A 9-year-old male presents with right elbow pain after a fall onto the elbow. What is your diagnosis? What common pediatric elbow findings are you looking for? What is your management and disposition in the ED? (Image 1: Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 47354)
This is a normal radiograph for the patient’s age. The bone fragments near his olecranon are part of his regular ossification center.
- Pearl: The elbow has multiple ossification centers that can make reading pediatric radiographs challenging. Although the timing of ossification varies by patient, an often utilized mnemonic is CRITOE. The ages in the chart below are approximated years:
Image 2: Fully ossified elbow with centers labeled. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 20908
Image 3: Ossification in 2-year-old for comparison. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 20908
- Pearl: Comparisons to normal pediatric imaging of similar age can be helpful when determining if there is pathology. Check out The Bone Pit – a free online favorite of the author.
- Fat pads
- Posterior Fat Pad: Always pathologic, even if no fracture is seen. In pediatric patients, it is commonly a supracondylar fracture, though it may represent any intra-articular injury [1].
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Anterior Fat Pad: Routinely a normal finding, though larger sizes can also be pathologic (such as in Image 4).
- More than 15 degrees of angulation indicates likely effusion [2]
Image 4: Type I supracondylar fracture with anterior (blue) and posterior (orange) fat pads labeled. Case with annotations courtesy of Richard Hopkins, MD
- More than 15 degrees of angulation indicates likely effusion [2]
- Lines
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Anterior Humeral Line: Drawn down the anterior humeral shaft, it should intersect the middle ⅓ of the capitellum. If it doesn’t, consider a supracondylar fracture.
Image 5: Anterior humeral line. Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 41196
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Radiocapitellar Line – Drawn along the radial neck, it should intersect the capitellum. If it doesn’t, consider a radial head dislocation or fracture.
Image 6: Radiocapitellar line. Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 41196
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Anterior Humeral Line: Drawn down the anterior humeral shaft, it should intersect the middle ⅓ of the capitellum. If it doesn’t, consider a supracondylar fracture.
- Cortices
- Observe each edge for cracks, widening, or abnormal lucencies, especially the radial head and olecranon.
- Pearl: Consider ultrasound as an adjunctive imaging modality for the evaluation of an intra-articular effusion [3].
This patient’s family can be reassured and given instructions for symptomatic treatment. Follow-up can occur with a pediatrician as needed.
If there is no radiographic evidence, but there is clinical concern for a fracture, consider temporary immobilization with a sling or posterior long arm splint. Ensure close follow up in 1 week for re-evaluation. Long periods of immobilization may result in complications such as contractures, muscle atrophy, neuropraxia, infections, and ulcers.
Dealing with someone older? Check out EMRad’s approach to the traumatic elbow.
And don’t forget to investigate the SplintER archives.
References:
- DeFroda SF, Hansen H, Gil JA, Hawari AH, Cruz AI. Radiographic evaluation of common pediatric elbow injuries. Orthop Rev (Pavia). 2017;9(1):21-26. PMC: 5337779.
- Blumberg S, Kunkov S, Crain E, Goldman H. The predictive value of a normal radiographic anterior fat pad sign following elbow trauma in children. Pediatr Emerg Care. 2011;27(7):596-600. https://www.ncbi.nlm.nih.gov/pubmed/21712751.
- Kim HH, Gauguet JM. Pediatric Elbow Injuries. Semin Ultrasound, CT MRI. 2018;39(4):384-396. PMID: 9435010
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