced periosteal new bone formation in children, some bone defects may fill in spontaneously, particularly in young children.
3. Wound cultures
a. Wound cultures are contraindicated in the absence of clinical signs of infection.
b. The correlation of both pre- and postdebridement cultures with the development of infection is low, and such cultures should not be performed routinely.
4. Fracture fixation (internal or external) is almost universally indicated to stabilize the soft tissues, allow wound access, and maintain alignment.
1. Complications associated with specific fractures are discussed in section IV, with the discussion of the particular fracture type.
2. Compartment syndrome is a significant risk, particularly in children with a head injury or other distracting injuries.
3. Infection risk is minimized with the prompt administration of intravenous antibiotics and appropriate I & D.
4. Chronic pain and psychological sequelae are common manifestations following severe trauma.
IV. Fractures of the Shoulder and Humeral Shaft
A. Clavicle fractures
1. General information—Clavicle fractures account for 90% of obstetric fractures. There is a high incidence of concomitant clavicle fracture and obstetric brachial plexus palsy.
2. Fracture location
a. Medial clavicle fractures
i. The medial clavicular physis is the last physis in the body to close, at 23 to 25 years of age.
ii. Most medial clavicle fractures are physeal fractures; sternoclavicular joint dislocations are rare.
iii. Posteriorly displaced fractures may impinge on the mediastinum (including the great vessels and trachea).
b. Clavicle shaft fractures—Displaced fractures rarely cause problems, although compression of the subclavian vessels and brachial plexus can occur.
c. Lateral clavicle fractures—A lateral clavicle fracture may be confused with an acromioclavicular joint dislocation, which is very rare in children.
a. Medial clavicle fractures
i. Nonsurgical treatment, with a sling for 3 to 4 weeks as needed, is sufficient.
ii. Percutaneous reduction with a towel clip may be indicated for posteriorly displaced fractures impinging on the mediastinum. Some authors recommend that a vascular surgeon be present because of potential vascular complications.
iii. Open reduction may be needed for open fractures or if percutaneous reduction fails. Suture fixation generally suffices in such cases.
b. Clavicle shaft fractures
i. Nonsurgical treatment (with a figure-of-8 harness or sling for 4 to 6 weeks) is appropriate for most of these fractures. A swathe may be used in infants.
ii. Open reduction and internal fixation (ORIF) may be indicated in the instance of floating shoulder injuries or potentially with multiple trauma. Fixation with pins should be avoided because of the risk of pin migration.
c. Lateral clavicle fractures
i. Most of these fractures are treated symptomatically with a sling.
ii. For markedly displaced fractures, the consideration of surgical treatment is controversial.
a. Medial fractures—Compression of the mediastinal structures may occur with posteriorly displaced fractures.
b. Shaft fractures
i. Complications are rare with closed treatment, although prominence at the fracture site is expected.
ii. Compression of the subclavian vessels and brachial plexus is rare.
iii. Surgical treatment increases the risks of infection, delayed union, and malunion. Fixation with pins may result in pin migration.
c. Lateral fractures—Complications are rare with closed treatment.
B. Proximal humerus fractures
1. General—Because 90% of humeral growth is proximal, these are very forgiving fractures.
a. Plain radiographs are almost universally sufficient for evaluation of fracture configuration and to rule out associated shoulder dislocation.
b. Because of its proximity, the brachial plexus may be injured with these fractures. Most associated brachial plexus palsies are neurapraxias, which resolve rapidly.
3. Classification—The Neer and Horwitz classification is used to define the amount of fracture displacement. Grade I fractures are displaced ≤5 mm, grade II fractures ≤1/3 of the humeral diameter, grade III fractures ≤2/3 of the humeral diameter, and grade IV fractures >2/3 of the humeral diameter.
4. Nonsurgical treatment
a. Most of these fractures can be treated nonsurgically.
b. Reduction may be performed for Neer and Horwitz III and IV fractures.
i. Reduction is generally obtained by shoulder abduction to 90° and external rotation to 90°.
ii. Impediments to reduction may include the long head of the biceps, the periosteum, or the glenohumeral joint capsule.
c. Nonsurgical treatment options include sling and swathe, shoulder immobilizer, or coaptation splint.
d. Gentle shoulder range-of-motion (ROM) exercises should be started 1 to 2 weeks after injury.
5. Surgical treatment
a. Surgical treatment is indicated only for adolescents with Neer and Horwitz grade III and IV injuries and for children of any age with open fractures.
b. Closed reduction and percutaneous pinning is used in most surgical cases. The pins are removed 2 to 3 weeks postinjury.
c. Open reduction and pinning is necessary if interposed structures (biceps tendon, periosteum, and/or joint capsule) prevent closed reduction in adolescents with grade III or IV injuries.
a. Malunion, growth arrest, and other complications are rare.
b. Brachial plexus injuries are almost always stretch injuries, which resolve spontaneously.
C. Humeral shaft fractures
1. Evaluation—Radial nerve palsy occurs in <5% of humeral shaft fractures and is almost always a neurapraxia following middle or distal third fractures.
2. Nonsurgical treatment
a. Nonsurgical therapy is the mainstay of treatment.
b. Significant displacement and angulation (up to 30°) are acceptable because range of shoulder motion is generally excellent.
c. Typical immobilization is via sling and swathe, sugar-tong splint, or fracture brace; ROM exercises are started by 2 to 3 weeks postinjury.
3. Surgical treatment
a. Indications for surgical treatment include open fractures, multiple trauma, and floating elbow or shoulder injuries.
i. Intramedullary rod fixation (flexible titanium nails) is the preferred surgical treatment of most shaft fractures requiring fixation.
ii. Plate fixation results in increased scarring and puts the radial nerve at risk during the procedure.
a. Malunion rarely has functional consequences because normal shoulder ROM is excellent.
b. Primary radial nerve palsies (present at the time of injury) are almost always due to neurapraxia and resolve spontaneously. Primary nerve palsies should be observed. If they do not resolve spontaneously by 3 to 4 months, then electrophysiologic studies are indicated and surgical exploration may be needed.
c. Secondary nerve palsies (present after intervention) are often more complete injuries and require exploration acutely.
d. Stiffness is rare; early ROM minimizes this risk.
e. Limb-length discrepancy is common but is generally mild and of no functional consequence.
V. Supracondylar Humerus Fractures
1. Supracondylar humerus (SCH) fractures account for more than half of pediatric elbow fractures.
2. 95% to 98% are extension-type injuries.
B. Relevant anatomy
1. Distal humeral anatomy is shown in
2. The Baumann angle may be measured on AP radiographs of the distal humerus to assess the coronal plane fracture alignment, but it is used less commonly now because of difficulty and variability in its measurement.
C. Associated injuries
1. Vascular injuries occur in ~1% of SCH fractures. Because of the rich collateral flow at the elbow, distal perfusion may remain good despite a vascular injury (
2. Nerve injuries—see
D. Classification—The modified Gartland classification is widely used to classify SCH fractures (
E. Nonsurgical treatment
1. Type I fractures are treated closed with a long-arm cast in ~90° of elbow flexion.
2. A minority of type II fractures may be treated closed in a cast.
3. Closed treatment is considered for type II fractures only if the following criteria are met:
a. No significant swelling is present.
b. The anterior humeral line intersects the capitellum.
c. There is no medial cortical impaction of the distal humerus.
4. In essentially all cases, the casts are removed after fracture healing at 3 weeks.
F. Surgical treatment
1. Indications—Most type II and all type III (and IV) fractures are treated with reduction and pinning.
[Figure 2. Typical anatomic relationships in the elbow. A, The anterior humeral line, shown as would be drawn on a lateral radiograph, should bisect the capitellum. In extension-type supracondylar fractures, the capitellum moves posterior to the anterior humeral line. B, The Baumann angle (shown as would be measured on an AP view) is the angle subtended by a line perpendicular to the long axis of the humerus and a line along the lateral condylar physis. The Baumann angle may be used to assess the adequacy of the reduction in the coronal plane and may be compared to the contralateral elbow.]
[Table 4. Treatment for Vascular Injuries With Supracondylar Humerus Fractures]
[Table 5. Nerve Injuries With Supracondylar Humerus Fractures]
[Figure 3. Gartland classification of supracondylar fractures. Type I injuries are nondisplaced. Type II injuries are displaced but have an intact hinge of bone (located posteriorly in extension-type fractures). Type III fractures are completely displaced and there is no intact hinge. Type IV fractures are completely displaced fractures that are unstable in both flexion and extension.]
Figure 4. Typical pin configurations for crossed pinning (A) and lateral-entry pinning (B) for SCH fractures. Regardless of pin configuration, both the medial and lateral columns should be engaged proximal to the fracture site.]
2. Pin configuration (Figure 4 and
a. Crossed pins
i. Crossed pins have been found to be more stable biomechanically in laboratory studies than are lateral-entry pins.
ii. Use of a medial pin results in a significant risk (3% to 8%) of iatrogenic ulnar nerve injury. The risk is highest if the medial pin is inserted with the elbow in hyperflexion.
b. Lateral-entry pins
i. Lateral-entry pins should be separated sufficiently to engage both the medial and lateral columns of the distal humerus at the level of the fracture.
ii. When inserted with appropriate technique, lateral-entry pins have comparable success in maintaining reduction of SCH fractures.
iii. Iatrogenic ulnar nerve injury does not occur with lateral-entry pins.
[Table 6. Comparison of Crossed Pins and Lateral-Entry Pins for Supracondylar Humerus Fractures]
1. Volkmann ischemic contracture is the most disastrous result and is more commonly due to compression of the brachial artery with casting in >90° of flexion than to arterial injury.
2. Cubitus varus (gunstock deformity) is generally a cosmetic deformity with few functional sequelae. The rates of cubitus varus are much lower with reduction and pinning than with closed reduction and casting.
3. Recurvatum is common following cast treatment of type II and III fractures and remodels poorly because of the limited growth of the distal humerus.
4. Stiffness is rare following casting or reduction and pinning, particularly with cast removal at 3 weeks.
VI. Other Elbow Fractures
A. Relevant anatomy
1. Ossification centers of the elbow (
2. Distal humerus—The alignment (including anterior humeral line and Baumann angle) as noted in SCH fractures is essential to remember.
3. Proximal radius
a. There is normally a 12° valgus angle of the proximal radius.
b. The proximal radius should be directed toward the capitellum on all radiographs.
c. The relationships between the proximal radius and the capitellum and the ulna and the humerus often facilitate fracture identification (
B. Lateral condyle fractures
The most widely used classification of lateral condyle fractures is based on the amount of fracture displacement (
Figure 6). The oblique view is most sensitive for detecting maximal displacement and must be obtained if closed treatment is contemplated.
[Table 7. Order of Appearance of Ossification Centers of the Elbow on Radiographs*]
[Figure 5. Osseous relationships about the elbow as seen on AP radiographs of the elbow. In transphyseal fractures the radius is directed toward the capitellum; in elbow dislocations, the proximal radius is not directed toward the capitellum.]
[Figure 6. Illustration of types of lateral condyle fractures as typically classified. Type I fractures are displaced <2 mm and generally have an intact intraarticular surface. Type II fractures are displaced 2 to 4 mm and have a displaced joint surface. Type III injuries are displaced >4 mm and often are completely displaced and rotated.]
The Milch classification (
Figure 7) is rarely used because it is irrelevant to patient care. Milch I fractures are considered Salter-Harris IV fractures and are very rare. Milch II fractures are considered Salter-Harris II fractures.
2. Treatment algorithm
a. Type I fractures are treated with casting for 3 to 6 weeks, although 2% to 10% of these fractures displace sufficiently in a cast to require reduction and pinning.
b. Type II fractures are treated surgically with closed versus open reduction and percutaneous fixation (generally with smooth pins).
i. Closed reduction and pinning is appropriate if there is no intra-articular incongruity following pinning (as assessed on an intraoperative arthogram).
ii. Open reduction is required if joint congruity cannot be obtained with closed treatment.
c. Type III fractures—ORIF (with percutaneous pins or screws) is requisite.
3. Surgical technique
a. Pin configuration (
Figure 8)—The pins must be divergent to minimize the risk of fracture displacement, and the distal pin must engage at least a portion of the ossified distal humeral metaphysis.
b. Open reduction
i. The posterior soft tissues should never be dissected off the lateral condyle because the blood supply enters posteriorly and posterior dissection can result in osteonecrosis.
[Figure 7. Milch classification of lateral condyle fractures. In Milch I fractures, the fracture traverses the ossific nucleus of the capitellum, and in type II fractures, the fracture line is medial to the ossific nucleus.]
[Figure 8. Typical pin configuration for lateral condyle fractures. The pins must be divergent, and the distal pin should engage metaphyseal bone (rather than simply unossified cartilage).]
ii. The entire length of the fracture, including the joint line, must be visualized to ensure an anatomic reduction.
a. Stiffness is minimized by mobilizing the elbow once fracture healing is complete, generally by 4 weeks.
b. Osteonecrosis can be minimized by avoiding posterior soft-tissue dissection.
c. Nonunion is rare if the above protocol is followed.
i. If nonunion is evident within the first 6 to 12 months after injury, the nonunion may be treated with bone grafting and screw fixation.
ii. Cubitus valgus is frequent in the case of non-union.
d. Tardy ulnar nerve palsy may occur following nonunion and cubitus valgus, but it generally does not occur for decades after the injury, if ever. Treatment is ulnar nerve transposition.
C. Medial condyle fractures
1. Classification—Classification is based on the amount of displacement and is comparable to that noted above for lateral condyle fractures.
2. Treatment—Treatment is as described for lateral condyle fractures; however, type I medial condyle injuries are rare.
3. Complications—The most common complication is failure to recognize this fracture, though a metaphyseal fragment can generally be seen on plain radiographs in cases of medial condyle fracture. Elbow MRI or arthrogram may be indicated to accurately assess whether surgery is necessary.
D. Medial epicondyle fractures
a. The mechanism of injury is generally avulsion of the medial epicondyle apophysis.
b. Half of medial epicondyle fractures are associated with elbow dislocations.
2. Classification—The classification is based on the amount of displacement and whether the medial epicondyle is entrapped in the elbow joint.
3. Nonsurgical treatment
a. Nonsurgical care is the mainstay of treatment. (Exceptions are listed under Surgical treatment, below.)
b. Closed attempts to extricate an entrapped medial condyle may be undertaken by supinating the forearm, placing a valgus stress on the elbow, and extending the wrist and fingers.
c. Early motion (within 3 to 5 days) minimizes the risk of elbow stiffness.
4. Surgical treatment
i. Absolute—Intra-articular entrapment of the medial epicondyle.
ii. Relative—Dominant arm in a throwing athlete, weight-bearing extremity in an athlete (eg, gymnast), ulnar nerve dysfunction.
b. Technique—Open reduction with screw fixation is preferred to allow early motion. (Kirschner wires may be used in young children.) It is important to remember that the medial epicondyle is relatively posterior on the humerus.
a. Stiffness is almost universal, although rarely of functional consequence.
b. Ulnar neuropathy is generally a neurapraxia, which spontaneously resolves.
c. Chronic instability is rare.
d. Failure to diagnose an incarcerated medial epicondyle may lead to elbow stiffness and degenerative changes.
E. Lateral epicondyle fractures
1. Nonsurgical treatment is indicated for most of these fractures.
2. Surgery is indicated when the epicondyle has displaced into the elbow joint.
F. Distal humeral physeal fractures
1. Epidemiology—These fractures are most common in children younger than 3 years of age, but they may occur up to 6 years of age.
a. These fractures almost always displace posteromedially (
Figure 9) and are frequently misdiagnosed as elbow dislocations.
b. Elbow dislocations are very rare in young children, so a physeal fracture should be assumed in young children with displacement of the proximal radius and ulna relative to the distal humerus.
c. Elbow arthrography or MRI may be used to clarify the diagnosis.
3. Classification—The Salter-Harris classification is used, with all fractures being type I or II.
a. Closed reduction and percutaneous pinning is the mainstay of treatment.
b. Pin configuration is similar to that used for supracondylar fractures.
c. Closed reduction should not be performed if the injury is diagnosed late (after 5 to 7 days postinjury), to minimize the risk of iatrogenic physeal injury.
5. Complications are rare following prompt diagnosis and treatment, and misdiagnosis is the most common complication.
G. Proximal radius fractures
1. General—Most fractures are radial neck and/or physeal fractures and are typically associated with valgus loading of the elbow or elbow dislocation.
2. Classification—These fractures are most commonly classified based on the location of the fracture
[Figure 9. AP (A) and lateral (B) radiographs of the elbow of an 18-month-old infant with a physeal fracture of the distal humerus demonstrate typical alignment of the elbow following these injuries. Although the appearance resembles an elbow dislocation, the age of the child is younger and the radius can be noted to be directed at the capitellum in these radiographs. The vast majority of these injuries are displaced posteromedially. Periosteal new bone is evident in this 2-week-old fracture.]
(neck or head) and the angulation and/or displacement.
3. Nonsurgical treatment
a. Most of these fractures are treated closed.
b. Manipulative techniques
i. Patterson maneuver—Hold the elbow in flexion and varus while applying direct pressure to the radial head.
ii. Israeli technique—Direct pressure is held over the radial head with the elbow flexed 90° while the forearm is pronated and supinated.
iii. Elastic bandage—Spontaneous reduction may occur with tight application of an elastic bandage around the forearm and elbow.
c. Early mobilization (within 3 to 7 days) is indicated to minimize stiffness.
4. Surgical treatment
a. Indications following reduction:
i. >30° of residual angulation
ii. >3 to 4 mm of translation
iii. <45° of pronation and supination
i. Percutaneous manipulation is usually attempted using a Kirschner wire, awl, elevator, or other metallic device.
ii. The Metaizeau technique involves retrograde insertion of a flexible pin or nail. The pin is passed across the fracture site, and the fracture is reduced by rotating the pin.
iii. Open reduction via a lateral approach is rarely necessary, but it may be required for severely displaced fractures.
iv. Internal fixation is used only for fractures that are unstable following reduction.
a. Elbow stiffness is extremely common, even after nondisplaced fractures.
b. Overgrowth of the radial head is common.
H. Olecranon fractures
1. Evaluation—Palpation over the radial head is necessary to rule out a Monteggia fracture. Tenderness over a reduced radial head is indicative of a Monteggia fracture with spontaneous reduction of the radial head.
2. Classification—It is important to distinguish apophyseal fractures from metaphyseal olecranon fractures because the former may be the first indication of osteogenesis imperfecta.
3. Nonsurgical treatment—Most olecranon fractures are treated nonsurgically, with casting in relative extension (usually 10° to 45° of flexion) for 3 weeks.
4. Surgical treatment—Indicated for fractures that are displaced more than 2 to 3 mm using tension band fixation. (In children, an absorbable suture rather than a wire is often used as the tension band.)
5. Complications are rare and rarely of clinical significance, though failure to diagnose associated injuries (such as radial head dislocation) may be a cause of significant morbidity.
I. Nursemaid's elbow
1. Epidemiology—Nursemaid's elbow occurs with longitudinal traction on the outstretched arm of a young child (generally younger than 5 years of age) as the orbicular ligament subluxates over the radial head.
a. The history and physical examination are classic, with the child holding the elbow extended and the forearm pronated.
b. Radiographs are not needed unless the classic history and arm positioning are absent. If radiographs are obtained, they are normal in nursemaid's elbow.
3. Treatment—With one thumb held over the affected radial head (to feel for a "snap" as the orbicular ligament reduces), the forearm is supinated and the elbow is flexed past 90°.
4. Complications—Recurrent nursemaid's elbow is relatively common, although recurrences are rare after age 5 years.
VII. Fractures of the Forearm, Wrist, and Hand
A. Diaphyseal forearm fractures
1. Evaluation—Open wounds are often punctate and are commonly missed when the injury is not evaluated by an orthopaedic surgeon.
a. Greenstick fractures are incomplete fractures and are common in children. These should be described as apex volar or apex dorsal to facilitate reduction.
b. Complete fractures are categorized the same as in adults, by fracture location, fracture pattern, angulation, and displacement.
3. Nonsurgical treatment
a. Most pediatric forearm fractures can be treated without surgery.
b. Greenstick fractures are generally rotational injuries. Apex volar fractures (supination injuries) may be treated by forearm pronation, and apex dorsal injuries (pronation injuries) by forearm supination.
c. Casting for 6 weeks is typical.
4. Surgical treatment
i. Unacceptable alignment following closed reduction may necessitate open reduction. Unacceptable alignment includes angulation >15° in children younger than 10 years and >10° in children 10 years of age or older, and bayonet apposition in children older than 10 years.
ii. Significantly displaced fractures in adolescents are at high risk for redisplacement and are a relative indication for surgery.
iii. Open fractures are commonly treated surgically.
i. Advantages of intramedullary fixation are a smaller dissection, use of a load-sharing device, and fewer stress risers.
ii. Unlike in adults, intramedullary fixation in children results in rapid healing, and non-union is rare.
iii. Fixation of one bone is often sufficient to stabilize an unstable forearm (especially in children younger than 10 years).
a. Refracture occurs in 5% to 10% of children following forearm fractures.
b. Malunion is unusual if serial radiographs are obtained during healing (usually weekly for the first 2 to 3 weeks after complete fractures).
c. Compartment syndrome may occur, particularly in high-energy injuries. The rate after intramedullary fixation is high, likely due to selection bias and multiple attempts at reduction and rod passage.
d. Loss of pronation and supination is common, though generally mild.
B. Monteggia fractures
Palpation over the radial head must be performed for all children with ulnar fractures because spontaneous relocation of the radial head is relatively common in pediatric Monteggia injuries.
Isolated radial head dislocations almost never occur in children. Such presumed "isolated" injuries are almost universally due to plastic
Table 8. Bado Classification of Monteggia Fractures]
deformation of the ulna with concomitant radial head dislocation.
a. The Bado classification (Table 8) is most commonly used to describe these fractures.
b. Fractures may be classified as acute or chronic (>2 to 3 weeks since injury).
3. Nonsurgical treatment
a. Nonsurgical treatment is much more common (and successful) in children with Monteggia fractures than in adults.
b. Reestablishment of ulnar length is of primary importance to maintain reduction of the radial head.
c. For type I and III fractures, the forearm should be supinated in the cast.
4. Surgical treatment
a. Acute fractures should be operated on if they are open and/or unstable. For closed fractures, reduction is frequently successful, and an intramedullary nail is often used to maintain ulnar length (
Figure 10). For comminuted fractures, plate fixation may be needed. Annular ligament reconstruction is almost never needed for acute fractures.
b. Chronic Monteggia fractures should be reduced surgically (preferably within 6 to 12 months postinjury). They require an ulnar osteotomy and annular ligament reconstruction.
a. Posterior interosseous nerve palsy occurs in up to 10% of acute injuries but almost always resolves spontaneously.
b. Delayed or missed diagnosis is common when the child is not seen by an orthopaedic surgeon.
c. Complication rates and severity are much greater if the diagnosis is delayed more than 2 to 3 weeks.
[Figure 10. Bado I Monteggia fracture-dislocation. A, Preoperative radiograph. B, Postoperative radiograph shows that the fracture was treated by closed reduction and intramedullary nail fixation.]
C. Distal forearm fractures
a. Physeal fractures are categorized by the Salter-Harris classification.
b. For metaphyseal fractures, distinction is made between buckle fractures and complete fractures.
2. Nonsurgical treatment
a. Most of these fractures are treated by closed means.
b. Physeal fractures heal in 3 to 4 weeks and metaphyseal fractures in 4 to 6 weeks. Buckle fractures heal in 3 weeks.
3. Surgical treatment
i. The most common indications for surgical intervention are ipsilateral elbow fractures, open fractures, or unacceptable alignment following reduction. Unacceptable alignment for complete metaphyseal fractures is >15° to 20° of angulation in any age child and bayonet apposition in children older than 10 years. For physeal fractures, residual displacement >50% is unacceptable.
ii. For children with ipsilateral elbow fractures, percutaneous pinning of the distal radius results in much lower rates of loss of reduction and malunion.
iii. For physeal fractures, no more than one or two reduction attempts should be attempted in the emergency department. Physeal fractures should not be manipulated more than 5 to 7 days postinjury.
i. Closed reduction is successful in reducing most of these fractures.
ii. Percutaneous pinning (avoiding the superficial radial nerve) is generally sufficient to maintain reduction.
a. Malunion generally results in cosmetic deformity rather than functional deficits and often remodels spontaneously.
b. Growth arrest occurs in <1% to 2% of distal radius physeal fractures and <1% of metaphyseal fractures.
D. Carpal injuries
1. Nonsurgical treatment
a. Scaphoid fractures are most commonly treated with a thumb spica cast. There is no consensus regarding short- or long-arm thumb spica use.
i. Distal pole fractures routinely heal with closed treatment.
ii. Waist fractures (especially in adolescents) have worse results and may result in osteonecrosis and/or nonunion.
b. Triangular fibrocartilage complex (TFCC) tears may be seen with distal radial and/or ulnar styloid fractures and are generally treated closed.
2. Surgical treatment
a. Scaphoid fractures may be treated with ORIF for displaced waist fractures or with ORIF and bone grafting for established nonunions.
b. If there is ongoing wrist pain following closed treatment of a wrist fracture, TFCC tears may be repaired arthroscopically.
a. Scaphoid waist fractures can result in osteonecrosis and nonunion.
b. TFCC tears may result in chronic wrist pain.
E. Metacarpal fractures
a. For growth plate injuries, the Salter-Harris classification is used.
b. For nonphyseal fractures, classification is based on fracture location, configuration, angulation, and displacement, as in adults.
c. Some of these fractures are "open" injuries ("fight bites" or "clenched-fist" injuries), and lacerations over the knuckles should be sought to rule out such an injury.
2. Nonsurgical treatment
a. Most of these fractures are treated closed.
i. Rotational alignment must be good for closed treatment to be acceptable.
ii. Acceptable sagittal angulation increases from radial to ulnar as in adults, with the following general guidelines: second metacarpal, 10° to 20°; third metacarpal, 20° to 30°; fourth metacarpal, 30° to 40°; and fifth metacarpal, 40° to 50°.
b. Closed treatment is generally successful for diaphyseal and metaphyseal fractures of the thumb metacarpal.
3. Surgical treatment
a. Surgical indications are unacceptable rotational, sagittal, and/or coronal alignment.
b. Physeal fractures of the base of the thumb metacarpal often require surgery because of instability and/or intra-articular step-off.
4. Complications—The most common complication is malalignment (including rotational deformity with overlapping fingers) requiring late osteotomy.
F. Phalangeal fractures
a. Physeal fractures are assessed via the Salter-Harris classification.
b. Shaft and neck fractures are categorized by fracture type and displacement.
2. Nonsurgical treatment suffices for most fractures, with healing in ~3 weeks.
3. Surgical treatment
a. Indications—Surgical treatment is needed for most intra-articular phalangeal fractures.
i. Closed reduction and pinning is indicated for most minimally displaced intra-articular fractures.
ii. Open reduction and pinning is often needed for more displaced unicondylar and bicondylar fractures.
4. Complications—Stiffness, fixation loss, growth disturbance, and malunion are relatively uncommon given the frequency of these injuries in children.
Top Testing Facts
1. Children can remain hemodynamically stable following significant blood loss, but then can rapidly decline into hypvolemic shock and the "triad of death" (acidosis, hypothermia, and coagulopathy).
2. The orthopaedic surgeon should assume that complete recovery from other injuries (including head injuries) will occur, as many children make excellent recoveries from such injuries.
3. In a child without a head injury, the acute onset of mental status changes, tachypnea, tachycardia, and hypoxemia are classic for fat embolism syndrome.
1. Prompt administration of intravenous antibiotics is the most important factor in decreasing the rate of infection following open fractures.
2. Routine wound cultures are misleading and should not be performed in the absence of clinical signs of infection.
Fractures of the Shoulder and Humeral Shaft
1. Obstetric clavicle fractures are frequently associated with brachial plexus palsies.
2. The medial clavicular physis is the last physis in the body to close, at age 23 to 25 years.
3. Posteriorly displaced medial clavicle fractures can impinge on the mediastinal structures, including the great vessels and trachea.
4. Proximal humerus fractures have tremendous remodeling potential, so surgery is rarely needed.
5. With fractures of the humeral shaft, primary radial nerve palsies should be observed; however, secondary radial nerve palsies require urgent exploration.
Fractures of the Elbow and Nursemaid's Elbow
1. A pulseless, well-perfused hand may be observed following SCH fracture because of the excellent collateral circulation around the elbow.
2. Injury to the anterior interosseous nerve is the most common nerve injury associated with SCH fractures.
3. Ulnar nerve injury with SCH fractures is almost always iatrogenic and is due to medial pin insertion. The risk is greatest if the medial pin is inserted with the elbow in a hyperflexed position.
4. Cubitus varus (gunstock deformity) after treatment of SCH is generally a cosmetic deformity with few functional consequences. Tardy ulnar nerve palsy is rare.
5. The oblique radiograph is the most sensitive for detecting maximal displacement of lateral condyle fractures and must be obtained when contemplating closed treatment.
6. During open reduction of lateral condyle fractures, posterior soft-tissue dissection must be avoided to avoid osteonecrosis.
7. The only absolute indication for surgical treatment of medial epicondyle fractures is entrapment of the medial condyle within the joint.
8. Elbow dislocations in young children are exceedingly rare, so transphyseal fractures should be suspected in patients with displacement of the proximal radius and ulna relative to the humerus. Elbow arthrography or MRI may be performed to confirm the diagnosis if the diagnosis is unclear.
9. To diagnose nursemaid's elbow, the classic position of elbow extension and forearm pronation should be sought. If the classic history and positioning are absent, then radiographs should be obtained before manipulation.
Fractures of the Forearm, Wrist, and Hand
1. With forearm fractures, bayonet apposition is acceptable in children younger than 10 years of age.
2. Isolated radial head dislocations almost never occur in children. These presumed "isolated" injuries are almost always the result of plastic deformation of the ulna with concomitant radial head dislocation (Monteggia fracture).
3. Closed treatment is often successful in pediatric Monteggia fractures (unlike in adults).
4. Late treatment of Monteggia fractures has far worse results than does acute treatment, so a delayed or missed diagnosis must be avoided.
5. Reduction loss and malunion are much higher for distal radius fractures with a concomitant elbow fracture. These rates can be minimized with internal fixation of the distal radius fracture.
6. With distal forearm physeal fractures, to minimize the risk of iatrogenic physeal injury, no more than one or two reduction attempts should be performed in the emergency department, and rereduction should not be performed more than 5 to 7 days after injury.
7. Distal pole fractures of the scaphoid are common in children and uniformly do well, though scaphoid waist fractures, particularly in adolescents, have poorer outcomes and may result in osteonecrosis and/or non-union.
8. With metacarpal fractures, check for lacerations over the knuckles ("fight bites" or "clenched-fist injuries"), which are indicative of open injuries.
9. Intra-articular physeal fractures of the phalanges generally require surgery.
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