Pediatric Elbow Injuries -...

Pediatric Elbow RadiologySeema Awatramani, MDFriday, April 5, 2018ACOEP Spring Seminar

Disclosure

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Background

• 65% of all fracture/dislocation are UE

• Elbow fractures more common in kids

• Supracondylar fractures

• 16.6% of all childhood fractures

• 30% of fractures from 0-7 years

Recommended Resource

Radiology Cases in Pediatric Emergency MedicineUniversity of Hawaii

http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

Topic Outline

• Back to Basics

• Anatomical & radiographic markers

• Xray

Anatomy• Bony anatomy

• Joint anatomy

• Ossification

• Radiographic anatomy

Anatomy -basics

POSTERIOR VIEW ANTERIOR VIEW

Gray's Anatomy, 40th Edition

Anatomy -basics

POSTERIOR VIEW ANTERIOR VIEW

Articular Surfaces

DISTAL HUMERUSANTERIOR VIEW

DISTAL HUMERUSPOSTERIOR VIEW

ULNAOBLIQUE VIEW

The Joint

www.uptodate.com: Elbow anatomy and radiographic diagnosis of elbow fracture in children

Supracondylar Fractures

Green NE. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children, 3rd, Green NE, Swiontkowski MF. (Eds), WB Saunders, Philadelphia 2003. p.207-276.

www.uptodate.com: Evaluation and management of supracondylar fractures in children

Putting it Together

Radiographic Anatomy of Adult Elbow. OrthopaedicsOneArticles. ver.4. http://www.orthopaedicsone.com/x/lgBeAQ.

1 lateral supracondyle ridge

2 medial supracondyle ridge

3 olecranon fossa

4 medial epicondyle

5 lateral epicondyle

6 capitulum

7 olecranon

8 trochlea

9 coronoid process of ulna

10 proximal radioulnar joint

11 head of radius

12 neck of radius

13 tuberosity of radius

14 ulna

Putting it Together1 supracondylar ridge

2 trochlea

3 olecranon

4 trochlear notch

5 coronoid process of ulna

6 head of radius

7 neck of radius

8 tuberosity of radius

9 ulna

Radiographic Anatomy of Adult Elbow. OrthopaedicsOne Articles. ver.4. http://www.orthopaedicsone.com/x/lgBeAQ.

Ossification Centers

The Growth Plate

Location Age

C capitellum 1

R radial head 3

I internal (medial) epicondyle 5

T trochlea 7

O olecranon 9

E external (lateral) epicondyle 11

Radiographic Anatomy

• AP: epicondyles and articular surfaces

• Lateral: humerus to forearm, fat pads

• Oblique: coronoid, radio-ulnar joint

Radiographic Lines

ANTERIOR HUMERAL LINERADIOCAPITELLAR LINE

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondylar_fracture_of_the_humerus_Emergency_Department/

Radiographic Anatomy

ANTERIOR HUMERAL LINERADIOCAPITELLAR LINE

http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.html

Fat Pads

http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.html

Fat-Pads

• Fat pad = joint effusion

• Fat pad without fracture = occult fracture?

Skaggs DL, et al; The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 1999 Oct;81(10):1429-33.

Donnelly LF, et al, ; Traumatic elbow effusions in pediatric patients: are occult fractures the rule? AJR Am J Roentgenol. 1998 Jul;171(1):243-5.Pudas T, et al; Magnetic resonance imaging in pediatric elbow fractures. Acta Radiol. 2005 Oct;46(6):636-44.

Al-Aubaidi Z, et al.; The role of fat pad sign in diagnosing occult elbow fractures in the pediatric patient: a prospective magnetic resonance imaging study. J Pediatr Orthop B. 2012 Nov;21(6):514-9.

Major NM et al; Elbow effusions in trauma in adults and children: is there an occult fracture? AJR Am J Roentgenol. 2002 Feb;178(2):413-8.de Beaux AC et al; Elbow fat pad sign: implications for clinical management. J R Coll Surg Edinb. 1992 Jun;37(3):205-6.

Hourglass Sign

ABNORMALNORMAL

Proper Positioning

http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.htmlGreen NE. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children, 3rd, Green NE,

Swiontkowski MF. (Eds), WB Saunders, Philadelphia 2003. p.207-276www.uptodate.com: Evaluation and management of supracondylar fractures in children.

The checklist

Summary Outline

1 Anterior fat pad

2 Posterior fat pad

3 Anterior humeral line

4 Radial head contour

5 Radiocapitellar line

6 Ossification centers

7 Hourglass sign

8 Distal humerus

9 Ulna/Olecranon

10 Clinical correlation

Sample Case

CHECKLIST✓Anterior fat pad✓Posterior fat pad

✓Anterior humeral line✓Radial head contour✓Radiocapitellar line✓Ossification centers✓Hourglass sign✓Distal humerus✓Ulna/Olecranon✓Clinical correlation

Joint EffusionSupracondylar Fracture

Thank You.Questions?

Sample Case 2

CHECKLIST✓Anterior fat pad✓Posterior fat pad

✓Anterior humeral line✓Radial head contour✓Radiocapitellar line✓Ossification centers✓Hourglass sign✓Distal humerus✓Ulna/Olecranon✓Clinical correlation

Joint EffusionNo visible fracture

Elbow Ultrasound

Rabiner JE et al; Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children. Ann Emerg Med. 2012 Nov 9. [Epub]

PROBE PLACEMENT NORMAL ABNORMAL

Elbow Ultrasound LONGITUDINAL TRANSVERSE

Rabiner JE et al; Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children. Ann Emerg Med. 2012 Nov 9. [Epub]

Elbow Ultrasound

• sensitivity 98% (88-100%)• specificity 70% (60-79%)• LR 3.3 (2.4-4.5)• NLR 0.03 (0.01-0.23)

Rabiner JE et al; Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children.Ann Emerg Med. 2012 Nov 9. [Epub]

Elbow Ultrasound•sensitivity 98% (88-100%)

•specificity 70% (60-79%)

•LR 3.3 (2.4-4.5)•NLR 0.03 (0.01-

0.23)Rabiner JE et al; Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children. Ann Emerg Med. 2012 Nov 9. [Epub]

Vessels

• Brachial artery prone to damage

• Extensive collaterals

• Ischemia is rare

Nerves

• Median nerve crosses elbow to form the interosseous

CASE ONECHECKLIST

✓Anterior fat pad

✓Posterior fat pad

✓Anterior humeral line

✓Radial head contour

✓Radiocapitellar line

✓Ossification centers

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

✓Clinical correlation

CASE ONE

Joint effusion, no fracture

CASE TWOCHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE TWO

Radial Metaphyseal

Head Fracturehttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

Radial

Fractures• about 5-8% of all pediatric elbow fx

• Ages 9-12

• FOOSH with extended elbow

• Pain/swelling proximal radius, pain on supination

Radial

Fractures• 50% accompanied by second injury

• accompanied by dislocations

REDUCTION DISLOCATION

Green NE. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children, 3rd, Green NE, Swiontkowski MF. (Eds), WBSaunders, Philadelphia 2003. p.207-276.

Radial

Fractures

AP & LATERAL OBLIQUE

CASE THREECHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE THREEJoint effusion, olecranon fracture

and radial head dislocation

Monteggia injuryhttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

Monteggia Fracture

• Proximal ulnar fracture accompanied by a radial head dislocation

• FOOS(Arm) in pronation

• 2% pediatric elbow fractures

CASE FOURCHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE FOUR

Joint EffusionSupracondylar

Fracturehttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

Supracondylar Fracture• 60% pediatric elbow fractures

• 5-10 years

• flexion and extension mechanisms

• 70% fall on outstretched arm

• non-dominant arm more common

• <3 ft fall for children <3yo

Pertinent Anatomy

Complications

PROXIMALLATERAL

DISPLACEMENT

PROXIMALMEDIAL

DISPLACEMENT

Complications

Classifications

I II III IV

PE minimal swellingTTP

pain with elbow movement

some movement

no movementarm in extension

much swellingecchymosis

no movementmuch swelling

eccymosismore unstable

tx posterior splint vs. sling

ortho, closed vs. reduction w/pin

Bony Injuries to the ElbowCondylar Fractures

• Medial condyle• Lateral condyle

T-Condylar Fractures

Capitellar Fracture

Epicondylar Fractures

• Medial epicondyle• Lateral epicondyle

Transphyseal Fractures

Floating Elbow Fractures

Proximal Elbow Fractures

• Radial head/neck• Coronoid• Olecranon• Monteggia

Supracondylar Fractures

Dislocations

• Elbow Joint• Radial Head

Radial Head Subluxation

Questions?

Thank You!Happy Holidays!!

• sds

CASE SIXCHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

http://emedicine.medscape.com/article/415822

CASE SIX

Medial Epicondylar Fracture

http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.htmlwww.uptodate.com: Epicondylar and transphyseal elbow fractures in children

• 10% pediatric elbow fractures

• boys >> girls

• 9-14 yo

• associated with posterior elbow dislocation

CASE SEVENCHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE SEVEN

Salter Harris II fracture of Humerus

CASE EIGHTCHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE EIGHT

Joint effusion Ulna fracture

CASE NINECHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE NINEJoint effusion Supracondylar

fracture Possible proximal

radius fracturehttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

CASE TWOCHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE TWO

Joint effusion, no fracture

Other Modalities:Ultrasound

• Looking for posterior fat pad

• More sensitive than X-ray for fat pad

• Can also see lipohemarthrosis

CASE xCHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE x

CASE OCHECKLIST

✓Anterior fat pad

✓Hourglass sign

✓Distal humerus

✓Ulna/Olecranon

CASE O

• Joint effusion. Radial head fracture.

Oblique View

• Coronoid process

• Trochlear notch

• Medial trochlear profile

Bony AnatomyFun Fact #2

• The cubit is a traditional unit of length: from the elbow to the tip of the middle finger.

• Standard/Biblical cubits: 6 palms x 4 fingers = 24 digits

• Egyptian Royal cubits: 7 palms x 4 fingers = 28 digits

Olecranon Fx

Mechanism of flexion injuries.(A) In the flexed elbow, force develops on the posterior aspect of the olecranon (small double arrow) because of the pull of the brachialis and triceps muscles (large arrows).(B) Failure occurs on the tension side, which is posterior as a result of the muscle pull or a direct blow to the prestressed posterior olecranon.

Reproduced with permission from: Erickson M, Frick S. Fractures of the proximal radius and ulna. In: Rockwood and Wilkins' Fractures in Children, 7th ed, Beaty JH, Kasser JR (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. Copyright © 2010 Lippincott Williams & Wilkins.

Coronoid Fx

Proper Positioning

http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.htmlGreen NE. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children, 3rd, Green NE, Swiontkowski MF. (Eds), WB

Saunders, Philadelphia 2003. p.207-276.

Proper Positioning

http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.htmlwww.uptodate.com: Evaluation and management of supracondylar fractures in children

Carrying Angle

• Females > Males

• Check alignment after injury

VALGUS CARRYING

FUN FACT!!!!#4

Fat-Pads

• Prospective cohort 231 elbow injuries

• Normal AFP is highly associated with absence of elbow fracture

• sensitivity 96.4% (86.6%-99.4%)

• NPV was 98.2% (93.1%-99.7%).

Blumberg SM et al.; The predictive value of a normal radiographic anterior fat pad sign following elbow trauma in children. Pediatr Emerg Care. 2011 Jul;27(7):596-600.

Fracture Description• Bony anatomy

• Joint anatomy

• Ossification

• Radiographic anatomy

• Vessels

• Nerves

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