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  • The clavicle is the most common bone to be fractured in a shoulder injury.
  • Small children with a clavicle fracture may present with refusal to move the arm after a fall.
  • The proximal humerus epiphyseal plate is sometimes confused for a fracture.
  • 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. Further evidence may be obtained from normal comparison views and oblique views.
  • Supracondylar fractures of the humerus can be associated with acute and delayed neurovascular compromise and require immediate orthopedic consultation.
  • Nursemaid's elbow is the most common pediatric elbow injury. X-rays are not required if there is no elbow swelling.
  • Fracture separation of the distal humeral physis may be the result of physical abuse.
  • 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 because the epiphysis in young children may not be ossified. Look for a mallet deformity and inability to extend the DIP joint.
  • Carpal fractures are rare in children due to the elasticity imparted by the cartilage surrounding the carpal bones. As in adults, scaphoid fractures are the most commonly encountered carpal fracture. A scaphoid view may improve fracture identification.


Children are prone to injuries of the upper extremity due to their natural curiosity, being active in sports, and due to risk-taking behaviors. Boys incur more injuries than girls. The highest incidence of injuries occurs 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 is the most commonly fractured bone during delivery and is the fourth most commonly fractured bone in older children. It is the most common bone fractured from a fall with a blow to the shoulder. The vast majority of injuries involve the area between the middle and distal third of the clavicle (>90%).1 Young children sustain incomplete injuries (greenstick or bowing fractures), whereas older children and adolescents present more often with displaced fractures.


Fractures of the medial clavicle are rare in children. The medial clavicular epiphysis is the last growth plate in the body to close, allowing physeal injuries to occur up to age 25. In contrast to adults, in whom sternoclavicular (SC) joint dislocations occur, children are most likely to experience Salter–Harris type I or II fracture, with or without epiphyseal separation. One must be ...

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