Professional Documents
Culture Documents
Elbow Injuries in Children
Elbow Injuries 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
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 losers 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.
SC # in position
Conditions where the radial line does not pass through centre of capitellum
a. b. c. d. Elbow dislocation Displased lateral condyle fractures Monteggia fracture dislocation Radial head dislocation
Condition 1 2 3 4 5 6 7 Normal elbow Supracondylar fracture Complete Physeal disruption Undisplased lateral condyle fractures Displaced Lateral condyle fractures Elbow dislocation Monteggia fracture dislocation
RC relationship N N N N D D D
Normal
What is normal
Baumann angle of 65-80 is normal with a mean of 75
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
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
Injured elbow
The stress views suggest unstable lateral condyle fracture which needs fixation
On AP view one gets impression of an undisplaced fracture but Internal oblique view shows the correct degree of displacement of lateral condyle fractre
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 taralnagda@gmail.com 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.