Common upper limb injuries in childhood David Rowland AbstractOrth opae dic injuries of the upper limb in children are common. The majority may be managed by simple non-operative means, but others require sur gical interve ntion. Common injuries in children will be dis- cussed along with the principles of their management and the possible complications. Keywords Children; fracture; orthopaedic; paediatric; upper limb Introduction Fractures of the upper limb account for more than half of the bony injuries sustained in children. They are uncommon below the age of 18 months as infants are less likely to fall on their outstretched arms. The frequency of injury rises with increasing mobility. Children’s bones are more malleable than those of adults. The peri os te um is thic ke r and the phys es are open. They ma y therefore suffer from fracture patterns not seen in adults such as buckle (torus) or greenstick fractures, plastic deformation and injuries affecting the physes. The majority of fractures affecting a child’s upper limb will hea l rap idl y and wit h min ima l int erv ent ion . The mod ell ing capabilities of growing bones can compensate for some degree ofmalun ion so perfe ct anato mica l reduction may not always be necessary. A proportion of these injuries will, however, require stabili- sation. Complications are few but may be significant and will be discussed in relation to specific fractures. No disc ussi on of chil dren’ s fractures is comp lete without reference to non-accidental injury. Factors such as an inconsis- tent history, multiple injuries, and delayed presentation should raise the susp icio ns of the examining practit ione r and initi ate appropriate referral for further investigation. Clinical assessmentInjur ed chil dren are usual ly reluc tant to be exami ned. Appro- priate analgesia will make the child more comfortable and more prone to comply with examination. Inspection may reveal deformities, bruising and wounds. The limb should be palpated to localise the area of maximal tender- ness. The joints above and below the injury should be assessed for range of movement and stability. Assessment of the distal nerve function and blood supply is ess ent ial . You ng chi ldr en wil l not und ers tan d compli cat ed instructions. It is easier to assess their motor function by asking them to copy simple movements and to assess their sensation by touc hing areas reliably suppl ied by each nerve ( Table 1). The diagnosis is confirmed with radiographs. Fractures of the clavicle AetiologyMost are caused by a fall onto the outstretched arm or onto the shou lder. Midshaf t clav icle fractures account for 10e15% ofchildren’s upper limb fractures. Diagnosis A swelling may be visible over the clavicle and the area of the fracture will be tender to palpation. Most of these fractures in children are of the greenstick type. TreatmentThe vast majority of clavicle shaft fractures will heal with no intervention. A prominent bump is usually seen, but will model over the next year. A broad arm sling is provided for comfort and may be discarded after 1e2 weeks. It is not usually necessary for these patients to be seen at the fracture clinic. Fractures through the lateral physis are uncommon. Most are treated non-operatively. Fra ctu res thr oug h the med ial phy sis are rare. Poster ior displacement may compromise the airway and require surgical reduction. Diag nosis on radio graph s is diffi cult. A comp uted tomography (CT) scan may be more useful. Fractures of the proximal humerus (Figure 1) AetiologyThe se inj uri es are mor e lik ely tha n dis loc ati on of the gle no- humeral joint in children. Even so they account for only 1% ofupper limb fractures in this age group. Diagnosis There may be tenderness to palpation. Sensation in the chevron area should be assessed to exclude injury to the axillary nerve. Simple examination of the nerves of the upper limb Nerve Motor Sensory Median Make a circl e with thumb and forefinger (OK sign). Pulp of index fingerLack of flexion at the thumb interphalangeal joint implies anterior interosseous nerve injury Ulna r Make a star (spr ead fingers wi de) Pulp of little finge rRadial Thumbs up First dorsal web space Table 1 David RowlandMA FRCS(Orth) is a Consultant in Children’s Orthopaedics at The Royal Hospital for Sick Children in Glasgow, UK. Conflicts ofinterest: none declared. ORTHOPAEDICS V: PAEDIATRICS SURGERY 29:4 153 Ó 2011 Elsevier Ltd. All rights reserved.
