Have you ever been working a shift at 3 am and wondered, “Am I missing something? I’ll just splint and instruct the patient to follow up with their PCP in 1 week.” This can be a reasonable approach, especially if you’re concerned there could be a fracture. But we can do better. Enter the “Can’t Miss” series: a series organized by body part that will help identify common and catastrophic injuries. This list is not meant to be a comprehensive review of each body part, but rather to highlight and improve your sensitivity for these potentially catastrophic injuries. We reviewed the approach to the pediatric elbow previously. Now, the “Can’t Miss” pediatric elbow injuries.
The Pediatric Elbow
- 10% of all pediatric fractures involve the elbow [1].
- Missed injuries can cause significant deformity, pain, or functional/neurologic complications [1].
- With many ossification centers, subtle injuries, and significant consequences, the pediatric elbow x-ray can be challenging but important to interpret.
- Non-accidental trauma is, unfortunately, a not uncommon reality. Have a high suspicion for it, especially when there are inconsistencies in the story, mechanism, or the child’s developmental stage. There are certain highly suspicious fracture patterns to be aware of that will be highlighted when appropriate.
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Epidemiology: The most common fracture in children <8 years old.
- The majority occur between 3-10 years old with peak age 5-7 years old [2].
- Complications:
- Malunion, ischemic (Volkmann) contracture from brachial artery damage / volar compartment syndrome, nerve injuries [3].
- Most common: injury to the anterior interosseous nerve [2].
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Physical Exam: Tenderness at the elbow. S-shape deformity in severe fracture.
- Evaluate the function of the anterior interosseous nerve (AIN) (figure 1), radial artery, ulnar nerve, and radial nerve.
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Pearl: If the radial pulse is missing, management differs depending on perfusion.
- If the hand is poorly perfused, perform emergent traction and/or reduction [2].
- If the hand is well-perfused, consult orthopedics emergently. This is a contraindication to manipulation in the emergency department [2, 3].
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Diagnostic Imaging: Fracture of the distal humerus, possibly with posterior displacement.
- A “sail sign”, posterior fat pad, and/or abnormal anterior humeral line alone is concerning for an occult supracondylar fracture.
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Treatment: [2]
- Type I (non-displaced): Long arm splint/cast and prompt ortho follow-up within 2-7 days.
- Type II (displaced with intact posterior cortex): ED orthopedic consultation.
- Type III (complete displacement): ED orthopedic consultation.
Figure 1: A) Median nerve assessment. B) Simulation of anterior interosseous nerve neurapraxia.
Figure 2: Lateral and AP X-rays of type 1 supracondylar fracture with posterior fat pad (blue arrows), anterior cortical disruption (red arrows) and displacement of anterior humeral line (green dotted line). Case courtesy of Dr. Frank Gaillard, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
Figure 3: Lateral X-ray of (a) type 2 supracondylar fracture with anterior cortical disruption (red arrow) without posterior cortical disruption. Case courtesy of Dr. Mohamed Walaaedlin, Radiopaedia.org. Annotations by Daniel Ichwan, MD. (b) type 3 supracondylar fracture with complete displacement. Case courtesy of Dr. Benoudina Samir, Radiopaedia.org.
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Epidemiology [4]: Second most common pediatric pediatric elbow fracture. The peak is at approximately age 6 years old.
- A missed fracture is a common cause of nonunion
- Other known complications:
- Malunion
- Osteonecrosis
- Cubitus valgus
- Tardy ulnar nerve palsy.
- Physical Exam: Tenderness/edema of the lateral elbow.
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Diagnostic Imaging: Can be a subtle, small bone fragment next to capitellum.
- Pearl: An internal oblique view should be obtained if the index of suspicion is high.
- Displacement is measured on the internal oblique view.
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Treatment:
- Because of well-known complications, discuss fracture with orthopedics [2]. Weiss Classification:
- Type 1 (<2 mm displacement on internal oblique view): long arm casting/splint and close follow-up within 1 week for repeat films [4].
- Type 2 (2-4 mm displacement on internal oblique view): ED orthopedics consult.
- Type 3 (>4 mm displacement on internal oblique view): ED orthopedics consult.
- Because of well-known complications, discuss fracture with orthopedics [2]. Weiss Classification:
Figure 4: AP, internal oblique, and lateral X-rays of lateral humeral condyle fracture (red arrows) with associated “sail sign” (blue arrow). Case courtesy of Dr. Maulik S Patel, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
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Epidemiology: 10-20% of pediatric elbow injuries [5]. Usually older children and adolescents [2, 5].
- Complications if suboptimal healing [5]:
- Non-union
- Instability
- Tardy ulnar nerve palsy
- Complications if suboptimal healing [5]:
- Physical Exam: Tenderness/edema over the medial elbow. Pain worse with supination and flexion of forearm, wrist, and digits. Special attention should be given to the ulnar nerve.
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Diagnostic Imaging: Soft tissue swelling, widening of the growth plate (compared to contralateral side), obvious displacement, and/or fracture through adjacent humeral metaphysics.
- Pearl: Using CRITOE helps, as an avulsed/displaced medial epicondyle can mimic another center but it is actually avulsed into the joint.
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Treatment [5]:
- Controversial – discuss with orthopedics.
- Nondisplaced non-dominant arm of non-athlete or minimally displaced – long arm cast/splint and ortho follow-up at 5-7 days.
- Displacement or unstable (especially if athlete or dominant arm) – ED ortho consult.
Figure 5: Lateral and AP X-rays of medial epicondyle avulsion (red dotted line). Case courtesy of Dr. Andrew Dixon, Radiopaedia.org.
- Epidemiology: Peak incidence between 4-10 years old [6].
- Physical exam: Tenderness/edema in the lateral elbow. Increased pain with pronation and supination.
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Diagnostic Imaging: Displaced radiocapitellar line.
- Pearl: Check for an associated ulnar fracture that occurs due to the proximal and distal radioulnar joints (“Monteggia fracture-dislocation”, more commonly a bowing ulna fracture in pediatrics) or entire elbow dislocation.
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Treatment: Reduction with sling and ortho follow-up [6, 7].
- Consult orthopedics if irreducible, unstable, neurovascular compromise, or associated fracture [7].
Figure 6: Lateral view of elbow demonstrating radial head dislocation and displacement of radiocapitellar line (red line). Case courtesy of Dr. Matt Skalski, Radiopaedia.org.
Figure 7: Lateral and AP X-rays views demonstrating radial head dislocation and corresponding displacement of the radiocapitellar line (red line). Case courtesy of Dr. Gerry Gardner, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
- Epidemiology: 5-10% of pediatric elbow injuries [8].
- Mechanism: FOOSH with an extended elbow and supinated forearm (radial head impacted against capitellum)
- Physical exam: Tenderness/edema in the lateral elbow. Special attention should be given to the posterior interosseous nerve (PIN, branch of radial nerve) and corresponding finger extension [8].
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Diagnostic Imaging: Curvature of the anterior cortex of radial head.
- Possible concurrent elbow effusion (pathologic fat pads).
- Look for concurrent elbow dislocation, olecranon fracture, and medial epicondyle fracture.
- Pearl: Oblique view can be better in visualizing the radial head.
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Treatment:
- Minimal displacement (<2mm) and angulation (<30 degrees): Long-arm splint/cast and ortho follow-up in 2-7 days.
- Otherwise: ED ortho consult [8].
- If closed reduction is attempted, flex the elbow to 90 degrees and supinate. Apply anterior pressure on proximal radial shaft to reduce shaft to head [8].
Figure 8: Lateral and AP X-rays views demonstrating an angulated radial neck fracture (red arrows). Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
- Epidemiology: <5% of pediatric elbow injuries [9].
- Physical exam: Tenderness/edema over the posterior elbow. Special attention should be given to the ulnar nerve.
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Diagnostic Imaging: Best seen on the lateral view.
- Pearl: Frequently displaced and associated with radial neck fracture or elbow dislocation.
- Treatment: If minimal displacement (<4mm): Long arm splint/cast and ortho follow-up in 24 hours. Otherwise, ED orthopedics consult [9].
Figure 9: Lateral and AP X-rays views demonstrating an olecranon fracture (red arrows) and posterior fat pad (blue arrows) in a 4-year-old. Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
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Epidemiology: Most common large joint dislocation in children [10].
- Can be associated with brachial artery injury (especially with open fractures) [10].
- Physical exam: Elbow in 45 degrees of flexion. Prominent olecranon with significant swelling later in the course. Special attention should be given to the ulnar/median nerve and brachial artery [2].
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Diagnostic Imaging: Usually obvious posterior dislocation. Displaced anterior humeral and radiocapitellar lines.
- Pearl: Can have associated lateral/medial epicondyle fracture or radial neck fractures in children [10].
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Treatment:
- If no associated fracture: closed reduction with immobilization x1-2 weeks and orthopedic follow-up [2].
- If complex / associated / unstable fracture: ED orthopedics consult [10].
Figure 10: Lateral and AP X-rays views demonstrating an elbow dislocation (red arrows), displaced anterior humeral line (green dotted line), and associated medial epicondyle fracture (blue arrows). Case courtesy of Dr. Maulik S Patel, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
References
- DeFroda SF, Hansen H, Gil JA, Hawari AH, Cruz AI Jr. Radiographic Evaluation of Common Pediatric Elbow Injuries. Orthop Rev (Pavia). 2017;9(1):7030. Published 2017 Feb 20. PMID: 28286625
- Boutis K. Pediatric Orthopedic Emergencies. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed December 23, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=220291079
- Allen SR, Hang JR, Hau RC. Review article: paediatric supracondylar humeral fractures: emergency assessment and management. Emerg Med Australas. 2010;22(5):418-426. PMID: 20874821
- Tejwani N, Phillips D, Goldstein RY. Management of lateral humeral condylar fracture in children. J Am Acad Orthop Surg. 2011;19(6):350-358. PMID: 21628646
- Beck JJ, Bowen RE, Silva M. What’s New in Pediatric Medial Epicondyle Fractures?. J Pediatr Orthop. 2018;38(4):e202-e206. PMID: 27861213
- Imani G, Graber M. Radial Head Dislocation. 2020 Sep 2. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 31335090
- Chow YC, Lee SW. Elbow and Forearm Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed December 23, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=222324767
- Pring ME. Pediatric radial neck fractures: when and how to fix. J Pediatr Orthop. 2012;32 Suppl 1:S14-S21. PMID: 22588098
- Holme TJ, Karbowiak M, Arnander M, Gelfer Y. Paediatric olecranon fractures: a systematic review. EFORT Open Rev. 2020;5(5):280-288. Published 2020 May 1. PMID: 32509333
- Kuhn MA, Ross G. Acute elbow dislocations. Orthop Clin North Am. 2008;39(2):155-v. PMID: 1837480
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