10. Fat Pad sign
Lateral view, 90° flexion
Anterior Fat Pad
POSITIVE
Posterior Fat Pad
In presence of trauma, predicts
fracture in 76% of cases
•Distension of the joint
capsule
•Joint effusion
•Haemarthrosis
General principles
15. General Principles
Radiocapitellar line.
• “A line drawn from the centre of the radial
neck should pass through the center of the
capitulum in all views”
Anterior humeral line.
• “A line drawn along the anterior cortex of the
humerus in lateral view should pass through
the middle third of the capitulum.”
19. Supracondylar fractures
• >60% of all elbow fractures in children
• 95% are hyperextension injuries
• The elbow becomes locked in hyperextension
20. Supracondylar fractures
• >60% of all elbow fractures in children
• 95% are hyperextension injuries
• The elbow becomes locked in hyperextension
21. Supracondylar fractures
• >60% of all elbow fractures in children
• 95% are hyperextension injuries
• The elbow becomes locked in hyperextension
22. Supracondylar fractures
• >60% of all elbow fractures in children
• 95% are hyperextension injuries
• The elbow becomes locked in hyperextension
23. Supracondylar fractures
• Flexion – type fractures are uncommon (5%)
• Direct impact to the flexed elbow
• Ulnar nerve injury common
• More likely to be unstable than extension injuries
24. Supracondylar fractures
Gartland Classification Management
1 Minimally displaced fracture Conservative
2 Displaced with intact posterior cortex Closed reduction and percutaneous
fixation
3 Complete displacement (Posteromedial
75%, Posterolateral, 25%)
Closed/open reduction and fixation
IIII II
27. Lateral condyle fractures
• 2nd
most common elbow
fracture in children (17%)
• Varus force to an extended elbow
• Localised swelling over the lateral
• Intrarticular
• Salter-Harris IV
• Instability due to forearm extensors
• Can be challenging to see
on radiograph
28. Lateral condyle fractures
Milch Classification
1. - Fracture line traverses lateral to capitello-trochlear groove
- Elbow is stable
2. - Fracture passes through the capitello-trochlear groove
- Elbow is unstable
Hard to classify on radiograph as fracture fragments are primarily cartilagenous
33. Complications
• Non union
• Malunion
• Excessive bone
formation
• Avascular necrosis of lateral condyle (iatrogenic)
• Ulnar nerve neuropathy (22 years post fracture,
Cubitus Valgus)
Lateral condyle fractures
Cubitus Varus Cubitus Valgus
35. Medial Epicondyle Avulsion
• 3rd
most common elbow fracture
in children
• adolescent boys
• Acute valgus stress
(sometimes during armwrestling)
• Severe pain over medial aspect,
“pop” sound, Ulnar nerve irritation
• Elbow dislocations occur in 50% of cases
40. • Adults – articular surface of radial head
• Children – Radial neck (metaphyseal bone weaker due to
constant remodeling)
• Fall on extended and supinated outstretched hand
• 90% are Salter Harris II
Proximal Radius fractures
41. Management
Children under 4 have a normal valgus angulation
to the radial neck (Up to 15°)
<30° Conservative
>30° Closed reduction
K-wires used if closed reduction unsuccessful or
unable to pronate and supinate upto 60°
Proximal Radius fractures
42. Radial Head Dislocations
• Radiocapitellar line useful!
• Can be obvious or quite subtle
• Always look for associated injury
•Monteggia Fracture
•Dislocation of the radial head with fracture
of the proximal third of the ulnar
•Fall on outstretched hand with forearm in
excessive pronation
44. Nursemaid’s elbow
• Annular ligament poorly attached in children <5
• If the forearm is pulled, radial head moves distally. The annular
ligament slips over the radial head and becomes trapped in the
joint
45. Nursemaid’s elbow
• Sudden longitudinal force applied to the forearm
• Audible snap
• Limb held in extension
• Pain on moving the forearm
• Radiograph is often normal
• Treatment – manipulation
- Supination & Flexion
- Pronation
47. References
• Agur, A.M.R. & Dalley, A.F. Grant’s Atlas of Anatomy (12th
ed). Lippincott, Williams & Wilkins
• John Harris et al The Radiology of Emergency Medicine, 3rd
Ed, Williams and Wilkins, 1993, p 352
• http://www.radiologyassistant.nl/en/4214416a75d87
• http://emedicine.medscape.com/article/415822-overview
• http://www.wheelessonline.com/ortho/frx_of_the_lateral
_condyle_in_children
• http://orthoinfo.aaos.org/topic.cfm?topic=A00037
• http://www.joint-pain-expert.net/index.html
Editor's Notes
It is not uncommon for the ossification centers to appear out of order
The ages are approximate, not exact
One study showed these centers developed 2 years later in boys than in girls
Normal olecranon but fractured radial neck
Dislocation of radius and olecranon fracture
Condyles displaced dorsally – ie supracondylar fracture
Red = brachial artery
Green = Median nerve
Overprojection of the capitulum
AVN – aggressive open reduction
Non union/malunion – pull of extensors
Valgus causes traction on medial epicondyle through flexors
Joint becomes locked
Radial neck fracture
Treatment of radial head dislocation is manipulation. Depends on if there is an associated fracture that makes the forearm stable. If so, needs to be repaired surgically.
Giovanni Battista Monteggia
Isolated radial head dislocation very rare in children. Much more common is subluxation…
Cochrane review on which method is best – conclusion is that it probably doesn’t make much difference