Upper Extremity Trauma in Children and Adolescents: An Update from the Hand and Upper Extremity Program
Donald S. Bae MD, Peter M. Waters MD
CHILDREN'S HOSPITAL, BOSTON, MA
Introduction
Children and adolescents use their upper extremities to
explore their environment, assist in independent tasks of daily
living, and participate in sports and play activities. For these
reasons, traumatic injuries of the hand and upper extremity
are extremely common in all age groups. As more information
regarding the epidemiology, treatment, and outcomes of these
injuries becomes available, treating physicians have become
better equipped to manage upper extremity injuries. The
purpose of this review is to provide a survey of recent research
performed at Children's Hospital on upper extremity trauma in
skeletally immature patients.
Wrist
Diagnosis of Instability
Carpal instability due to scapholunate ligament disruption
has been well described within the adult orthopaedic literature.
Typically, this injury results in a rotatory subluxation of the
scaphoid and a dorsal intercalated segment instability (DISI)
pattern. Patients will typically present with pain or symptoms
of wrist instability following an acute traumatic injury. In
adults, the diagnosis is often confirmed via plain radiographs
of the wrist, with a scapholunate interval of greater than 2mm
suggestive of scapholunate dissociation. Prompt recognition
and appropriate surgical treatment is critical to restore normal
wrist kinematics, alleviate symptoms, and prevent the longterm
functional compromise and arthrosis.
This radiographic diagnosis is more difficult to make in
children and adolescents, due to the developing carpus. In particular,
the lunate and scaphoid are usually not visible on plain
radiographs until the age of four to five years. Furthermore,
as there is often asymmetric carpal development, comparison
radiographs of the contralateral wrist may be unreliable. For
these reasons, the diagnosis of scapholunate dissociation is a
difficult one to make in the skeletally immature patient.
To address this problem, Kaawach, Ecklund, DiCanzio,
Zurakowski and Waters determined the age- and gender-based
normative values of scapholunate distances (SLD) as seen on
posteroanterior (PA) wrist radiographs in children between the
ages of 6 and 14 years1. The authors reviewed 119 PA wrist
radiographs in 85 asymptomatic patients and measured SLD in
each case. Repeated-measures analysis of variance revealed significant
age and gender differences, and linear regression was
used to determine normal SLD ranges for males and females
in an age-appropriate fashion. Intra- and inter-observer agreement
of these measurements was excellent. Interestingly, only
5 patients –all 12 years old or older—met the adult criterion
of normal (less than 2mm) SLD. The authors conclude that
by establishing normative values, orthopaedic surgeons and
radiologists may better evaluate wrist radiographs for evidence
of scapholunate injury.
Arthroscopic Treatment of Instability
The rising participation of children and adolescents in
recreational and competitive sports has been paralleled by a
rise in the incidence of acute and chronic wrist pain. At the
2003 Annual Meeting of the American Academy of Orthopaedic
Surgeons, Earp, Waters, and Wyzykowski presented the outcomes
of arthroscopic treatment of post-traumatic wrist instability
in skeletally immature patients2. Twenty-nine patients
with arthroscopically confirmed ligamentous wrist injuries
were treated with arthroscopic synovectomy, ligamentous or
chondral debridement, and/or ligament repair. (Figure 1) Wrist
symptoms and function as measured by the modified Mayo
Wrist Score improved significantly in the short term. Though
a very small number of patients required subsequent open
reconstruction, the authors concluded that wrist arthroscopy is
a valuable tool in the treatment of post-traumatic wrist instability
in children and adolescents.
Scaphoid Fractures
The scaphoid is the most commonly fractured bone of
the developing carpus. Historically, the most common pattern
of injury involved the distal pole, usually as a result of direct
trauma; these injuries may be successfully treated with cast
immobilization. Fractures through the scaphoid waist, however,
are becoming more common in the skeletally immature.
Currently, it is recommended that displaced fractures be treated
with anatomic reduction and internal fixation. In cases of fracture
nonunion, internal fixation with autologous bone grafting
has been successfully utilized.
Fractures of the proximal scaphoid are relatively rare injuries
in the skeletally immature patient population, with nonunion
and osteonecrosis being the most concerning potential
complications. While there have been recent reports on the use
of vascularized bone grafts to treat proximal scaphoid fracture
nonunions in adults, little is known about the treatment of
these entities in children and adolescents. Waters and Stewart
have recently published the first case series of nonunion and
osteonecrosis following proximal pole of scaphoid fractures in
skeletally immature patients3. (Figure 2) Three patients were
treated with vascularized bone grafting from the distal radius
at an average of 18 months following their original injury. The
diagnosis was confirmed via plain radiographs and computed
tomography in all patients. At an average follow-up of 5.5
years, all attained clinical and radiographic union. The authors
conclude that vascularized radial bone graft with internal fixation
is effective for proximal pole nonunion and osteonecrosis
in skeletally immature patients.
Growth Arrest of the Distal Radius
The distal radius is the most common site of fracture in
the immature skeleton, comprising approximately 20-25% of
all pediatric fractures. Approximately 15% of these fractures
involve the distal radial physis, representing nearly 40% of all
"growth plate" injuries in some series. Though unusual, growth
disturbance of the distal radial physis does occur, with an estimated
incidence of 1-7%. Growth arrest of the distal radial
physis may have important clinical consequences, including
pain, deformity, joint subluxation, and functional impairment.
Often these complications are severe enough to warrant surgical
correction.
Waters, Bae, and Montgomery have recently published
the results of surgical treatment for post-traumatic distal
radial growth arrest in children and adolescents4. Thirty
patients with progressive deformity, wrist pain, and/or loss of
motion secondary to distal radial growth arrest were treated
with a combination of ulnar epiphyseodesis, ulnar shortening
osteotomy, radial osteotomy, and/or radial epiphyseodesis
procedures. (Figure 3) Treatment was predicated on the degree
of deformity and amount of growth remaining. At average follow-
up of 21 months, all patients had significant improvement
in pain and function as assessed by the modified Mayo Wrist
Score. Radiographically, ulnar variance was corrected from an
average of 4.5mm positive to neutral and radial inclination was
corrected from an average of 8.5 to 15.5 degrees. The authors
conclude that surgery for post-traumatic distal radial growth
arrest can improve pain and range of motion and prevent progressive
deformity in skeletally immature patients.
Elbow
Radial Neck Fractures
Fractures of the proximal radius in skeletally immature
patients most commonly involve the physis and radial neck.
This is partly due to the fact that the radial head is mostly comprised
of cartilage. Radial neck fractures account for 8 percent
of all pediatric elbow fractures, occurring most commonly in
children between the ages of 9 and 12 years. Treatment is based
upon degree of angulation. Most authorities agree that fractures
with less than 30 degrees of angulation will remodel over time
and do not require specific intervention. Fractures with greater
than 30 degrees of angulation benefit from closed reduction.
In cases of displaced fractures in which closed or percutaneous
reduction is not successful or in which a stable reduction is not
obtained, open reduction with internal fixation is indicated.
Radial neck fracture nonunion is a rare complication of
displaced injuries in skeletally immature patients. To further
identify risk factors and treatment options for this unusual
complication, Waters and Stewart performed a retrospective
review of nine cases of radial neck nonunion5. Patient age averaged
8 years, and all sustained Salter-Harris type II fractures
with average angulation and displacement of over 80 degrees
and 80 percent, respectively. The majority of cases underwent
anatomic open reduction, but initial reduction was lost in all
patients. Treatment was comprised of observation, radial head
excision, or open reduction and internal fixation with bone
grafting depending on symptoms, deformity, and functional
deficit. Interestingly, healing of the nonunion did not necessarily
lead to improvement of clinical symptoms in all cases.
Floating Elbows
"Floating elbow" injuries refer to ipsilateral forearm
and humerus fractures. As these injuries result from higher
energy trauma with concomitant soft tissue injury, there may
be significant swelling with the potential for compartment
syndrome, particular if circumferential cast immobilization is
utilized during treatment. Ring, Waters, Hotchkiss, and Kasser
recently reviewed the treatment 16 pediatric patients with floating
elbows treated at Children's Hospital6. Of the 10 patients
in whom casting was used to manage the forearm injury, two
developed compartment syndrome and four patients required
cast release due to symptoms of impending compartment
syndrome. Six patients were treated with percutaneous wire
fixation of both the humerus and forearm fractures without
complications. The authors recommend percutaneous pin
fixation of both the supracondylar and distal radius fractures in
floating elbow injuries to prevent the need for circumferential
casting and reduce the risk of compartment syndrome.
Elbow Arthroscopy
In a recent publication, Micheli, Luke, Mintzer and Waters
described the techniques and results of elbow arthroscopy in
pediatric and adolescent patients7. Forty-nine cases in 47 pediatric
patients were reviewed with average follow-up of 4.7 years.
The majority of procedures were performed for osteochondritis
dissecans; less common indications included arthrofibrosis,
synovitis, acute trauma, and posterior olecranon impingement.
(Figure 4) Greater than 80% of patients had good or excellent
results, with 90% of patients returning to sports without limitation.
There were no neurovascular or infectious complications.
The authors conclude that elbow arthroscopy has a safe and
effective role in the treatment of selected elbow problems in
children and adolescents.
Elbow Contracture
Elbow joint contractures occur most commonly following
traumatic injuries. In most cases, non-operative treatment
consisting of stretching exercises, dynamic and static splinting,
physical therapy, and manipulation provide adequate improvement
in elbow range of motion. The results of these treatment
modalities may be limited, however, in cases of long-standing
stiffness or those associated with intra-articular pathology.
Patients with persistent functional impairments despite
adequate trials of non-operative treatment may benefit from
surgical release. While there have been many previous reports
on the surgical treatment of post-traumatic elbow contracture
in adults, little is known about the results of surgical treatment
in pediatric patients.
Bae and Waters have recently published the results of
operative treatment of post-traumatic elbow contractures in
adolescents8. Thirteen patients were treated at an average
age of 16 years. When possible, an extensile medial approach
was utilized. Surgical releases involved excision of heterotopic
ossification, hardware removal, extensive capsular excision,
and when indicated, musculotendinous lengthenings of the
brachialis and flexor-pronator mass. All patients were treated
with continuous passive motion, physical therapy, and splinting
post-operatively. At average follow-up of 29 months,
average total arc of motion improved from 53 to 107 degrees.
The authors conclude that in appropriately selected patients,
surgical release combined with comprehensive post-operative
therapy can provide improvements in range of motion in cases
of post-traumatic elbow contracture.
Brachial Plexus
Examination of Brachial Plexus Birth Palsy
Brachial plexus birth palsy refers to the paralysis of the
upper extremity secondary to a traction or compression injury
sustained to the brachial plexus during birth. The majority of
infants will recover spontaneously and attain near normal upper
extremity function; however, some will have persistent deficits
and require surgical treatment. At present, physical examination
findings are used to predict recovery and determine the
need for surgical intervention. This practice highlights the
critical role that classification systems based upon physical
examination findings play in the evaluation and treatment of
these patients.
Bae, Waters, and Zurakowski have reported on the reliability
of three different classification systems measuring active
upper extremity motion in patients with brachial plexus birth
palsy9. Over 300 examinations were performed and findings
were recorded according to the modified Mallet Classification,
Toronto Test Score, and Hospital for Sick Children Active
Movement Scale. Intra- and inter-observer reliability among
examiners was determined to be fair to excellent using all classification
systems. In general, intra-observer agreement was
higher than inter-observer agreement. The authors concluded
that these classification systems are reliable and may be utilized
for future study of the natural history and results of surgical
treatment of brachial plexus birth palsy.
Compartment Syndrome
Compartment syndrome remains a concerning complication
of upper extremity trauma. The diagnosis is often difficult
to diagnose in children, and delays in treatment may lead to
disastrous complications. To further examine the current
treatment of pediatric compartment syndrome, Bae, Kadiyala,
and Waters reviewed 36 cases of compartment syndrome in
33 patients treated at Children's Hospital from January 1992
to December 199710. The average patient age was 10 years,
and 18 cases involved the upper extremity. Eleven of these
cases occurred in the setting of acute fractures and three
cases occurred following surgery (corrective upper extremity
osteotomies or fracture fixation). Interestingly, pain, pallor,
paresthesias, paralysis, and pulselessness were relatively unreliable
clinical signs of compartment syndrome in these children.
An increasing analgesia requirement in combination with
other clinical signs, however, was a more sensitive indicator of
compartment syndrome. Indeed, all ten patients with access to
patient-controlled or nurse-administered analgesia during their
initial evaluation demonstrated an increasing requirement
of pain medication. With prompt recognition and expedient
fasciotomy, over 90 percent of these patients had return to
pre-injury levels of activity at an average of 2.5 months after
surgery.
Notes:
Dr. Bae is a Resident in the Harvard Combined Orthopaedic Residency Program, Boston, MA.
Dr. Waters is Associated Professor of Orthopaedic Surgery, Harvard Medical School, and Director of the Hand and Upper Extremity Program, Department of Orthopaedic Surgery, Children's Hospital, Boston, MA.
Please address correspondence to: Dr. Peter M. Waters Department of Orthopaedic Surgery Children's Hospital 300 Longwood Avenue, Hunnewell 2 Boston, MA 02115 (617) 355-6617 peter.waters@tch.harvard.edu
References:
- Kaawach W, Ecklund K, Di Canzio J, Zurakowski D, Waters PM. Normal ranges of scapholunate distance in children 6 to 14 years old. J Pediatr Orthop 2001;21:464-7.
- Earp BE, Waters PM, Wyzykowski R. Arthroscopic treatment of post-traumatic wrist instability in pediatric and adolescent patients. Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons, February 5 – 9, 2003, New Orleans, LA.
- Waters PM, Stewart SL. Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg 2002; 84A:915-20.
- Waters PM, Bae DS, Montgomery KD. Surgical management of posttraumatic distal radial growth arrest in adolescents. J Pediatr Orthop 2002; 22:717-24.
- Waters PM, Stewart SL. Radial neck fracture nonunion in children. J Pediatr Orthop 2001; 21:570-6.
- Ring D, Waters PM, Hotchkiss RN, Kasser JR. Pediatric floating elbow. J Pediatr Orthop 2001; 21: 456-9.
- Micheli LJ, Luke AC, Mintzer CM, Waters PM. Elbow arthroscopy in the pediatric and adolescent population. Arthroscopy 2001; 17:694-9.
- Bae DS, Waters PM. Surgical treatment of posttraumatic elbow contracture in adolescents. J Pediatr Orthop 2001; 21:580-4.
- Bae DS, Waters PM, Zurakowski D. "Reliability of Three Classifications Systems Measuring Active Motion in Brachial Plexus Birth Palsy." J Bone Joint Surg, in press.
- Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop 2001; 21: 680-8.
|