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Chapter 30

#### High-Yield Facts

• Small children with a clavicle fracture may present with refusal to move the arm after a fall.

• Children are more likely to suffer a Salter–Harris type II fracture separation of the proximal humerus than a true shoulder dislocation.

• Indirect radiographic evidence of elbow fracture includes the presence of a posterior fat pad, an exaggerated anterior fat pad, and an abnormal radiocapitellar or anterior humeral line.

• Supracondylar fractures of the humerus can be associated with acute and delayed neurovascular compromise and require immediate orthopedic consultation.

• Fracture of the radius or ulna requires x-ray evaluation of the elbow and wrist to determine if a Monteggia or Galeazzi fracture is present.

• The normal cascade of the resting hand shows increasing flexion from the index to little fingers and from the distal interphalangeal (DIP) joints to the metacarpophalangeal (MCP) joints. Deviation from this normal cascade implies a tendon laceration.

• A Salter–Harris type I or II fracture of the distal phalanx may not be seen on x-ray. Look for a mallet deformity and inability to extend the DIP joint.

• As in adults, scaphoid fractures are the most commonly encountered carpal fracture.

#### Injuries in the Upper Extremity

Children are prone to injuries of the upper extremity due to their natural curiosity, being active in sports, and risk-taking behaviors. Boys incur more injuries than girls with the highest incidence of injuries occurring between 10 and 18 years of age. This chapter will review the diagnosis and management of injuries to the upper extremities and hands.

#### The Clavicle and Acromioclavicular Joint

The clavicle is the most commonly fractured bone during delivery and is the fourth most commonly fractured bone in older children. The vast majority of injuries involve the area between the middle and distal third of the clavicle (>90%).1 The majority of fractures are due to a direct fall onto the lateral aspect of the shoulder. Direct blows only account for about 10% of midshaft fractures and an indirect mechanism, such as falling on an outstretched hand, accounts for less than 5% of these injuries.2 Young children can sustain incomplete injuries (green-stick or bowing fractures).

#### Medial Clavicle Fractures

Fractures of the medial clavicle are rare in children. The medial clavicular epiphysis is the last growth plate to close, allowing physeal injuries to occur up to age 25. In contrast to adults, in whom sternoclavicular (SC) joint dislocations occur more frequently, children are most likely to experience a posteriorly displaced Salter–Harris type I or II fracture of the medial clavicular physis, with or without epiphyseal separation. It is important to distinguish a medial physeal injury from a posterior dislocation of the SC joint. Posterior dislocations of the SC joint, though very rare, are often associated with other complications such as brachial plexus injuries, pneumothorax, and neurovascular compromise from compression of mediastinal structures. Accurate determination of medial ...

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