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Upper Limb Injuries in Children

Clavicle fractures in growing children should be treated with a collar and cuff sling worn for 2-4 weeks. Surgical treatment can be considered for transverse fractures in teenagers involving clear shortening.
Physical exercise can be started when the full, painless range of shoulder motion has been restored, usually a few weeks after stopping wearing the collar and cuff sling.

Fractures of the proximal humerus are usually treated with a collar and cuff sling worn for 2-4 weeks. Even significant angulation (≤ 30°) or shortening (bayonet dislocation) is reversible if the proximal humeral epiphyseal line is clearly open.
Surgical treatment is justified in fractures with shortening if the patient's growth is about to end or has ended.
Physical exercise can be started when the full, painless range of shoulder motion has been restored, usually a few weeks after stopping wearing the collar and cuff sling.

Well-aligned fractures should be treated with a collar and cuff sling or elbow flexion splint worn for 2-3 weeks.
Distal humeral fractures with displacement or angulation are often treated surgically.
Appropriate treatment is particularly important in fractures involving the joint - do not hesitate to consult a paediatric orthopaedist.

Dislocation can often be distinguished from fracture based on how the elbow looks.
Closed reduction of a recently dislocated elbow joint is usually easy to do at an outpatient clinic. Successful reduction can be felt as a clunk with subsequently free and painless motion of the elbow joint.
- A local anaesthetic should be injected into the joint if more than 2 hours have gone from the injury.
- Reduction must be done under general anaesthesia if 1-2 attempts are not sufficient to reduce the elbow joint or if there is an old injury.
- After reduction or a reduction attempt, x-rays should be taken of the elbow joint, looking for fractures (protuberance of the medial epicondyle of the humerus, coronoid process of the ulna, radial head).
The upper limb should be supported (with the elbow joint at a 90° angle) with a collar and cuff sling unless movement after reduction dislocates the joint again.
The stability and range of motion of the elbow joint should be checked one week after injury, and the patient should be given instructions for elbow joint exercises. A collar and cuff sling should be worn for 2-3 weeks.
Physical exercise can be started when the full, painless range of elbow joint motion has been restored, usually 6-8 weeks after injury.

In 1-4-year-old children, the radial head may be subluxated by sudden traction in the direction of the forearm with the elbow joint straight, such as if the child trips with his/her mother holding his/her hand to prevent falling.
Subluxation is followed by pain and crying and failure to use the arm at all because the elbow joint cannot be moved without pain from slight flexion. Subluxation will not cause malposition or oedema.
If the history and findings are consistent with subluxation, the radial head can be reduced, with the child sitting on his/her caregiver's lap, by flexing the elbow joint and simultaneously rotating the forearm outward (supination) and then, if necessary, inward (pronation). Reduction can usually be felt as a snap followed by crying but the child will start using his/her arm in 15 minutes.
The elbow joint should be x-rayed if the symptoms started after falling from standing or from a height, if there is oedema and/or malposition of the elbow joint or if the child does not start using his/her hand after the reduction attempt.

If a diaphyseal fracture is suspected, the whole forearm must be x-rayed making sure that the elbow and wrist joints can be seen in both anterior and lateral projections to be able to assess whether joints are in correct position.
- Monteggia fractures involve dislocation of the radial head and Galeazzi fractures dislocation of the distal radioulnar joint.
- X-rays also show the type (bowing, greenstick or transverse fracture) and position (angulation, displacement, shortening) of the fracture.
Realignment of the fracture is indicated whenever the forearm appears deformed. Remaining angulation measured in x-ray pictures must not exceed 10-15°.
Diaphyseal fractures of the forearm should be treated by either a long arm cast (4-6 weeks) or by surgery.
Physical exercise can be started one month after cast removal if the range of motion of the forearm is full and painless.

Fracture of the distal radius is the most common fracture in growing children.
Soft bandaging with a ready-made or individually fabricated splint removed by the caregiver 2-3 weeks after injury is sufficient for the treatment of torus fractures. Healing of the fracture need not be checked.
In transverse fractures, any visible angulation should usually be corrected.
- The fracture should be supported with a plaster cast.
- In patients over 10 years of age, the alignment of the fracture should be checked once by x-ray after 7-10 days.
- The plaster cast should be removed 3-5 weeks after injury, clinically checking the consolidation of the fracture.
- Physical exercise can be resumed as soon as there is full, painless range of wrist motion, usually 1-3 weeks after cast removal.
In prepubertal children, realignment of fractures involving the epiphyseal plate must be done within a few days from injury because later realignment will increase the risk of growth disturbance.
- The fracture should be supported with a plaster cast for 3-4 weeks. Repeat x-rays are unnecessary.
- Fractures involving the epiphyseal plate in patients whose growth is coming to an end should be treated according to the same principles as fractures of the distal radius in adults.

These kinds of fracture are common in children of all ages.
Based on clinical examination, targeted x-rays should be taken of the metacarpal bone or the finger in AP and lateral projections. X-raying of the entire hand is only indicated if simultaneous fractures of several metacarpal or finger bones are suspected.
Extra-articular fractures with no visible malposition can usually be treated by taping the fractured finger to the neighbouring finger for 2-3 weeks.
Rotation of the finger should be assessed clinically by slow active or passive movement of the finger, comparing its position to the position of the finger in the opposite hand.
Fractures involving a joint often require specialized care.

Gao B, Dwivedi S, Patel SA et al. Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures in Pediatric and Adolescent Patients: A Systematic Review and Meta-Analysis. J Orthop Trauma 2019;33(11):e439-e446. [PubMed]
Handoll HH, Elliott J, Iheozor-Ejiofor Z et al. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev 2018;12():CD012470. [PubMed]
Silva M, Sadlik G, Avoian T et al. A Removable Long-arm Soft Cast to Treat Nondisplaced Pediatric Elbow Fractures: A Randomized, Controlled Trial. J Pediatr Orthop 2018;38(4):223-229. [PubMed]
Capstick R, Giele H. Interventions for treating fingertip entrapment injuries in children. Cochrane Database Syst Rev 2014;(4):CD009808. [PubMed]