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

Pediatric Elbow Radiology Seema Awatramani, MD Friday, April 5, 2018 ACOEP 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 Medicine University 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

DISTAL HUMERUS ANTERIOR VIEW DISTAL HUMERUS POSTERIOR VIEW Articular Surfaces ULNA OBLIQUE 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 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. http://www.orthopaedicsone.com/x/lgbeaq.

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. http://www.orthopaedicsone.com/x/lgbeaq.

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

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 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 RADIOCAPITELLAR LINE ANTERIOR HUMERAL LINE http://www.rch.org.au/clinicalguide/guideline_index/fractures/supracondylar_fracture_of_the_humerus_emergency_department/

Radiographic Anatomy RADIOCAPITELLAR LINE ANTERIOR HUMERAL 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 NORMAL ABNORMAL http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

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

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

Dx: Joint Effusion Supracondylar Fracture http://www.hawaii.edu/medicine/pediatrics/p emxray/pemxray.html

Thank You. Questions?

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

Dx: Joint Effusion No visible fracture http://www.hawaii.edu/medicine/pediatrics/p emxray/pemxray.html

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. 2012 Nov 9. [Epub]

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]

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

CASE TWO Radial Metaphyseal Head Fracture http://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), WB Saunders, Philadelphia 2003. p.207-276.

Radial Fractures AP & LATERAL OBLIQUE http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

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

CASE THREE Joint effusion, olecranon fracture and radial head dislocation http://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 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 http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

CASE FOUR Joint Effusion Supracondylar Fracture http://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), WB Saunders, Philadelphia 2003. p.207-276. www.uptodate.com: Evaluation and management of supracondylar fractures in children

Complications PROXIMAL LATERAL DISPLACEMENT PROXIMAL MEDIAL DISPLACEMENT www.uptodate.com: Evaluation and management of supracondylar fractures in children

Complications

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 2003. p.207-276.

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

Questions?

Thank You! Happy Holidays!!

sds

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

CASE SIX Medial Epicondylar Fracture http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

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

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

Joint CASE effusion NINE Supracondylar fracture Possible proximal 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 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 http://www.hawaii.edu/medicine/pediatrics/pemxray/pemxray.html

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

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 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 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

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.html www.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