Here it is: the dreaded pediatric elbow. Is it a fracture? An ossification center? Shouldn't there be a bone there? No, it's Superman.Radiographic assessment of acute pediatric elbow trauma requires a firm grasp of developmental anatomy, radiographic landmarks, and common injury patterns. By using a systematic approach to reading elbow x-rays delineated below, you can begin to feel more confident and adept at evaluating the subtle signs of pediatric fractures. Show
Why is the pediatric elbow difficult? 1. Ensure adequate films 2. Look for joint effusion and soft tissue swelling Distention of a structurally intact joint causes displacement of the fat pads - the posterior fat pad moves posteriorly and superiorly and becomes visible; the anterior fat pad becomes more sail-like.4 (Fig 2) On the lateral x-ray of the elbow, a joint effusion can be inferred when there is displacement of the anterior fat-pad or presence of the posterior fat pad. An elbow joint effusion without a visible fracture seen on radiographs can suggest an occult fracture and should prompt further evaluation. A study by Major et al.5 showed that a joint effusion without visible fracture seen on conventional radiographs is often associated with an occult fracture and bone marrow edema on MRI. The study found that 57% of imaging where the only finding was joint effusion had a fracture and 100% had bone marrow edema on MRI. In cases where an occult fracture is suspected, follow-up radiographs in 7-10 days can be obtained to evaluate for the presence or absence of sclerosis or periosteal new bone formation as indicators of healing. For suspected occult fractures, standard of care remains posterior elbow splinting with follow-up radiographs at 7-10 days. 3. Check bone alignment The anterior humeral line is drawn along the anterior cortex of the humerus and should bisect the middle third of the capitellum. Malalignment indicates a fracture - in most cases, posterior displacement of the capitellum in a supracondylar fracture. This sign relies on adequate ossification of the capitellum and therefore is reliable in children over the age of 4 years only.6 (Fig 3) The radiocapitellar line evaluates the relationship of the proximal radius to the capitellum on all views (Fig 4). If the integrity of this line is compromised, then dislocation should be suspected (Fig 5) 4. Identify ossification centers The medial epicondyle fuses to the shaft of the humerus at 13 years for females and 15 years for males. The growth plates are vulnerable to traction or shearing forces which result in fracture and/or apophyseal injuries. Displaced epicondyle fractures can be missed if the normal pattern of ossification development is not recognized.7 5. Identify Distal Humeral Fractures
Identify Radial and Ulnar Fractures
7. Management Upon discharge, include ED return precautions, information on splint care, and provide a sling. Cases that require immediate attention in an operating room include open reductions, inability to reduce with procedural sedation, and any contraindications to procedural sedation. References
Which of the following are fat pads or fat stripes that may be visible on the lateral projection of the elbow during trauma?The supinator fat pad/stripe is located at the proximal radius just anterior to the head, neck, and tuberosity. The posterior fat pad is not visible radiographically in the normal elbow. in the lateral projection of the elbow (the posterior pad only in the presence of trauma/injury). 1.
Which of the following projections of the elbow will show the radial head neck and tuberosity free of superimposition by the ulna?Chapter 5. Which of the following projections of the elbow will demonstrate the olecranon process within the olecranon fossa?The elbow internal oblique view is a specialized projection, utilized to demonstrate both the coronoid process in profile and the olecranon process sitting within the olecranon fossa of the humerus.
Which fat pad lies parallel with the anterior aspect of the proximal radius?Upper Extremeties. |