Upper Extremity Fractures

Children break bones more easily than adults - so pediatric fractures are very common. There are several unique features of the pediatric musculoskeletal system that need to be considered in management decisions of all of these injuries - growth plates, plasticity, callus formation, remodeling potential, and partial breaks are some of the key ones. Recognition and appropriate management of pediatric fractures by ED providers is critical. While some common minor wrist and ankle fractures can be treated with a less conservative approach encouraging an early return to activities, other fractures if not treated properly can result in long term functional problems for the child and/or be a sign of child maltreatment.



Key studies

Key Study: Cost analysis and performance in distal pediatric forearm fractures: is a short-arm cast superior to a sugar-tong splint?


Acree JS, Schlechter J, Buzin S

The aim of this study is to compare splint versus cast immobilization for maintaining alignment following closed reduction of distal 1/3 radius and both-bone forearm fractures.

Key Study: Do All Clavicle Fractures in Children Need To Be Managed by Orthopedic Surgeons?


Adamich J, Howard A, Camp M

Development of evidence-based clinical care pathway can help unnecessary radiation exposure to this patient population and reduce costs to patient families and the health care system.

Key Study: Bivalved Versus Circumferential Cast Immobilization for Displaced Forearm Fractures: A Randomized Clinical Trial to Assess Efficacy and Safety


Bae DS, Valim C, Connell P, Brustowicz KA, Waters PM

The purpose of this study was to determine the effects of bivalved versus circumferential cast immobilization on maintenance of reduction and associated complications after closed reduction of radius and/or ulna fractures in children.

Key Study: Valve or No Valve: A Prospective Randomized Controlled Trial of Casting Options for Pediatric Forearm Fractures


Baldwin PC III, Han E, Parrino A, Solomito MJ, Lee MC

The purpose of this study was to determine the rate of cast-related complications when using split or intact casts.

Key Study: Adolescent Distal Humerus Fractures: ORIF Versus CRPP


Bell P, Scannell BP, Loeffler BJ, Brighton BK, Gaston RG, Casey V, Peters ME,...

The purpose of this study was to review the treatment and outcomes of consecutive series of distal humerus fractures in adolescents and to compare outcomes between patients treated with percutaneous skeletal fixation and those treated with open reduction and fixation.

Key Study: Intravenous regional anaesthesia (Bier's block) for pediatric forearm fractures in a pediatric emergency department-Experience from 2003 to 2014


Chua ISY, Chong SL, Ong GYK

The objective of the study was to evaluate the efficacy (length of stay in the emergency department and failure rate of Bier's block) and safety profile (death and major complications) of Bier's block in its use for manipulation and reduction of paediatric forearm fractures.

Key Study: Patient and Parent Satisfaction With Sling Use After Pediatric Upper Extremity Fractures: A Randomized Controlled Trial of a Customized Cast-sling Versus Standard Cast and Sling


Cruz AI Jr, DeFroda SF, Gil JA, Hansen H, Bolous A, Procaccini M, Zonfrillo MR

The purpose of this investigation was to compare patient/parent centered outcomes after the use of a customized sling compared with a standard sling by utilizing a prospective, randomized-controlled trial.

Key Study: Obesity Increases Risk of Loss of Reduction after Casting for Diaphyseal Fractures of the Radius and Ulna in Children: An Observational Cohort Study


DeFrancesco CJ, Rogers BH, Shah AS

The objective of this study was to determine if high body mass index increases the risk of loss of reduction following closed reduction and casting for displaced concomitant fractures of the radial and ulnar shafts in pediatric patients.

Key Study: The utility of clinical ultrasonography in identifying distal forearm fractures inthe pediatric emergency department


Galletebeitia Laka I, Samson F, Gorostiza I, Gonzalez A, Gonzalez C

The aim of this study is to evaluate the utility of point-of-care ultrasound for diagnosing distal forearm fractures in pediatric emergency departments.

Key Study: Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures


Gladstein AZ, Schade AT, Howard AW, Camp MW

The primary outcome of the study was the proportion of proximal humerus fractures, initially treated non-operatively, for which displacement or angulation on follow-up radiographs led to a change to operative treatment.

Key Study: The Use of Magnetic Resonance Imaging in Management of Minimally Displaced or Nondisplaced Lateral Humeral Condyle Fractures in Children


Haillotte G, Bachy M, Delpont M, Kabbaj R, Ducou le Pointe H, Vialle R

The purpose of this study was to investigate the use of MRI in diagnosis and therapeutic decision in minimally displaced lateral condyle fractures in children.

Key Study: Minimal training sufficient to diagnose pediatric wrist fractures with ultrasound


Hedelin H, Tingstrm C, Hebelka H, Karlsson J

The aim of this study was to evaluate the role of ultrasound (US) as a point-of-care triage tool for pediatric wrist injuries with limited training.

Key Study: Functional outcomes following non-operative versus operative treatment of clavicle fractures in adolescents


Herzog MM, Whitesell RC, Mac LM, Jackson ML, Culotta BA, Axelrod JR, Busch MT...

This study aimed to assess shoulder function in adolescents following shortened clavicle fracture and compare operative versus non-operative treatment.

Key Study: Emerging U.S. National Trends in the Treatment of Pediatric Supracondylar Humeral Fractures


Holt JB, Glass NA, Bedard NA, Weinstein SL, Shah AS

Understanding national treatment trends will provide important insight into variations in regional treatment standards and help identify areas for improvement in value in care delivery.

Key Study: Outcome of Pediatric Forearm Fracture Reductions Performed by Pediatric Emergency Medicine Providers Compared With Reductions Performed by Orthopedic Surgeons: A Retrospective Cohort Study


Milner D, Krause E, Hamre K, Flood A

The aim of this study was to describe the outcome differences between board-certified orthopedists and pediatric emergency medicine physicians conducting forearm fracture reductions.

Key Study: Procedural Sedation With Ketamine Versus Propofol for Closed Reduction of Pediatric Both Bone Forearm Fractures


Morrison T, Carender C, Kilbane B, Liu RW

The current study was conducted to answer 2 questions for pediatric both bone forearm fractures treated with closed reduction with either ketamine or propofol procedural sedation : 1) Is there a difference in the rate of unacceptable alignment 4 weeks after reduction? 2) Is there a difference in the rates of major sedation-related complications?

Key Study: External validation of clinical decision rules for children with wrist trauma


Mulders MA, Walenkamp MM, Dubois BF, Slaar A, Goslings JC, Schep NW

The primary aim of this study was to provide an overview of all existing non-validated clinical decision rules for wrist trauma in children and to externally validate these rules in a different cohort of patients.

Key Study: Capitellar Fractures in Children and Adolescents: Classification and Early Results of Treatment


Murthy PG, Vuillermin C, Naqvi MN, Waters PM, Bae DS

The purpose of this investigation was to characterize capitellar fracture patterns in children and adolescents and to assess early clinical and radiographic treatment outcomes.

Key Study: Point-of-care Ultrasound for Nonangulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes


Poonai N, Myslik F, Joubert G, Fan J, Misir A, Istasy V, Columbus M, Soegtrop...

The objectives of the study were to examine the test performance characteristics of point-of-care ultrasound for nonangulated distal forearm injuries in children and compare to x-ray with respect to pain, caregiver satisfaction, and procedure duration.

Key Study: Bedside Ultrasound vs X-Ray for the Diagnosis of Forearm Fractures in Children


Rowlands R, Rippey J, Tie S, Flynn J

The primary aim of this study was to determine if a cohort of physicians with little or no previous experience with US could, after a short training program, safely exclude forearm fractures in children.

Key Study: Relevance of MRI for management of non-displaced lateral humeral condyle fractures in children


Thvenin-Lemoine C, Salanne S, Pham T, Accadbled F, Baunin C, Sales De Gauzy J

The primary objective of this study was to evaluate the ability of MRI to determine whether the fracture line is complete or incomplete in cases of non-displaced lateral humeral condyle fractures in children.

Key Study: Childhood Obesity Increases the Risk of Failure in the Treatment of Distal Forearm Fractures


Auer RT, Mazzone P, Robinson L, Nyland J, Chan G

A retrospective case-controlled study was conducted to determine whether obesity is an independent risk factor for the failure of closed reduction and casting.

Key Study: Influence of Immobilization Time on Functional Outcome in Radial Neck Fractures in Children


Badoi A, Frech-Drfler M, Hcker FM, Mayr J

The aim of the study was to analyze the influence of immobilization time on functional outcome.

Key Study: Functional Outcomes After Treatment of Scaphoid Fractures in Children and Adolescents


Bae DS, Gholson JJ, Zurakowski D, Waters PM

The purpose of this investigation was to characterize the functional outcomes of children and adolescents treated for scaphoid fractures.

Key Study: Diagnostic value of ultrasonography in elbow trauma in children: Prospective study of 34 cases


Burnier M, Buisson G, Ricard A, Cunin V, Pracros JP, Chotel F

This study evaluated the diagnostic contribution of ultrasonography in the treatment of acute elbow injuries in children and the strategic and economic impact of using this tool alongside radiography.

Key Study: Adherence behavior in an acute pediatric hand trauma population: A pilot study of parental report of adherence levels and influencing factors


Cole T, Underhill A, Kennedy S

The hand is a common site of injury in children; however, little is known regarding adherence to hand trauma management in this population.

Key Study: Forearm-Based Ulnar Gutter versus Hand-Based Thermoplastic Splint for Pediatric Metacarpal Neck Fractures: A Blinded, Randomized Trial


Davison PG, Boudreau N, Burrows R, Wilson KL, Bezuhly M

Primary outcome of this study was the difference in active range of motion between a conventional forearm-based ulnar gutter or hand-based thermoplastic splint.

Key Study: Reduced Length of Stay and Adverse Events Using Bier Block for Forearm Fracture Reduction in the Pediatric Emergency Department


Fauteux-Lamarre E, Burstein B, Cheng A, Bretholz A

This study sought to compare Bier block and procedural sedation for forearm fracture reduction.

Key Study: MRI shows a high incidence of carpal fractures in children with posttraumatic radial-sided wrist tenderness


Jrgsholm P, Thomsen N, Besjakov J, Abrahamsson S, Bjrkman A

This study describes fractures revealed by magnetic resonance imaging (MRI) in a prospective population of children and adolescents with posttraumatic radial-sided wrist tenderness, and compare the diagnostic value of radiographs and computed tomography (CT) with that of MRI.

Key Study: Primary Care Physician Follow-up of Distal Radius Buckle Fractures


Koelink E, Schuh S, Howard A, Stimec J, Barra L, Boutis K

The main objective was to determine the proportion of children referred to a primary care provider (PCP) for follow-up of a distal radius buckle fracture who subsequently did not deviate from this reassessment strategy.

Key Study: Manipulation and reduction of paediatric fractures of the distal radius and forearm using intranasal diamorphine and 50% oxygen and nitrous oxide in the emergency department: a 2.5-year study


Kurien T, Price KR, Pearson RG, Dieppe C, Hunter JB

This study presents the results of managing children's fracture of the distal forearm in the ED using intranasal diamorphine and Entonox to allow manipulation and discharge on the same day.

Key Study: Acute ischemia and pink pulseless hand in 68 of 404 gartland type III supracondylar humeral fractures in children: Urgent management and therapeutic consensus


Louahem D, Cottalorda J

The purpose of this retrospective study was to describe our strategy and to determine the guidelines of therapeutic consensus.

Key Study: Radiographic Evaluation During Treatment of Pediatric Forearm Fractures: Implications on Clinical Care and Cost


Luther G, Miller P, Waters PM, Bae DS

The purpose of this study was to analyze the clinical utility and cost of the week 4 radiograph following closed treatment of pediatric forearm fractures.

Key Study: Introduction of a simple guideline to improve neurological assessment in paediatric patients presenting with upper limb fractures


Marsh AG, Robertson JS, Godman A, Boyle J, Huntley JS

This study aimed to assess the improvement in documented neurological examination for children presenting with upper limb fractures following introduction of a simple guideline.

Key Study: Effect of a Computerized Reminder on Splinting of Pediatric Upper Limb Fractures in the Emergency Department


Mills E, Craig S, Oakley E

The primary objective was to assess if a computerized pop-up reminder increased splint application before X-ray in pediatric emergency department patients with deformed upper limb fractures.

Key Study: Is softcast (3M) strong enough for potentially unstable paediatric forearm fractures?


Patel N, Wilson L, Wansbrough G

This study aimed to investigate whether the mechanical properties of Softcast are sufficient to stabilize a paediatric forearm fracture and protect the patient from further injury against clinically defined failure parameters.

Key Study: Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary


Schuld JC, Volker ML, Anderson SA, Zwank MD

The objectives of this study were to determine how often X-rays are obtained after splinting of non-displaced fractures to identify if postsplinting X-rays change treatment management in the ED, and identify if there are medical complications at follow-up.

Key Study: A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules


Slaar A, Walenkamp MM, Bentohami A, Maas M, van Rijn RR, Steyerberg EW, Jager...

The objective of this study was to develop and validate a clinica decision rule to decide whether radiography in children with wrist trauma is required.

Key Study: Reducing Cost and Radiation Exposure During the Treatment of Pediatric Greenstick Fractures of the Forearm


Ting BL, Kalish LA, Waters PM, Bae DS

The purpose of this investigtion was to evaluate the LOR rate requiring intervention - including either repeat closed reduction or surgical reduction and fixation- following closed reduction and cast immobilization of pediatric greenstick forearm fractures.

Key Study: Long-term Functional Results of Neurological Complications of Pediatric Humeral Supracondylar Fractures


Valencia M, Moraleda L, Dez-Sebastin J

The aim of this study is to report the long-term functional outcome of neurological complications associated to pediatric supracondylar fractures.

Key Study: Using softcast to treat torus fractures in a paediatric emergency department


Callender O, Koe S

Wrist torus fractures in children are a frequent reason for Emergency Department (ED) visits. Torus fractures traditionally were treated with a backslab cast in the Children's ED and then referred to the Fracture Clinic. Guidelines were developed in order to standardise the care for children who attended the ED with a torus fracture. All patients who were seen & treated by the Advanced Nurse Practitioner (ANP) over a one year period with a diagnosis of a torus fracture were treated with immobilisation in a softcast. 119 patients met the criteria for inclusion. There were no adverse events recorded and no patient required subsequent visits to the Fracture Clinic. There was a cost savings of 18,596 as compared with the normal referral pathway to the Fracture Clinic.

Key Study: Feasibility of a reduction protocol in the emergency department for diaphyseal forearm fractures in children


Pesenti S, Litzelmann E, Kahil M, Mallet C, Jehanno P, Mercier JC, Ilharrebor...

The purpose of this study was to analyze the results of diaphyseal forearm fractures in the emergency department in children.

Key Study: Accuracy of ultrasonography for determining successful realignment of pediatric forearm fractures


Dubrovsky AS, Kempinska A, Bank I, Mok E

The primary objective of this study is to assess the accuracy of point-of-care ultrasonography compared with blinded orthopedic assessment of fluroscoppy in determining successful realignment of pediatric forearm fractures.

Key Study: Synthetic versus plaster of Paris casts in the treatment of fractures of the forearm in children: a randomised trial of clinical outcomes and patient satisfaction


Inglis M, McClelland B, Sutherland LM, Cundy PJ

The aim of this study was to investigate which cast material is superior for the management of fractures of the forearm.

Key Study: Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: a randomised multicentre study


Colaris JW, Biter LU, Allema JH, Bloem RM, van de Ven CP, de Vries MR, Kerver...

The purpose of this study was to find out whether below-elbow casts cause equal limitation of pronation and supination but with higher comfort level, compared with above-elbow casts.

Key Study: Bedside ultrasound in the diagnosis of pediatric clavicle fractures


Chien M, Bulloch B, Garcia-Filion P, Youssfi M, Shrader MW, Segal LS

The objective of this study was to determine the diagnostic accuracy of pediatric emergency physicians in diagnosing clavicle fractures by bedside ultrasound.

Key Study: Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial


Boutis K, Willan A, Babyn P, Goeree R, Howard A

This study aimed to determine whether the use of a prefabricated splint is as effective as a cast in the recovery of physical function.

Key Study: A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children


Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L

The objective of this study was to determine if children with distal radius and/or ulna buckle fractures treated with a removable splint have better physical functioning than those treated with a short arm cast for 3 weeks.

Key Study: Simple treatment for torus fractures of the distal radius


Davidson JS, Brown DJ, Barnes SN, Bruce CE

Based on the results of a postal questionnaire and a prospective randomised trial, this study descibes a simple treatement for a torus fracture of the distal radius, which saves both time and money.