Pediatric Elbow Radiology. Seema Awatramani, MD Friday, April 5, 2018 ACOEP Spring Seminar

Transcription

1 Pediatric Elbow Radiology Seema Awatramani, MD Friday, April 5, 2018 ACOEP Spring Seminar

2 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.

3 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

4 Recommended Resource Radiology Cases in Pediatric Emergency Medicine University of Hawaii

5 Topic Outline Back to Basics Anatomical & radiographic markers Xray

6 Anatomy Bony anatomy Joint anatomy Ossification Radiographic anatomy

7 Anatomy - basics POSTERIOR VIEW ANTERIOR VIEW Gray's Anatomy, 40th Edition

8 Anatomy - basics POSTERIOR VIEW ANTERIOR VIEW Gray's Anatomy, 40th Edition

9 DISTAL HUMERUS ANTERIOR VIEW DISTAL HUMERUS POSTERIOR VIEW Articular Surfaces ULNA OBLIQUE VIEW Gray's Anatomy, 40th Edition

10 The Joint Elbow anatomy and radiographic diagnosis of elbow fracture in children

11 Supracondylar Fractures Green NE. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children, 3rd, Green NE, Swiontkowski MF. (Eds), WB Saunders, Philadelphia p Evaluation and management of supracondylar fractures in children

12 Putting it Together 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 Radiographic Anatomy of Adult Elbow. OrthopaedicsOne Articles. ver.4.

13 Putting it Together 1 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.

14 Ossification Centers

15 Ossification Centers

16 The Growth Plate Elbow anatomy and radiographic diagnosis of elbow fracture in children

17 Ossification Centers Elbow anatomy and radiographic diagnosis of elbow fracture in children

18 Location Age C capitellum 1 Ossification Centers R radial head 3 I internal (medial) epicondyle 5 T trochlea 7 O olecranon 9 E external (lateral) epicondyle 11

19 Ossification Centers

20 Ossification Centers

21 Radiographic Anatomy AP: epicondyles and articular surfaces Lateral: humerus to forearm, fat pads Oblique: coronoid, radio-ulnar joint

22 Radiographic Lines RADIOCAPITELLAR LINE ANTERIOR HUMERAL LINE

23 Radiographic Anatomy RADIOCAPITELLAR LINE ANTERIOR HUMERAL LINE

24 Fat Pads

25 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 Oct;81(10): Donnelly LF, et al, ; Traumatic elbow effusions in pediatric patients: are occult fractures the rule? AJR Am J Roentgenol Jul;171(1): Pudas T, et al; Magnetic resonance imaging in pediatric elbow fractures. Acta Radiol Oct;46(6): 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 Nov;21(6): Major NM et al; Elbow effusions in trauma in adults and children: is there an occult fracture? AJR Am J Roentgenol Feb;178(2): de Beaux AC et al; Elbow fat pad sign: implications for clinical management. J R Coll Surg Edinb Jun;37(3):205-6.

26 Hourglass Sign NORMAL ABNORMAL

27 Proper Positioning Green NE. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children, 3rd, Green NE, Swiontkowski MF. (Eds), WB Saunders, Philadelphia p Evaluation and management of supracondylar fractures in children.

28 Summary Outline 1 Anterior fat pad 2 Posterior fat pad The checklist 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

29 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 Sample Case

30 Dx: Joint Effusion Supracondylar Fracture emxray/pemxray.html

31 Thank You. Questions?

32 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 Sample Case 2

33 Dx: Joint Effusion No visible fracture emxray/pemxray.html

34 LONGITUDINAL Elbow Ultrasound TRANSVERSE PROBE PLACEMENT NORMAL ABNORMAL Rabiner JE et al; Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children. Ann Emerg Med Nov 9. [Epub]

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

36 Elbow Ultrasound sensitivity 98% (88-100%) specificity 70% (60-79%) LR 3.3 ( ) NLR 0.03 ( ) Rabiner JE et al; Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children. Ann Emerg Med Nov 9. [Epub]

37 Elbow Ultrasound sensitivity 98% (88-100%) specificity 70% (60-79%) LR 3.3 ( ) NLR 0.03 ( ) Rabiner JE et al; Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children. Ann Emerg Med Nov 9. [Epub]

38 Vessels Brachial artery prone to damage Extensive collaterals Ischemia is rare Gray's Anatomy, 40th Edition

39 Nerves Median nerve crosses elbow to form the interosseous Elbow anatomy and radiographic diagnosis of elbow fracture in children

40 CASE ONE 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

41 CASE ONE Joint effusion, no fracture

42 CASE TWO 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

43 CASE TWO Radial Metaphyseal Head Fracture

44 Radial Fractures about 5-8% of all pediatric elbow fx Ages 9-12 FOOSH with extended elbow Pain/swelling proximal radius, pain on supination

45 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), WB Saunders, Philadelphia p

46 Radial Fractures AP & LATERAL OBLIQUE

47 CASE THREE 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

48 CASE THREE Joint effusion, olecranon fracture and radial head dislocation

49 Monteggia Fracture Proximal ulnar fracture accompanied by a radial head dislocation FOOS(Arm) in pronation 2% pediatric elbow fractures

50 CASE FOUR 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

51 CASE FOUR Joint Effusion Supracondylar Fracture

52 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

53 Pertinent Anatomy Green NE. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children, 3rd, Green NE, Swiontkowski MF. (Eds), WB Saunders, Philadelphia p Evaluation and management of supracondylar fractures in children

54 Complications PROXIMAL LATERAL DISPLACEMENT PROXIMAL MEDIAL DISPLACEMENT Evaluation and management of supracondylar fractures in children

55 Complications

56 Classifications PE I II III IV minimal swelling TTP pain with elbow movement some movement no movement arm in extension much swelling ecchymosis no movement much swelling eccymosis more 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), WB Saunders, Philadelphia p

57 Bony Injuries to the Elbow Condylar 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

58 Questions?

59 Thank You! Happy Holidays!!

60

61

62 sds

63 CASE SIX 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

64 CASE SIX Medial Epicondylar Fracture

65 Medial Epicondylar Fracture Epicondylar and transphyseal elbow fractures in children

66 Medial Epicondylar Fracture 10% pediatric elbow fractures boys >> girls 9-14 yo associated with posterior elbow dislocation

67 CASE SEVEN 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

68 CASE SEVEN Salter Harris II fracture of Humerus

69 CASE EIGHT 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

70 CASE EIGHT Joint effusion Ulna fracture

71 CASE NINE 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

72 Joint CASE effusion NINE Supracondylar fracture Possible proximal

73 CASE TWO 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

74 CASE TWO Joint effusion, no fracture

75 Other Modalities: Ultrasound Looking for posterior fat pad More sensitive than X-ray for fat pad Can also see lipohemarthrosis

76 CASE x 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

77 CASE x

78 CASE O 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

79 CASE O Joint effusion. Radial head fracture.

80

81 Oblique View Coronoid process Trochlear notch Medial trochlear profile

82 Bony Anatomy Fun 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

83 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 Copyright 2010 Lippincott Williams & Wilkins.

84 Coronoid Fx

85 Proper Positioning Green NE. Fractures and dislocations about the elbow. In: Skeletal Trauma in Children, 3rd, Green NE, Swiontkowski MF. (Eds), WB Saunders, Philadelphia p

86 Proper Positioning Evaluation and management of supracondylar fractures in children

87 Carrying Angle Females > Males Check alignment after injury VALGUS CARRYING ANGLE FUN FACT!!!! #4

88 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 Jul;27(7):

89 Fracture Description Bony anatomy Joint anatomy Ossification Radiographic anatomy Vessels Nerves