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Upper-extremity impairment in young children
1Division of Emergency Medicine, Children's Hospital, Boston, Massachusetts, USA.
Insights
Most young children with upper extremity immobility have radial head subluxation (RHS) or fractures. Clinical findings can help differentiate diagnoses, but rare non-trauma causes like infection should be considered in infants.
Area of Science:
- Pediatric Emergency Medicine
- Orthopedic Surgery
- Pediatric Traumatology
Background:
- Upper extremity injuries are common in young children.
- Accurate diagnosis is crucial for appropriate management and to avoid complications.
Purpose of the Study:
- To determine the spectrum of pediatric upper extremity disorders in children under 6 years.
- To identify clinical findings associated with specific diagnoses.
Main Methods:
- Prospective observational study in a pediatric emergency department.
- Inclusion of children under 6 years with upper extremity injury or immobility over a 6-month period.
- Analysis of diagnoses and clinical findings.
Main Results:
- 178 episodes evaluated; Radial Head Subluxation (RHS) was most common (63%), followed by fractures (22%) and soft-tissue injuries (13%).
- Younger children (<4 months) with immobility were more likely to have infection or neurologic impairment.
- Clinical signs like point tenderness and swelling correlated with fractures, while decreased arm movement and a "pull" mechanism suggested RHS.
Conclusions:
- Bony or soft-tissue trauma, primarily RHS, accounts for most pediatric upper extremity injuries.
- Clinical assessment aids in differentiating RHS from fractures, guiding decisions on reduction or radiography.
- Non-trauma diagnoses are rare but important considerations, especially in infants; appropriate immobilization and follow-up are key for unclear cases.
Study Objective:
To determine the spectrum of disorders in children younger than 6 years with upper-extremity injury or immobility and to identify clinical findings associated with specific disorders.
Design:
Prospective patient series.
Setting:
Urban pediatric emergency department.
Participants:
Children younger than 6 years seen during a 6-month period with injury or immobility of an upper extremity.
Results:
We identified 178 episodes of immobility or injury of an upper extremity. Radial head subluxation (RHS) was the most frequent diagnosis (63%; 99 definite and 13 probable), followed by fracture (22%) and soft-tissue injury (STI; 13%). One patient each had humeral osteomyelitis and neurologic impairment. The mean age of children with RHS was significantly less than that of children with fractures (27 +/- 12 months versus 39 +/- 19 months, P < .01); the only diagnoses in children younger than 4 months old were infection and neurologic impairment. Multivariate regression analysis showed point tenderness and swelling correlated with fractures (P < .05). Decreased arm movement, absence of swelling, and a pull as the mechanism of injury correlated with RHS (P < .05). However, arm traction occurred in only 55% of the children with RHS (95% confidence interval = .46 to .64). By 1 week after the evaluation, all children without fractures had recovered, except one each with a sprain, osteomyelitis, and neurologic impairment.
Conclusion:
Most children with arm injury or immobility have bony or soft-tissue trauma, the majority being RHS. Clinical findings varied between diagnoses and may aid the clinician in deciding whether attempted reduction of RHS is indicated or whether radiographs are warranted first. Nontrauma diagnoses are unusual but should be considered, particularly in the child younger than 6 months old. Appropriate immobilization and follow-up are important for the management of children without a clear diagnosis at the initial evaluation.