pediatric elbow injuries -...
TRANSCRIPT
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Pediatric Elbow RadiologySeema Awatramani, MDFriday, April 5, 2018ACOEP Spring Seminar
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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.
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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
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Recommended Resource
Radiology Cases in Pediatric Emergency MedicineUniversity of Hawaii
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Topic Outline
• Back to Basics
• Anatomical & radiographic markers
• Xray
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Anatomy• Bony anatomy
• Joint anatomy
• Ossification
• Radiographic anatomy
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Anatomy -basics
POSTERIOR VIEW ANTERIOR VIEW
Gray's Anatomy, 40th Edition
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Anatomy -basics
POSTERIOR VIEW ANTERIOR VIEW
Gray's Anatomy, 40th Edition
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Articular Surfaces
Gray's Anatomy, 40th Edition
DISTAL HUMERUSANTERIOR VIEW
DISTAL HUMERUSPOSTERIOR VIEW
ULNAOBLIQUE VIEW
Gray's Anatomy, 40th Edition
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The Joint
www.uptodate.com: Elbow anatomy and radiographic diagnosis of elbow fracture in children
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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
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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
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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.
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Ossification Centers
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Ossification Centers
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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The Growth Plate
www.uptodate.com: Elbow anatomy and radiographic diagnosis of elbow fracture in children
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Ossification Centers
www.uptodate.com: Elbow anatomy and radiographic diagnosis of elbow fracture in children
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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
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Ossification Centers
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Ossification Centers
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Radiographic Anatomy
• AP: epicondyles and articular surfaces
• Lateral: humerus to forearm, fat pads
• Oblique: coronoid, radio-ulnar joint
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Radiographic Lines
ANTERIOR HUMERAL LINERADIOCAPITELLAR LINE
http://www.rch.org.au/clinicalguide/guideline_index/fractures/Supracondylar_fracture_of_the_humerus_Emergency_Department/
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Radiographic Anatomy
ANTERIOR HUMERAL LINERADIOCAPITELLAR LINE
http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.html
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Fat Pads
http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.html
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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.
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Hourglass Sign
ABNORMALNORMAL
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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.
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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
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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
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Dx:
Joint EffusionSupracondylar Fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Thank You.Questions?
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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
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Dx:
Joint EffusionNo visible fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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
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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]
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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]
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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]
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Vessels
• Brachial artery prone to damage
• Extensive collaterals
• Ischemia is rare
Gray's Anatomy, 40th Edition
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Nerves
• Median nerve crosses elbow to form the interosseous
www.uptodate.com: Elbow anatomy and radiographic diagnosis of elbow fracture in children
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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
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CASE ONE
Joint effusion, no fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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
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CASE TWO
Radial Metaphyseal
Head Fracturehttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Radial
Fractures• about 5-8% of all pediatric elbow fx
• Ages 9-12
• FOOSH with extended elbow
• Pain/swelling proximal radius, pain on supination
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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.
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Radial
Fractures
AP & LATERAL OBLIQUE
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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
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CASE THREEJoint effusion, olecranon fracture
and radial head dislocation
Monteggia injuryhttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Monteggia Fracture
• Proximal ulnar fracture accompanied by a radial head dislocation
• FOOS(Arm) in pronation
• 2% pediatric elbow fractures
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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
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CASE FOUR
Joint EffusionSupracondylar
Fracturehttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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
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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
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Complications
www.uptodate.com: Evaluation and management of supracondylar fractures in children
PROXIMALLATERAL
DISPLACEMENT
PROXIMALMEDIAL
DISPLACEMENT
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Complications
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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.
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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
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Questions?
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Thank You!Happy Holidays!!
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• sds
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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
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CASE SIX
Medial Epicondylar Fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.htmlwww.uptodate.com: Epicondylar and transphyseal elbow fractures in children
Medial Epicondylar Fracture
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• 10% pediatric elbow fractures
• boys >> girls
• 9-14 yo
• associated with posterior elbow dislocation
Medial Epicondylar Fracture
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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
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CASE SEVEN
Salter Harris II fracture of Humerus
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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
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CASE EIGHT
Joint effusion Ulna fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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
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CASE NINEJoint effusion Supracondylar
fracture Possible proximal
radius fracturehttp://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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
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CASE TWO
Joint effusion, no fracture
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Other Modalities:Ultrasound
• Looking for posterior fat pad
• More sensitive than X-ray for fat pad
• Can also see lipohemarthrosis
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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
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CASE x
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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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
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CASE O
• Joint effusion. Radial head fracture.
http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html
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Oblique View
• Coronoid process
• Trochlear notch
• Medial trochlear profile
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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
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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.
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Coronoid Fx
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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.
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Proper Positioning
http://www.radiologyassistant.nl/en/p4214416a75d87/elbow-fractures-in-children.htmlwww.uptodate.com: Evaluation and management of supracondylar fractures in children
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Carrying Angle
• Females > Males
• Check alignment after injury
VALGUS CARRYING
ANGLE
FUN FACT!!!!#4
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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.
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Fracture Description• Bony anatomy
• Joint anatomy
• Ossification
• Radiographic anatomy
• Vessels
• Nerves