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Arora 2014
Arora 2014
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.
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
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
and II injuries. There is great potential a boxers fracture (Figure 7B). The et al. Epidemiology of childhood fractures
in Britain: a study using the General Prac-
for remodeling, and outcomes are quite phalanges too are frequently fractured, tice Research Database. J Bone Miner Res.
good.30 Surgical indications include with distal phalanx being the most com- 2004;19(12):1976-1981.
open fractures, Salter-Harris type III and mon. The usual mechanism of injury to 4. Lyons RA, Delahunty AM, Kraus D, et al.
Childrens fractures: a population based
IV fractures of the distal radial physis, the distal phalanx is a crush or axial load
study. Inj Prev. 1999;5(2):129-132.
failed or unstable reductions, associated injury.32 Often there is associated finger- 5. Beaty JH, Kasser JR. The elbow region:
vascular injuries, and fractures in skel- tip or nail bed injury. The assessment general concepts in the pediatric patient. In:
etally mature individuals. for hand injury should include finger Rockwood CA, Wilkins B, eds. Fractures in
Children. 5th ed. Philadelphia, PA: Lippincott
alignment, as any rotational deformity Williams & Wilkins; 2001.
WRIST AND HAND FRACTURES is unacceptable. The radiographs should 6. Rennie L, Court-Brown CM, Mok JY, Beattie
Carpal bones are predominately car- be thoroughly examined for rotation, TF. The epidemiology of fractures in children.
Injury. 2007;38(8):913-922.
tilaginous until late childhood. There- shortening, and angulation.33 Pediatric 7. Peterson HA, Madhok R, Benson JT, el al.
fore, mechanisms that would produce hand injuries are mostly managed non- Physeal fractures: Part 1. Epidemiology in
bony wrist injuries in adults would pro- operatively. Non-displaced metacarpal Olmsted County, Minnesota, 1979-1988. J
Pediatr Orthop. 1994;14(4):423-430.
duce fracture of the forearm in young fractures can be immobilized in a radial
8. Neer II CS, Horwitz BZ. Fractures of the
children. Acute injuries to the wrist or ulnar gutter splint. Most phalangeal epiphyseal plate. Clin Orthop Relat Res.
usually result from a FOOSH or blunt fractures can be treated with splinting 1965;41:24-31.
trauma. The scaphoid bone is the most or buddy taping for 3 to 4 weeks. Anti- 9. Salter RB, Harris WR: Injuries involv-
ing the epiphyseal plate. J Bone Joint Surg.
common carpal bone to be fractured biotic therapy should be prescribed for 1963;45:587-622.
(Figure 7A). Clinically, there is radial- distal phalangeal fractures with associ- 10. Peterson HA. Physeal and apophyseal inju-
sided wrist pain and swelling, with ten- ated nail trauma, as they are technically ries. In: Rockwood CA, Wilkins KE, Beaty
JH, eds. Fractures in Children. 4th ed.
derness that is often localized to the an- open fractures. Fractures associated with Philadelphia, PA: Lippincott Williams &
atomic snuffbox. Scaphoid fractures can open injury, rotational deformity, unac- Wilkins; 1996.
be difficult to diagnose on plain films, ceptable angulation, and intraarticular 11. Whiting SJ. Obesity is not protective for
bones in child-hood and adolescence. Nutr
with reported sensitivities between 70% displacement require surgical manage-
Rev. 2002;60(1):27-30.
and 86%.31 Hence in an acute setting, ment. 12. Goulding A, Taylor RW, Jones IE, et al. Over-
any suspected scaphoid injury should weight and obese children have low bone
be managed with a splint. CT or MRI CONCLUSION mass and area for their weight. Int J Obes
Relat Metab Disord. 2000;24:627-632.
may be needed to make the diagnosis of Upper-extremity fractures occur fre- 13. Davidson PL, Goulding A, Chalmers DJ.
subtle or stress fractures. Treatment and quently in the pediatric and adolescent Biomechanical analysis of arm fracture
prognosis is dependent on the location patient population. It is important for in obese boys. J Paediatr Child Health.
2003;39(9):657-664.
of the fracture. Distal and middle one- the primary care physician to be cogni- 14. James JR, Massey PA, Hollister AM, Greber
third scaphoid fractures are often non- zant of the key skeletal differences and EM. Prevalence of hypovitaminosis D among
displaced and treated with a short arm unique fracture patterns in children, as children with upper extremity fractures. J Pe-
diatr Orthop. 2013;33:159-162.
thumb spica cast for 4 to 8 weeks. Since they can directly impact patient man-
15. Bachman D, Santora S. Orthopedic trauma.
they have a good vascular supply, dis- agement and outcome. A thorough, sys- In: Fleisher GL, Henretig FM, Ruddy RM,
tal and middle third scaphoid fractures tematic approach will enable providers Silverman BK, eds. Textbook of Pediatric
heal well without complications. Proxi- to accurately identify these injuries, Emergency Medicine Philadelphia. 4th ed.
Philadelphia, PA: Lippincott Williams &
mal or displaced scaphoid fractures of- institute the initial treatment, and offer Wilkins; 2000.
ten require surgery as they have a more appropriate anticipatory guidance for a 16. Al Ansari K, Howard A, Seeto B, et al. Mini-
precarious blood supply and, hence, a positive outcome. mally angulated pediatric wrist fractures: is
casting without manipulation enough? CJEM.
higher incidence of nonunion. 2007;9:9-15.
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