Asynchrony PEM: Upper Extremity Fractures in Kids

Welcome to Asynchrony PEM (Pediatric EM), brought to you by the PEM faculty and fellows of Warren Alpert Medical School/Brown University's Pediatric Emergency Medicine fellowship.
Each week we'll be curating content from the #FOAMpeds and #FOAMed world into modules organized by topic and relevant to the pediatric population. Follow @AsynchronyEM and @BrownEMRes on Twitter for new releases!

Let’s face it, kids are total klutzes! As they start learning how to get around and become increasingly mobile during play, they start falling and ending up with upper extremity fractures. In fact, nearly two-thirds of all boys and half of all girls will have sustained a fracture by age 15 (Arora R et al.,Pediatr Ann. 2014; 43: 196-204 [link]). While the majority of these injuries will likely heal quickly with minimal intervention, it is important to maintain a high level of suspicion for growth plate injuries. If undetected, these could result in growth arrest.


On a lighter note, let’s start with our requisite music video before breaking into the Asynchrony material!


1)  Let's first review Salter Harris Fractures with these Patwari Academy/ALiEM short videos. The videos go over some good cases and provide you with answers/explanations as well. 


2) It can be confusing to distinguish fractures from ossification centers. That’s when the mnemonic CRITOE comes in handy. Here is a short ALiEM video on CRITOE. (The video is narrated by a man with a British accent- sounds so beautiful!)


3) Neuro exam for Upper Limb Injuries: Rock, Paper, Scissors, OK!

4) This is a nice website that reviews all types of fractures from the ED management perspective and ortho f/u perspective. In the next week, review the material on humerus, elbow, forearm and wrist fractures (and focus on ED management of course.)

Clinical Fracture Guide


5) Lastly, as with an child presenting with an injury, remember to always keep non-accidental trauma on your differential - make sure that you can explain every injury with the described mechanism and that every mechanism is consistent with the child’s developmental stage (PEM-ED podcast, about 54 minutes.)  Also be suspicious of the following highly suspicious fractures (PEM Blog):

  1. Metaphyseal corner fractures

  2. Rib fractures

  3. Fractures of the sternum, scapula, or spinous processes

  4. Long bone fracture in a nonambulatory infant

  5. Multiple fractures in various stages of healing

  6. Bilateral acute long bone fractures

  7. Vertebral body fractures and subluxations in the absence of a history of high force trauma

  8. Digital fractures in children younger than 36 months of age or without corresponding historyEpiphyseal separations

  9. Severe skull fractures (i.e., multiple, stellate, or depressed) in children younger than 18 months of age


6) If anything smells fishy to you, call the Aubin Center (in Rhode Island) or your hospital's child safety team. This may be your single opportunity to intervene and save this child’s life.


7) Bonus!!

a) From EM Docs: Open Fractures: Pearls and Pitfalls

b) Review of evidence to support use of velcro splints in buckle fractures (from CanadiEM).

c) Distal Radius Ulnar Joint (DRUJ) Dislocation- an uncommon injury mostly in adults that is often missed. From EM Cases.

That's it for this week! See you next week with another edition of Asynchrony PEM!


Frances Turcotte Benedict, MD MPH (@fturcotteMD) is an Assistant Professor, Department of Emergency Medicine and Pediatrics at Alpert Medical School of Brown University. Her interests in medicine include injury prevention with a focus on youth violence prevention, medical education and simulation.

Additional editing by: Dr. Julie Leviter