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Dr. Sumit Kumar Gupta, MD, FRCSC
Assistant Professor of Orthopaedics
University of Missouri
UPPER EXTREMITY FRACTURES
FREQUENCY OF FRACTURES

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FREQUENCY BY SEASON
More Common during the
summer.
Out of school – more
vigorous and
unsupervised physical
activities
FREQUENCY BY TIME OF DAY

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SPECIFIC FRACTURE TYPES
ACTIVITIES ASSOCIATED WITH FRACTURES
• Playground
• 90% were upper extremity fractures from a fall off of monkey bars or
climbing equipment
• Change of playground surfaces
• concrete / dirt / rubber => bark (impact-absorbing)
• Skateboarding
• Nature of skateboarding being high speed and extreme maneuvers
causes high-energy trauma fractures
• Roller Skates & In-line Skates
• Most injuries involve elbow, forearm, wrist, and fingers; < 20% use
protective gear

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ACTIVITIES ASSOCIATED WITH FRACTURES
• Trampoline
• 1/3 of injuries result from falling off the trampoline
• Skiing
• More than half of the injuries occur due to collisions with stationary
objects; i.e. trees, poles, stakes
• Snowboarding
• Compared to skiers, snowboarders have 2-½ times as many fractures
OUTLINE
• Clavicle
• Shoulder
• Humerus – shaft
• Elbow
• Supracondylar, Lateral condyle, Medial epicondyle, Radial Head/neck,
Olecranon
• Forearm
• Wrist

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CLAVICLE FRACTURES
• Birth – most common bone broken at delivery
• 0.4-1% of vaginal births – can happen with normal delivery
• Decreased movement of arm should raise suspicion
• 1 of 11 clavicle fractures can have associated brachial plexus palsy
McBride MT, Hennrikus WL, Mologne TS. Newborn clavicle fractures. Orthopedics. 1998 Mar;21(3):317-9; discussion 319-20.
Lurie S, Wand S, Golan A, Sadan O. Risk factors for fractured clavicle in the newborn. J Obstet Gynaecol Res. 2011 Nov;37(11):1572-4. doi: 10.1111/j.1447-0756.2011.01576.x. Epub 2011 Jul 25.
CLAVICLE FRACTURES
• Rarely need surgery in children
• Shoulder sling has same outcome as figure of eight, but more comfortable
• Adolescents may do better with operative fixation if
• 100% displaced
• >2cm shortening
• Open injuries
• Neurovascular injury
Pandya NK, Namdari S, Hosalkar HS. Displaced clavicle fractures in adolescents: facts, controversies, and current trends. J Am Acad Orthop Surg. 2012 Aug;20(8):498-505. doi:
10.5435/JAAOS-20-08-498.

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CONGENITAL PSEUDARTHROSIS
• Not painful
• No callus formation on follow-up xrays
• Most commonly on right
DISTAL CLAVICLE FRACTURES
• 10% of clavicle fractures
• Not a true dislocation of the AC joint
• Fracture through the distal physis
• Periosteal sleeve is intact

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DISTAL CLAVICLE FRACTURES
DISTAL CLAVICLE FRACTURES

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PROXIMAL HUMERUS FRACTURES
• 80% of humeral growth comes form proximal
growth plate
• Have a high potential to remodel, so can
accept a lot of deformity
PROXIMAL HUMERUS FRACTURES
Extraordinary
remodeling
potential of the
proximal
humerus

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PROXIMAL HUMERUS FRACTURE
• Accept any alignment if ≥ 2 yrs growth
• Sling
• Sling and Swathe
• Hanging cast

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HUMERAL SHAFT FRACTURES
• Excellent healing and remodeling potential
• “If the bones are in the same room it will heal”
http://www.rch.org.au/clinicalguide/guideline_index/fractures/Humeral_shaft_fractures_Emergency_Department/

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HUMERAL SHAFT FRACTURES
• Treatment:
• Sling and coaptation splints
• Hanging arm cast
• Internal fixation, flexible nails
• Overgrowth of ~ 1 cm occurs
ELBOW FRACTURES
• Supracondylar fractures (70%)
• Lateral condylar fractures (15%)
• Medial epicondylar fractures
• Radial head/neck fractures
• Transphyseal
• Olecranon

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ELBOW FRACTURES
• Supracondylar fractures (70%)
• Lateral condylar fractures (15%)
• Medial epicondylar fractures
• Radial head/neck fractures
• Transphyseal
• Olecranon
ELBOW FRACTURES
• Supracondylar fractures (70%)
• Lateral condylar fractures (15%)
• Medial epicondylar fractures
• Radial head/neck fractures
• Transphyseal
• Olecranon

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ELBOW FRACTURES
• Supracondylar fractures (70%)
• Lateral condylar fractures (15%)
• Medial epicondylar fractures
• Radial head/neck fractures
• Transphyseal
• Olecranon
ELBOW FRACTURES
• Supracondylar fractures (70%)
• Lateral condylar fractures (15%)
• Medial epicondylar fractures
• Radial head/neck fractures
• Transphyseal
• Olecranon

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ELBOW FRACTURES
• Supracondylar fractures (70%)
• Lateral condylar fractures (15%)
• Medial epicondylar fractures
• Radial head/neck fractures
• Transphyseal
• Olecranon
ELBOW FRACTURES
• Supracondylar fractures (70%)
• Lateral condylar fractures (15%)
• Medial epicondylar fractures
• Radial head/neck fractures
• Transphyseal
• Olecranon

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ELBOW FRACTURES
• 5-10% of all pediatric fractures
• Knowledge of ossification centers is essential for correct diagnosis
SUPRACONDYLAR FRACTURE
• 70% of all elbow fractures in children
• Average age: 6 y/o
• Anatomic predisposition:
• Ligamentous laxity
• Metaphyseal “remodeling”
• Thin cortex

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MECHANISM
• Extension injury – 97%
• Flexion injury – 3%
FAT PAD SIGN
• Anterior fat pad => means nothing!
• Posterior fat pad => 76% occult fracture

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CLASSIFICATION
Tachdjian’s Pediatric Orthopaedics, 4th Ed.
VASCULAR INJURY
• 0.5-1% incidence
• Important to document clinical exam
• Pulses
• Perfusion
• Need urgent OR for reduction
Tachdjian’s Pediatric Orthopaedics, 4th Ed.

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NERVE INJURY
• Occurs 7%
• Anterior Interosseus Nerve
• Most common
• Radial nerve
• Posteromedial displacement
• Median nerve
• Posterolateral displacement
• Ulnar nerve
• Iatrogenic from pin placement
TYPE 1 SUPRACONDYLAR FRACTURE
• Long arm cast
• 4-6 weeks
• Sling is recommended
• Parents should be instructed on elevation of the extremity to reduce
swelling
• Fingers above the elbow
• Elbow above the heart

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TYPE 2 AND 3 SUPRACONDYLAR FRACTURES
• OR for closed reduction and pinning
TYPE 2 AND 3 SUPRACONDYLAR FRACTURES
• OR for closed reduction and pinning

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TYPE 2 AND 3 SUPRACONDYLAR FRACTURES
• OR for closed reduction and pinning
TYPE 2 AND 3 SUPRACONDYLAR FRACTURES

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FLEXION TYPE SUPRACONDYLAR
TRANSPHYSEAL FRACTURES
• Children < 2 years old
• Diagnosis usually missed
• Distal humerus being entirely cartilaginous
• Distinguishing a transphyseal fracture from an elbow dislocation
• Child abuse
• 50% of children less than 2 years of age

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LATERAL CONDYLE FRACTURES
• 2nd most common elbow fracture
LATERAL CONDYLE FRACTURE
• Most need surgical management
• Any displacement – high rate of non-union when treated with cast
• Avoid unnecessary dissection especially posterior - AVN

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LATERAL CONDYLE FRACTURE
LATERAL CONDYLE FRACTURE – NON-UNION

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MEDIAL EPICONDYLE
• Common in age 9-14
• Mechanism
• Direct trauma
• Muscle pull from flexor mass
• Associated with elbow dislocation – upto 50%
• Historically treated non operatively
• Relative indications for treatment
• Displacement > 1cm
• Elbow instability
• Ulnar nerve symptoms
• Higher demand patients
ELBOW DISLOCATION

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REDUCED
ORIF – EXCISION OF FRAGMENT AND
REDUCTION

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NURSEMAIDS ELBOW
• Radial head subluxation
• Common injury in 1-6 years of age
• Mechanism is usually of longitudinal traction while forearm is pronated and elbow
extended
NURSEMAIDS ELBOW
• Anatomy
• Annular ligament normally passes around radial head
• The immature radial head is more spherical and smooth (cartilaginous), and can
slide out
• The annulus then gets trapped in the joint
Robert E. Kaplan and Kathleen A. Lillis, Recurrent Nursemaid’s Elbow (Annular Ligament Displacement) Treatment Via Telephone, PEDIATRICS Vol. 110 No. 1 July 1,
2002 pp. 171 -174

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NURSEMAIDS ELBOW
• Presentation
• Arm held in pronation, elbow partially flexed
• Unwillingness of child to use that arm
• Tenderness in antero-lateral elbow
• No erythema, swelling, warmth, abrasions or ecchymosis
NURSEMAIDS ELBOW
Supination: Simultaneous
supination of the wrist and
extension of the elbow (A),
followed by flexion of the elbow
with the forearm maintained in
supination (B).
Hyperpronation: Simultaneous
pronation of the wrist and
extension of the elbow (A),
followed by flexion of the elbow
with the forearm maintained in
pronation (B).
Robert E. Kaplan and Kathleen A. Lillis, Recurrent Nursemaid’s Elbow (Annular Ligament Displacement) Treatment Via Telephone, PEDIATRICS Vol. 110 No. 1 July 1, 2002 pp. 171 -174

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FOREARM FRACTURES
• Common injury
• Most kids with >2years growth remaining can be
treated with closed reduction

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FOREARM FRACTURE
• Long arm cast – safe and effective
Bae DS. Pediatric Distal radius and forearm fractures. J hand Surg Am. 2008 Dec;33(10):1911-23

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WHAT IS THE INJURY?
MONTEGGIA FRACTURE

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DISTAL RADIUS/ULNA FRACTURES
• Most common fracture in children
• Majority are managed in cast
• Commonly a result of a fall on an outstretched hand
DISTAL RADIUS/ULNA FRACTURES
• Well molded cast is key
• Cast Index
• x/y
• Ideally > 0.7
• Strongest predictor of loss of
reduction
• Short arm cast is usually sufficient
• Pin fractures if they redisplace
• Higher risk of growth plate
injury with repeat closed
reduction

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TAKE HOME POINTS
• Clavicle fractures
• Majority are non-operative
• Growth and remodeling until 22 years of age
• Proximal humerus
• Non operative if > 2 years growth remaining
• High potential for remodeling
• Elbow
• Recognize the anatomy and ossification centers
• Cannot tolerate any significant deformity
• Have a low threshold to refer these
TAKE HOME POINTS
• Supracondylar fractures
• Always assess neurovascular status – Anterior interosseus nerve, brachial artery
• Do not attempt a closed reduction in the ER or clinic
• Lateral condyle
• Any displacement needs anatomic open reduction
• High risk of complications including non union and AVN
• Medial Epicondyle
• Can be treated non op for minimally displaced, younger patients or inactive patients
• 50% associated with elbow dislocations
• Think of this fracture with significant elbow injury and no fracture seen

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TAKE HOME POINTS
• Forearm and wrist fracture
• Always look at the joint above and below – pay particular attention to radial head
dislocation
• Most can be managed non operatively
• Need close follow-up for displaced fractures to ensure reduction is maintained
• Do not attempt multiple reductions – increased incidence of growth arrest
• Well molded cast is essential to success