This document discusses common upper extremity injuries in children. It describes injuries such as Monteggia fractures, Galeazzi fractures, greenstick fractures, torus fractures, Salter-Harris fractures, scaphoid fractures, Bennett fractures, Rolando fractures, boxer's fractures, and proximal, middle, and distal phalanx fractures. For each injury, it discusses the mechanism of injury, clinical findings, imaging needed for diagnosis, and treatment options such as splinting, casting, closed reduction, and open reduction with internal fixation. The goal of treatment is to properly immobilize and reduce fractures as needed to promote healing while minimizing long-term functional deficits.

1. COMMON UPPER
EXTREMITY INJURIES
PART 2
DR ABDULLAH ALZAHRANI
PEM F1
KSUMC

2. 3 y/o boy fell approximately 2 meters off the top
of a slide at the park. landing on his outstretched
right arm . He is crying with palpation of his
elbow to his wrist.

3. Monteggia
• Ulnar shaft fracture
with radial head
dislocation.
• Pain and swelling at
the elbow with
limited flexion and
forearm supination
• Weakness or
paralysis of the
extension of the
fingers or thumb

4. Monteggia fracture
• Closed reduction
• Long arm splinting
• Open reduction and internal fixation is
reserved for fractures that cannot be
reduced

5. 15-y/o , landing on her
outstretched right hand. ,
immediate pain in her
wrist and arm and
decreased range of
motion at the wrist.
• this injury is MOST
likely require
A. closed reduction and
a long arm cast
B. closed reduction and
a thumb spica cast
C. long arm cast with
later physical
therapy
D. open reduction and
fixation
E. removable volar
splint

6. Galeazzi fracture
• Fracture of the radius
with dislocation of the
distal radioulnar joint.
• Resist pronation and
supination and
tenderness on the
wrist .
• Chronic pain,
weakness, and
limitation of supination
and pronation from
missed injuries.
• Closed reduction
followed by casting
(skeletally immature
children) .
• Internal fixation
(skeletally mature
adolescents).

7. • 8 y/o girl, falling down and landing on her
outstretched left arm. mild swelling and
tenderness over the midportion of her left
forearm MOST likely diagnosis is …..

8. Greenstick fracture
• For very minimally angulated , casted without
previous reduction, and then gently reduced
while the cast materials are setting. The
reduction is held in place with a three-point
smoothly molded cast
• Reduction is necessary for angulation,
displacement, and rotation
• Once reduced, sugar tong splint or long arm
cast with molding that provides three-point
fixation to hold the reduction in place

9. Plastic deformation “Bowing”
• Remodeling is minimal, and failure to correct
bowing can result in permanent loss of
supination and pronation
• If the deformation is less than 20 degrees or if
the deformity occurs in a young child (<4 years of
age), angulation is often corrected with
immobilization alone
• More extensive plastic deformation can result in
narrowing of the interosseous space requires
referral to an orthopedist

10. 8 yo boy presents with
pain to his right wrist and
forearm・He was running
at School and fell with
his arm outstretched
• most appropriate ED
management？
A. Closed reduction
B. Application of a volar
splint
C. Emergent orthopedic
consultation
D. Application of a long
arm cast
E. Application of an
ulnar gutter splint

11. Torus fracture “Buckle”
• Subtle, one projection and minor irregularity in the
contour of the cortex.
• Short arm volar splint or, if the swelling is minimal, a
short arm cast for 3 to 4 weeks is recommended.
• Removable splint for 3 to 4 weeks has been shown
to be as effective as casting, with the additional
advantage of interfering less with physical functioning
and activities.
• Follow-up with the orthopedic surgeon, and serial
radiographs to guide management are infrequently
needed.

12. Complete fracture

14. Salter–Harris fractures
• Nondisplaced Salter I or
II fractures should
receive immobilization
with a sling and a short
arm splint or short arm
cast for three weeks
• Displaced Salter I or II
fractures : reduction
should be performed as
soon as possible (within
5 days), immobilization
with a splint or cast for
three to four weeks.

15. Salter–Harris fractures
• Salter type III fractures
involve the joint
surface , need open
reduction to obtain a
stable joint.
• Salter type IV and V
fractures also typically
require open reduction
with internal fixation
• These fractures usually
heal in four to six
weeks.

16. • 12 y/o male who fell off his skateboard on to his right
wrist . tenderness over this area with minimal swelling .
His wrist x-ray is normal, Your next step is?
A. Discharge with a wrist wrap and
follow up as needed
B. Apply a thumb spica splint and
repeat x-ray in 10 days
C. Obtain dedicated forearm x-ray
D. Obtain an emergent CT scan of
the wrist
E. Discharge with ibuprofen prn
and clinic follow up

18. Scaphoid
• Most commonly
fractured carpal bone
• Late childhood and
adolescence
• FOOSH , direct
lateral impact of the
wrist
• Snuffbox tenderness
• Pain with axial thumb
compression
Normal x ray
• MRI or CT
immediately, or
radionuclide bone
scan at least 72 hours
after injury
• No consensus on
which imaging
modality is the gold
standard
• Recent publications
demonstrating the use
of ultrasound to detect
scaphoid fractures

19. scaphoid fracture
• Negative physical exam, negative radiograph, low
suspicion mechanism:
• No splinting is required, follow up as needed if pain is not
improved in 5 days.
• One or more physical exam tests are positive,
negative radiograph:
• Immobilize in a short-arm thumb spica splint and
recommend follow up with an orthopedic or hand
specialist in 5-7 days, and/ or obtain repeat X-rays in 14
days.
• Alternatively, more sensitive imaging such as CT or MRI
may be warranted in the acute setting.

20. scaphoid fracture
• Positive fracture on the radiographs with no
displacement, (defined as less than 1 mm
separation and no cortex step off):
• Immobilize in a long-arm thumb spica splint and
recommend follow up with an orthopedic or hand
specialist in 5-7 days.
• Positive fracture on the radiographs with
displacement greater than 1 mm, angulation,
comminution, any proximal pole fracture, or
instability:
• Emergent orthopedic/ hand consultation and long-arm
thumb spica.

21. Bennett fracture Rolando fracture

22. bennett
• Most common thumb MC
fractures,
• Axial loading of a flexed
metacarpal. punching a
solid object or falling onto
the thumb.
• Closed reduction and
immobilization if
displaced less than 1 mm,
• Closed reduction with
percutaneous pinning if
displaced 1-3 mm,
• Open reduction and
internal fixation if
displaced more than 3
mm.
Rolando
• Comminuted
• hyperextension and
hyperabduction .
• Unstable , at least three
fragments,
• Closed reduction with
percutaneous pinning or
open reduction and
internal fixation.
• Functional outcome
despite optimal treatment
is worse when compared
to Bennett fractures.

23. A. Application of a volar
splint
B. Application of an
ulnar gutter splint
C. Application of a
thumb spica splint
D. Arranging for open
reduction and internal
fixation
E. Application of buddy
tape
15 yo male complains of hand pain after punching a
wall.His hand is swollen and tender over the 4th and
5th knuckles and over that side of his hand・
What is the most appropriate treatment of this injury?

24. Boxer’s fracture
• Most common
metacarpal fracture
• Contamination from
an opponent’s mouth
during a fight
• Minimally or
nondisplaced
fractures are generally
managed with a splint
or cast.
• Displaced fractures
often require closed
reduction, possible
pinning and
subsequent casting.

25. Metacarpal fractures
• Amount of angulation can be tolerated :
• from 10 to 20 degrees for the index finger up to 40
degrees for the small finger
• Closed reduction is needed in fractures that exceed the
tolerable amount of angulation, except in unstable
fractures.
• Thumb spica splint
• Ulna gutter-type splints
• Radial gutter-type splints
• Casting in an intrinsic plus position.
• Indications for orthopedic referral include
intraarticular fractures, comminuted or unstable
fractures, displaced fractures, CMC dislocations,
significant angulation, and postreduction injuries.

27. Proximal phalanx fractures
• Minimally displaced or nondisplaced requiring
only immobilization
• Displaced and unstable treated with closed
reduction and percutaneous pinning or open
reduction with internal fixation (ORIF).
• finger splint does not provide adequate support for
a proximal phalanx fractures, therefore a wrist or
forearm splint is necessary
Middle phalanx fractures are generally managed
similarly to proximal phalanx injuries

28. Distal phalanx injuries
• Very common and often associated with nail and
nail bed injuries
• Nondisplaced distal phalanx fractures should be
splinted with the (DIP) joint in extension for a
minimum of three to four weeks.
• The splint should extend past the tip of the distal
phalanx to protect it from injury
• When associated with nail bed injuries, after the
nail is removed (if necessary), the open fracture
should be copiously irrigated and the nail bed
repaired, followed by splinting.

29. Tuft fractures
• Most common distal
phalanx injury.
• Comminuted fracture
,without any displacement or
angulation, generally stable.
• Lacerations, crush forces,
and subungual
hematomas.
• If open; irrigation with
debridement of devitalized
tissue is necessary. The use
of prophylactic antibiotics
for open tuft fractures is still a
subject of controversy.

30. Seymour fractures
• Salter–Harris I or II fracture of
the distal phalanx associated
with exposure of the proximal
aspect of the nail and damaged
germinal matrix.
• Nail appear longer than
normal
• Tissue interposed into the physis
may prevent the fracture from
healing
• Require operative intervention
to prevent growth arrest and nail
plate deformity

31. Refrences
• Fleisher & Ludwig's Textbook of Pediatric Emergency Medicine
by Fleisher & Ludwig's Textbook of Pediatric Emergency
Medicine , 7th edition
• An Update on Common Orthopedic Injuries and Fractures in
Children: Is Cast Immobilization Always Necessary? Brian Tho
Hang*, Claire Gross†,2017 Published by Elsevier Inc.
• Five Key Injuries of the Pediatric Wrist and Hand by Ann M.
Dietrich, MD, Editor , pediatric emergency medicine report
Volume 17, Number 5 / May 2012
• Pediatric Hand Injuries by Susan K. Yaeger, MD , Mananda S.
Bhende, MD , 2016 Published by Elsevier Inc
• Uptodate.com
• Pediatric emergency medicine Question review book 2017