pediatric elbow injuries -...
TRANSCRIPT
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
Gray's Anatomy, 40th Edition
Articular Surfaces
Gray's Anatomy, 40th Edition
DISTAL HUMERUSANTERIOR VIEW
DISTAL HUMERUSPOSTERIOR VIEW
ULNAOBLIQUE VIEW
Gray's Anatomy, 40th Edition
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
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
Ossification Centers
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
The Growth Plate
www.uptodate.com: Elbow anatomy and radiographic diagnosis of elbow fracture in children
Ossification Centers
www.uptodate.com: Elbow anatomy and radiographic diagnosis of elbow fracture in children
Ossification Centers
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
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
Ossification Centers
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
Ossification Centers
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
Dx:
Joint EffusionSupracondylar Fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
Thank You.Questions?
Sample Case 2
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
Dx:
Joint EffusionNo visible fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
LON
GIT
UDI
NAL
TRAN
SVER
SE
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
Gray's Anatomy, 40th Edition
Nerves
• Median nerve crosses elbow to form the interosseous
www.uptodate.com: Elbow anatomy and radiographic diagnosis of elbow fracture in children
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
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE ONE
Joint effusion, no fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE TWOCHECKLIST
✓Anterior fat pad
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE THREECHECKLIST
✓Anterior fat pad
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
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.
www.uptodate.com: Evaluation and management of supracondylar fractures in children
Complications
www.uptodate.com: Evaluation and management of supracondylar fractures in children
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
ortho, closed vs. reduction w/pin
ortho, closed vs. reduction w/pin
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.
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
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://emedicine.medscape.com/article/415822
CASE SIX
Medial Epicondylar Fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.htmlwww.uptodate.com: Epicondylar and transphyseal elbow fractures in children
Medial Epicondylar Fracture
• 10% pediatric elbow fractures
• boys >> girls
• 9-14 yo
• associated with posterior elbow dislocation
Medial Epicondylar Fracture
CASE SEVENCHECKLIST
✓Anterior fat pad
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE SEVEN
Salter Harris II fracture of Humerus
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE EIGHTCHECKLIST
✓Anterior fat pad
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE EIGHT
Joint effusion Ulna fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE NINECHECKLIST
✓Anterior fat pad
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE NINEJoint effusion Supracondylar
fracture Possible proximal
radius fracturehttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE TWOCHECKLIST
✓Anterior fat pad
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE TWO
Joint effusion, no fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE x
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE OCHECKLIST
✓Anterior fat pad
✓Posterior fat pad
✓Anterior humeral line
✓Radial head contour
✓Radiocapitellar line
✓Ossification centers
✓Hourglass sign
✓Distal humerus
✓Ulna/Olecranon
✓Clinical correlation
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
CASE O
• Joint effusion. Radial head fracture.
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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
ANGLE
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