Upper Extremity Injuries

Nursemaid's Elbow (Subluxation of the Radial Head)

This injury is most commonly seen in children 3-5 years of age and rarely occurs after seven years of age. The lack of ossification of the proximal radial epiphysis in children less than five years of age make it more pliable and prone to slippage of the annular ligament.

Mechanism of Injury
Injury is caused by longitudinal traction applied to pronated forearm and extended elbow (e.g. Child lifted or swung by the forearm). This results in subluxation of the radial head and interposition of the annular ligament into the radiocapitellar joint.

anatomy of the elbow  

anatomy of the elbow

Physical Examination
Initial pain subsides rapidly but child is reluctant to use the arm, choosing to keep it close to the body with elbow slightly flexed and forearm pronated. Any attempt to supinate the arm causes pain. Pain and tenderness to palpation of the lateral aspect of the elbow (around the radial head and annular ligament).

Evaluation: Imaging
X-rays are not routinely indicated with a reliable history consistent with physical exam. If X-rays are done, anteroposterior and lateral views are usually normal; many times the subluxation is reduced inadvertently when technician supinates the arm to take x-rays. If the history is inconsistent, suggestive of a possible compounding injury, or if there is noticeable significant swelling of the joint or surrounding soft tissue, obtain X-rays prior to attempting reduction.

Management
Two techniques for closed reduction (see image below). An audible or palpable click is associated with high probability of successful reduction. Child is able to use arm normally thereafter. If a definite snap or pop is not felt or if the patient fails to use the extremity, obtain x-rays if not yet done, and re-examine the entire extremity again carefully.

  

 

 

Supination-Flexion Technique

Place thumb over radial head and apply pressure. Manually supinate the arm and flex maximally - ideally past 90 degrees of flexion.

Forced Pronation Technique

Hold arm flexed 90 degrees at the elbow and hyperpronate at the wrist.

 

Little Leaguer's Shoulder

This condition is seen mostly in adolescent pitchers or tennis players. Typically, patients present with pain when throwing but may also present with decreased velocity and control.

acromioclavicular

Mechanism of Injury
Overuse injury is caused by overhand pitching without proper rest, pitching/throwing without proper technique, or lack of muscle strength of the shoulder and upper back. Microtrauma at the physis (Salter Harris Type 1) of the proximal humerus can also occur. There is widening of the growth plate that result in pain and swelling at the shoulder joint.

Physical Examination
Point tenderness over the shoulder physis and reproducible pain with shoulder rotation

Evaluation: Imaging

Image source: UTMB

Management      

 

Little League Baseball Pitch Count Regulations

Age

Limits Per Game

Rest Requirements

17-18 years

105/day

76 or more pitches -> 4 days rest

61-75 pitches -> 3 days rest

46-60 pitches -> 2 days rest

31-45 pitches -> 1 day rest

1-20 pitches -> 0 days rest

15-16 years

95/day

13-14 years

95/day

66 or more pitches -> 4 days rest

51-65 pitches -> 3 days rest

36-50 pitches -> 2 days rest

21-35 pitches -> 1 day rest

1-20 pitches -> 0 days rest

11-12 years

85/day

9-10 years

75/day

7-8 years

50/day

Little Leaguer's Elbow (Medial Apophysitis)

Apophysitis is defined as irritation of a bony protuberance that is a site of tendon or ligament attachment. Little leaguer's elbow is more commonly seen in active, growing children and adolescents. It is related to overuse in skeletally immature baseball pitchers (e.g. Excessive amount of pitches per game, excessive fastball speed, and continued pitching in spite of fatigue). This is a spectrum of injuries to the medial aspect of the elbow (due to excessive tension on medial epicondyle) with secondary tendinitis. The child typically develops decreased speed, accuracy and distance of pitches.

Little Leaguer Elbow

Mechanism of Injury
Injury is often associated with throwing curve balls. The excessively strong pull on the tendons and ligaments of the elbow cause repetitive microtrauma to the immature skeleton.

Physical Examination
Patient typically presents with a decrease in elbow extension. There is significant pain and swelling over the medial epicondyle accentuated by valgus stress to the elbow in extension.

Evaluation: Imaging

Management      

Rest - Return to play is done only when asymptomatic
Physical Therapy - focuses on arm and forearm strengthening
Ice - to help with acute swelling and pain in the shoulder
Throwing Program - progressively increases the force and demand on the arm and shoulder until able to return to competitive play with enforcement of pitch counts

Clavicular Fracture

Clavicular fractures is often seen in young, active patients. It is also the most common site of all obstetrical fractures (eg. LGA infants and those requiring instruments or special maneuvers for delivery). Associated injuries may include the scapula, the ribs, the lung (pneumothorax) and even the neurovasculature.

Mechanism of Injury

Classification based on anatomic location

Group I: Middle third (most common occurring 76-85%)
Group II: Distal third (10-21%)
Group III: Medial Third (3-5%)

acromioclavicular joing

Physical Examination
Patients typically present with moderate to severe pain in the shoulder, refusal to move arm on affected side, or swelling and bruising, along with a bony deformity.

Evaluation: Imaging
Anteroposterior radiograph is the standard study used. Other views used include cephalad-caudad (helpful to assess degree of displacement), apical-oblique (suited to identify fractures in the middle 1/3), apical-lordotic and axillary lateral view. CT may be useful for medial physeal fractures and sternoclavicular injuries.

Management      

sling
 

ORIF method results in faster union, improved functional outcome, better cosmetic results, and improved over all shoulder recovery.

Possible complications include: hardware prominence (25-30%), neurovascular injury (3%), nonunion (1-5%), infection (4-5%), mechanical failure (1-2%) and adhesive capsulitis (4%). 

Operative - Open Reduction, Internal Fixation (ORIF)

ORIF method results in faster union, improved functional outcome, better cosmetic results, and improved over all shoulder recovery.

Indication

Relative Contraindication

 

Nondisplaced fractures

Skin intact

Medically unfit for surgery

Open fractures

Multiple extremities injured

Skin tenting or impending skin necrosis

 

Comminuted fractures

Fractures with 100% displacement fractures

Prolonged nonunion

Open fractures

Floating shoulder

Neurovascular involvement

Significant shortening (>2 cm)

Vertical fragment

Infection

Infection

Severe skin condition (eg. acne)

Stroke patient with little extremity usage

Indications for Operative and Nonoperative Management
Management

 

Indication

 

Relative Contraindication

 

Nonoperative

 

Nondisplaced fractures

Skin intact

Medically unfit for surgery

 

Open fractures

Multiple extremities injured

Skin tenting or impending skin necrosis

 

Operative

 

Comminuted fractures

Fractures with 100% displacement fractures

Prolonged nonunion

Open fractures

Floating shoulder

Neurovascular involvement

Significant shortening (>2 cm)

Vertical fragment

Infection

 

Infection

Severe skin condition (eg. acne)

Stroke patient with little extremity usage

 

 

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