PEM Core: Give Me a Break! Managing Upper Extremity Trauma

PEM Core: Give Me a Break! Managing Upper Extremity Trauma

PEM Core is a monthly curriculum focused on reviewing PEM Certification Exam (Boards) Content.  It is not intended to be a complete review of a case or topic, but rather “hits the high points” about a board topic from the The American Boards of Pediatrics Pediatric Emergency Medicine Content Outline.

Orthopedic Trauma makes up of 10-15% of Emergency Department visits.  This month on PEM Core, we are discussing the management principals of extremity trauma. 

The Initial Approach

As in all cases of trauma, start with the ABC’s and/or ATLS.  Extremity deformities are a classic distracting injury, therefore a standardized approach will help prevent misses.  

Assess for Emergent Complications

Neurovascular Compromise 
Open Fractures
Presence of Compartment Syndrome 
Unrecognized Bleeding (Pelvic and/or Femur Fractures)

Key History Components

Subjective Dysfunction
(Injured extremity vs uninjured extremity)

Key Physical Exam Components

Compare Two Extremities
Range of Motion
Loading (Axial and Transverse) 

Criteria for Radiographic Evaluation

Point Tenderness
Pain with Loading
Significant Amount of Swelling
Very Limited or No Range of Motion 

The Upper Extremity

Clavicle Fracture

Usually from direct trauma, falls against the humerus, or FOOSH

Exam Features:

Carrying the injured arm 
Focal tenderness over the clavicle 
Positive Scarf Sign 


Point of Care Ultrasound: Sensitivity 95% and Specificity of 96% with similar pain scores. [1]


When proximal or sternoclavicular joint dislocation with posterior displacement (risk of great vessel injury and/or impingement)

Immobilize, RICE, Pain Control (tylenol/ibuprofen)
Orthopedics Referral if distal clavicle fracture

Posterior dislocation can lead to compression of Major Vessels, the Esophagus, the Trachea.

Be suspicious if the patient is having stridor, tachypnea, dysphagia, or significant tachypnea

Image taken from–conditions/sternoclavicular-sc-joint-disorders/

Separated Shoulder

AP XR image of anterior shoulder dislocation.

Ligamentous injury to the acromioclavicular joint +/- the coracoclavicular joint.

>95% are anterior dislocations in adolescents 

Usually injured from external rotation and abduction with force applied posteriorly   

Exam Features:

Significant pain 
High levels of anxiety
No ROM with a sulcus sign


Point of Care Ultrasound


Be sure to provide adequate analgesia and muscle relaxation. 
Intraarticular Lidocaine is a great alternative to conscious sedation. 

See video below for 10 different techniques by Larry Mellick at the Medical College of Georgia

Bankart Lesion: a tear of glenoid labrum
Hill-Sachs Fracture: an indentation fracture to the humerus

Proximal Humerus Fracture

AP XR image of a left proximal humerus fracture.

Usually from a direct blow, fall on adducted arm or external rotation with abduction and posterior force applied. 

Proximal fractures are more common in the 5-11 year age group.

Exam Features:

Arm held in extension
Significant point tenderness
Painful ROM 
Anterior mass as distal fragment is pulled forward by the upper arm muscles


Point of Care Ultrasound


Can tolerate 1cm separation, <40 degrees of angulation, no malrotation  
Sling and swath 
Pain Management
Outpatient Orthopedics follow-up in 1 week

Orthopedics Consultation in the ER if:
Significant displacement
>10yr old
Intra-articular involvement

Elbow Injuries


Rare in kids (~6%)
Commonly occurs with concurrent fractures 

Exam Features:

Obvious deformity
Localized pain and edema 
Carefully assess for ulnar nerve entrapment and brachial arterial injury




Make sure to obtain X-ray to check for associated fracture.
Orthopedics consultation
Prompt reduction required (video below from 




Mechanism of elbow dislocations from LOPT.

Image of an elbow dislocation from Life in the Fast Lane.

Elbow Fracture: Supracondylar Fractures 

Can be difficult to diagnose
Elbow injuries are associated with multiple complications 
TRASH Lesions: “The Radiographic Appearance Seemed Harmless”

Exam Features:

Can have an obvious deformity
Swelling (Almost always a sign of underlying injury)


X-ray Findings to Be Aware of:

Radiocapitellar Lines
Anterior Humeral Line
Ossification Centers of the Elbow (CRITOE)
Anterior and Posterior fatpads


Supracondylar Fractures [2]: Shown below

If displaced, requires closed reduction and casting. 

If there is swelling around the elbow, assume injury and discuss with orthopedics 

Supracondylar Fractures from Top to Bottom: Type 1 (anterior and posterior fat pads), Type 2 (abnormal anterior humeral line), Type 3 (obvious displacement

CRITOE Elbow Ossification from

Anterior and posterior fat pads on a supracondylar fracture

Forearm Injuries



Usually FOOSH
Direct Blow

Exam Features:

+/- Deformity
Localized pain and edema 
Decreased ROM



When to Call Orthopedics: 


If <8yo
>20°-25° of flexion-extension angulation
>10°of radial-ulnar deviation
The more proximal the injury, the less angulation is tolerated
Malrotation will not remodel

Salter Harris III or above

Open Fractures

Neruovascular compromise 

Monteggia or Galeazzi Fracture 

Monteggia Fracture: Ulnar fracture with radial head dislocation

Galeazzi Fracture: Fracture of the radius with ulnar head dislocation

Other Complicated Forearm Fractures from Zlotolow J Hand Surg Am 2012



Other Images taken from Dr. Gary Geis and his Extremity Trauma Lecture. 

Cross KP, et al. Acad Emerg Med. 2010 Jul;17(7):687-93.

Mulpuri J Pediatr Orthop 2012

Zlotolow J Hand Surg Am 2012; Bae J Hand Surg Am 2008

Dr. A van der Plas (MSK radiologist Maastricht UMC)

Ossification centers of the elbow

Dr Mike Cadogan, last update September 9, 2019 Elbow Dislocation

Physical Therapy in Lincoln and Ashland for Elbow Issues. Elbow Dislocation.

Should pitchers deadlift? Last Updated On: August 7, 2017

Sternoclavicular (SC) Joint Disorders–conditions/sternoclavicular-sc-joint-disorders/

Ashish Shah is an assistant professor and Pediatrics and Family Medicine Residency Education Director at Rady Children’s Hospital interested in creating PEM 4 all stages of learners caring for children seen in the emergency department

Leave a Reply