Elbow Injuries in Children
description
Transcript of Elbow Injuries in Children
How to solve the
maze of diagnosis of
the elbow fractures in
children
Dr Taral V Nagda
Pediatric Orthopedic Surgeon Hinduja Hospital Saifee Hospital Jupiter Hospital Mumbai Director Institute of Pediatric Orthopedic Disorders www.ipodindia.org Helpline 09320141234 09320151234
The pediatric elbow is a maze with four articulations and six ossification centres.
There are more han a dozen different types of injuries possible and many can be
difficult to differentiate from one other. Discussed here are 12 easy to follow
guidelines to diagnose accurately an elbow injury in children radiologically. These
guidelines are as follows:
1. Take a proper AP and lateral view
2. Draw the radio capitellar line and know ulno humeral relationship
3. Draw the anterior humeral line
4. Draw Bowmann line
5. Look at the fat pads
6. Know the ossification centres
7. Take xray of the opposite elbow
8. Take a traction view
9. Take a stress view
10. Take internal oblique view
11. Visualise the unossified cartilage with MRI or USG
12. Do an arthrogram
Let us go through the steps one by one…
1 Take a proper AP and Lateral view
Taking a proper AP view in an injured elbow is a challenge. In an injured elbow It
may not be possible to extend the arm. The reduction of supracondylar fracture is
done with elbow flexed making it necessary to take a Jone’s view
In a flexed elbow the radiology technicians many times take AP view with beam
directed at the angle of elbow which makes interpretation difficult due to overlap
between humerus and forearm bones. As one can neither see clearly lower end of
humerus or upper end of forearm bones this is referred to as the loser’s view. It may
be better to take separate AP of lower humerus and upper forearm.
For taking lateral xray the forearm must be supinated and upper arm must be
horizontal to the table as shown in the figure below
A true ulnoradial lateral view thus obtained is important to detect the rotational
malalignment in supracondylar fractures
Correct rotation Malrotation
2 Draw the radio capitellar line and know ulno humeral
relationship:
What is normal
A line drawn through shaft of radius always goes through centre of lateral
condyle ossification. This is in all views of elbow and all positions of elbow. As
the lateral condyle is the first ossification centre in elbow to appear the sign is
reliable even in young kids.
What happens in injured elbow
Conditions where the radial line passes through centre of capitellum
a. Normal elbow
b. Supracondylar fracture
c. Complete physeal separation
d. Undisplased lateral condyle fractures
Conditions where the radial line does not pass through centre of capitellum
a. Elbow dislocation
b. Displased lateral condyle fractures
c. Monteggia fracture dislocation
d. Radial head dislocation
SC # in position Displased
supracondylar fracture
and complete physeal
separation
Displaced Lateral condyle
fracture
Elbow Dislocation
Conditions where humero ulnar relationship is maintained
a. Normal elbow
b. All lateral condyle fractures
c. Monteggia fracture dislocation
d. Isolated radial head dislocation
Conditions where humero ulnar relationship is disrupted
a. Supracondylar fracture
b. Complete physeal separation
c. Elbow dislocation
Condition RC relationship Ulno humeral relationship
1 Normal elbow N N
2 Supracondylar fracture N D
3 Complete Physeal disruption
N D
4 Undisplased lateral condyle fractures
N N
5 Displaced Lateral condyle fractures
D N
6 Elbow dislocation D D
7 Monteggia fracture dislocation
D N
3.Draw the anterior humeral line
What is normal
Normally the anterior humeral line passes through middle of capitellum
What happens in in jured elbow
In extension type supracondylar fracture it passes anterior to center of capitellum
In flexion type supracondylar fractures it passes posterior to the capitellum
Normal Extension type
supracondylar
fracture
Flexion type
supracondylar
fracture
4.Measure the Bowmann angle
In the flexed elbow it is difficult to
determine the carrying angle of
elbow The Baumann an gle
which is the angle between line
through lateral condyle physis
and a perpendicular to humerus
axis represents the carrying
angle
What is normal
Baumann angle of 65-80 is normal
with a mean of 75
What happens in injured elbow
Baumann angle more than 80 suggests cubitus varus and less than 65
represents cubitus valgus This is useful in assessing quality of reduction in
supracondylar fractures
Bowmann
angle
Bowmann angle
75 Normal
alignment
Bowmann Angle
85 Cubitus
Varus
Bowmann angle
75 Normal
alignment
5. Look at the fat pad
The fat pad sign is a sign that is sometimes seen on lateral radiographs of the
elbow following trauma. Elevation of the anterior and posterior fat pads of the elbow
joint suggests the presence of an occult fracture. A small anterior fat pad may be
present in normal pediatric elbows.
The fat pad sign is invaluable in assessing for the presence of an intra-articular
fracture of the elbow. A anterior fat pad is often normal. However a posterior fat pad
seen on a lateral x-ray of the elbow is always abnormal
6. Know the ossification centres
The numerous ossification centers, which appear at different tines and fuse with
each other at different times, are confusing in a diagnostic setting because they can
often be mistakenly interpreted as fractures
In contrast a fracture may appear like an epiphyseal centre. What appears like a
medial epicondyle fracture at 5 year age may actually be a medial condylar fracture
with metaphyseal fragment giving appearance of the medial epicondyle
This fracture in a 6 year old is
a medial condyle fracture
The bony fracgment
represents a small
metaphyseal part of large
cartilaginous fracture
fracgment
7. Take xray of the opposite side
The timing of appearances of the epiphyseal ossification centres can vary
Whenever in doubt it is always better to take xray of the opposite side to
compare. This is specially helpful in fractures of medial condyle v/s
epicondyle, fractures of olecranon apophyses and intraarticular fractures
Injured elbow Injured elbow Normal elbow comparison
view helps to know the degree
of displacement
8. Take a traction view
In rotated and overlapped lateral condyle and supracondylar fractures it
becomes very difficult to diagnose the level of fractures due to overlap of the
fragments In these cases a traction view can greatly help. This view also
helps when the fracture line is oblique
The rotated fragment gives
impression of lateral condyle
fracture
The traction view shows that it is
a supracondylar fracture
9 Take stress views
Stress views are important to differenciate between type 1 and 2 lateral
condyle fractures. They also help to know the degree of ligamentous injury in
an epicondyle fracture
The stress views suggest
unstable lateral condyle
fracture which needs fixation
10 Take oblique xrays
Internal oblique view accurately shows the profile and displacement of a lateral
condyle fracture. Similarly internal and external oblique column views are important
to assess reduction in supracondylar fractures
On AP view one gets impression of an undisplaced
fracture but Internal oblique view shows the correct
degree of displacement of lateral condyle fractre
11 Visualize the unossified bone and articular surface by
MRI or ultrasound
In medial condyle fractures , some lateral condyle fractures, complete physeal
separation in neonate and complex elbow trauma it may become necessary to see
the radiologically unseen anatomy by doing an MRI or ultrasound. It also may be
indicated when differentiating between traumatic and post infective physeal
separations
MRI in this minimally displaced lateral condyle fracture
shows extension of the fracture line to articular surface
indicating unstable fracture and need to fix
MRI in this displaced lateral condyle fracture shows the
degree of displacement and indicates need to open
reduce
12 Do an arthrogram
Arthrogram delineates articular and fracture surfaces and can help to diagnose the
physeal and intraarticular fractures and assess the articular reduction in a closed
manner
Conclusion
Knowledge of anatomy, normal bony development, and radiographic features of the
pediatric elbow are essential to prompt recognition and treatment of elbow injuries in
children. In most instances, plain radiographs are adequate to detect fractures that
pose a threat to future growth and function. On occasion, additional modalities (eg,
ultrasound, magnetic resonance imaging, or arthrography) are needed to identify and
fully delineate elbow fractures, especially in infants and young children.
I hope that this text will be of help to orthopaedic surgeons to solve the puzzle. If you
are in doubt email your xrays to [email protected] and I will try help you to
arrive at some solution.
Acknowledgements I thank Dr Sandeep Patwardhan (Pune) and Dr Premal Naik (Ahemdabad) –both
well known Pediatric Orthopaedic Surgeons and great friends for some of the cases
used in illustrations.