Pediatric upper extremity trauma is common, with treatments including both surgical and nonsurgical management. The evaluation should begin with a thorough history and physical examination. As the only indications for emergent care for these fractures are neurovascular or open injuries, the physical examination should specifically identify if these injuries are or are not present. When assessing a long bone, radiographs of the bone and the adjacent joints should be obtained; similarly, when assessing a joint, the long bone or bones proximally and distally should be imaged as well. Interpretation of radiographs requires knowledge of the age-dependent ossification patterns of the developing upper extremity and the relative contributions of the most proximate physis (Figure 1).

The sternoclavicular joint connects the upper extremity to the axial skeleton. The medial clavicle is the last bone to ossify and last physis to close, at approximately age 18 to 20 years and 23 to 25 years, respectively.¹ Therefore, an injury that may initially appear to be a sternoclavicular dislocation may instead be a physeal injury. The sternoclavicular joint is a diarthrodial joint that is stabilized by the costoclavicular ligament and sternoclavicular capsule. Sternoclavicular dislocations/physeal injuries often occur because of indirect trauma to the shoulder joint and present with swelling and pain localized to the joint.¹ Less commonly, a high-energy direct blow to the sternoclavicular joint can result in injury. When a sternoclavicular injury is suspected on radiographs, serendipity radiographic views and advanced imaging are recommended.

The joint can dislocate both anteriorly and posteriorly. Anterior dislocations represent between 95% and 97% of dislocations and are managed with a sling.² Acute anterior dislocations can be managed with sedation and reduction within 7 to 10 days of injury, but redislocation occurs in 50% of patients.³ Although there are limited cohorts of patients with anterior sternoclavicular dislocations and long-term follow-ups, a small study of five patients demonstrated four patients with good/excellent outcomes and only one with fair/poor outcomes.⁴ As discussed in a 2020 study, posterior dislocations or posteriorly displaced fractures can lead to impingement of the clavicle on mediastinal structures (the trachea, esophagus, brachial plexus, and vascular structures), so they often require surgical management.⁵ These posterior dislocations are reduced in an operating room with a cardiothoracic or vascular surgeon on standby. Closed reduction is often unsuccessful or
unstable and can potentially lead to impingement of mediastinal structures or chronic instability, so fixation is advocated.⁵ Fixation methods include all-suture fixation, wire cerclage fixation, and plate fixation; Kirschner wire fixation is not recommended given migration potential. Postoperatively, patients are non-weight bearing in a sling for 4 to 6 weeks, followed by weight bearing as tolerated and progressive motion, with return to all activities by 3 months.⁶,⁷ A 2021 study of 37 patients who underwent open reduction and suture fixation of acute posterior sternoclavicular fracture-dislocations with 5-year follow-up demonstrated good functional outcomes, with most patients returning to full activity with no pain. Despite this, 29% of the patients reported that their injury affected their ability to participate in sports, citing difficulty with recreational activities that involve impact to the involved upper extremity.⁶

Clavicle fractures make up 8% to 15% of all pediatric fractures, with up to 85% occurring in the middle third, and are seen in all age ranges.⁸ Newborns may sustain birth-related fractures and present with pseudoparalysis of the arm because of pain. Birth-related fractures may also have concomitant brachial plexus injuries, so the patient should be evaluated with a thorough neurologic examination of the extremity. Infants with a clavicle fracture can be treated with pinning of the sleeve of the injured arm to the chest or with a swaddle. In an infant with an incidental finding of a clavicle fracture on radiographs with no tenderness, pseudarthrosis of the clavicle should be considered. Congenital pseudarthrosis presents with diaphyseal disruption, rounded-off edges of the clavicle on radiographs, is nontender, and usually on the right side because of the subclavian arch position.⁹

Children and adolescents with clavicle fractures are generally treated nonsurgically, although this continues to be a source of debate (Figure 2). Absolute surgical indications include vascular injury, threatening of the skin, and open fractures; relative surgical indications include significant shortening (2 cm) of the shoulder girdle, particularly on the dominant side in high-level athletes.¹⁰

A 2019 systematic review demonstrated that surgical fixation of displaced midshaft clavicle fractures resulted in faster return to activity and improved Constant scores, but it came at the cost of higher complications and frequent secondary surgical procedures to remove implants.¹¹ From 1999 to 2011, an increase in surgical fixation of clavicle fractures in adolescents was observed, despite a lack of evidence-based support.⁸ Adolescent patients who are treated for clavicle fractures in adult hospitals are five times more likely to undergo surgical fixation, compared with those treated in pediatric hospitals.¹²

However, more recent studies have found that there is no difference in outcomes in managing midshaft clavicle fractures surgically versus nonsurgically. In multiple studies, both groups have good functional outcomes and equivalent functional scores, and nonsurgical patients were found to have equal or better cosmetic satisfaction.¹³,¹⁴,¹⁵

Shoulder dislocations are less common in the pediatric population as the proximal humeral physis usually fails before the soft tissues of the joint. Most shoulder dislocations in the pediatric population occur in male adolescents during contact sports.¹⁶ Diagnostic radiographs should include an AP, scapular Y, and axillary views. Most commonly, the dislocation is anterior.

Patients undergo closed reduction, and the arm is placed into a sling. A postreduction neurologic examination should be documented; the axillary nerve is the most injured nerve. For first-time dislocators, patients can participate in physical therapy after a 1- to 2-week period of immobilization.¹⁷ Males and younger patients are more likely to sustain a second dislocation, with more than 70% sustaining a repeat dislocation.¹⁸,¹⁹ Given this statistic, and the damage that each dislocation has been found to cause to the glenoid, there has been a recent push for surgical management after first-time dislocations in high-risk patients.¹⁶,²⁰ In patients with recurrent dislocations, surgery may be indicated to prevent recurrence. Surgery, whether arthroscopic or open, is dictated by concurrent pathology in the shoulder, including Hill-Sachs lesions, labral tears, or bony Bankart lesions.

Proximal humerus fractures account for 2% of all pediatric fractures.²¹ The proximal humerus physis provides 80% of the growth of the bone, providing ample remodeling potential. Thus, most proximal humerus fractures can be managed nonsurgically. In patients older than 5 years, most fractures are Salter-Harris type II extending into metaphysis (Figure 3).

Nondisplaced fractures, or fractures that are sustained perinatally, can be managed with a sling, shoulder immobilizer, or a hanging arm cast in the older patient for 3 to 4 weeks duration.²¹ The only absolute surgical indications are open fractures and fractures associated with vascular injury.²² There is controversy surrounding what angulation or displacement necessitates surgical fixation; surgery may be beneficial if patients are older than 13 years, with angulation of over 40°, or with more than two-thirds displacement of the shaft width (Neer IV).²¹,²² Of note, an absolute number for angulation has not been defined by the literature. Patients with a block to internal/external rotation motion due to impingement of the shortened shaft on the glenoid or who have a block to reduction due to interposition of the biceps tendon will benefit from reduction and surgical fixation. Younger patients with more growth left tolerate more angulation and displacement than older patients. Surgical fixation options include closed or open reduction and fixation with percutaneous wires, cannulated screws, plates, or retrograde elastic intramedullary nails, all of which have been shown to have excellent outcomes.²² Depending on the fracture severity and specific sport, most patients return to full activities by 3 to 4 months after surgical fixation.²¹

Humeral shaft fractures account for 5% of all pediatric fractures, and they most commonly occur in patients younger than 3 years or older than 10 years.²³ When associated with birth injury, infants require reassessment to evaluate for possible concomitant brachial plexus palsy, which occurs in nearly one-fourth of birth-related humeral shaft fractures.²⁴ Patients may also present with initial pseudoparalysis because of pain of the fracture.
Humeral shaft fractures in infants are managed with a swathe or pinning of a sleeve to the chest.

Older children and adolescents with humeral shaft fractures are most often treated nonsurgically with a coaptation splint, Sarmiento brace, or hanging arm cast for approximately 6 weeks.²³ Surgical fixation is indicated for open fractures and may be indicated for greater than 15° to 30° angulation, particularly those with varus angulation, with less angulation tolerated with more distal fractures.²⁵ Flexible elastic intramedullary nails, plating, and external fixation techniques have all been described.²³ After flexible nailing, patients are immobilized for 1 to 2 weeks, and radiographic union is achieved between 7 and 10 weeks postoperatively.²³,²⁵ When compared with nonsurgical management, surgical management was found to have shorter immobilization time and improved radiographic appearance but showed no difference in functional long-term outcomes or posttreatment pain.²³

Supracondylar humerus fractures are the most common elbow fractures in the pediatric population and commonly occur in patients between age 5 and 8 years. They are classified based on the direction of displacement, either into extension or flexion. More than 90% of the fractures are extension type, which is further classified by the Gartland classification system.²⁶ The Gartland classification system is based on posterior displacement of the distal fragment (Figure 4). On the lateral elbow radiograph, the anterior humeral line should
intersect the middle third of the capitellum, unless a patient is younger than 5 years, in which case the anterior humeral line should touch the capitellum.²⁶ Type I fractures are nondisplaced or minimally angulated, and on a lateral elbow radiograph, they may only be evident based on a posterior fat pad sign. Type II fractures have an intact posterior hinge, whereas type III fractures are completely displaced posteriorly because of complete disruption of the posterior cortex. A modification to the Gartland classification added a type IV, which can only be diagnosed intraoperatively. In type IV fractures, there is circumferential disruption of both the anterior and posterior periosteum, creating a fracture that is grossly unstable in both flexion and extension.