X-Rays: AP c elbow in ext/forearm in supination
Lat c elbow flexed
Small anterior fat pad is normal
Posterior fat pad is never normal,
Anterior humeral line-on a lateral, anterior line of humerus should hit middle 1/3 of capitellum
If patient can fully extend and lock elbow and pronate/supinate: pt does not have fracture with good sens/spec (
Docherty MA et al:
Can elbow extension be used as a test of clinicallysignificant injury?
South Med J 95:539, 2002)
Carrying Angle-angle between middle 1/3 of humerus and middle 1/3 of ulna should be ≤12º
Transcondylar fracture-always associated c posterior dislocation of the radius or the ulna
radial head displaces out of the annular ligament
acute interposition of the annular ligament into the
radiocapitellar joint, is a common injury and accounts for 22% of all upper
extremity injuries seen in pediatric ED's in children under 5 years of age.
Squeeze head, extend elbow, supinate forearm then flec at
elbow if it doesn’t work, try hyperpronation (Macias CG Radial head subluxation
Acad Emerg Med 2000; 7(2): 207-8, McDonald
J, et al. Radial head subluxation:
comparing two methods of reduction Acad Emerg Med 1999; (7):715-8)
can present with the complaint after 30 minutes or 6 months
4 Presentations
Pt has had it for 6 months
Febrile patient with red, hot, swollen elbow
Same as number two, but patient has a history of gout
Swelling After trauma
Aspirate all of them, it gives symptomatic relief and makes the patient feel better about treatment
Only send to lab if question of infection
Cell count>2000 WBCs sensitive and specific
If <1000 then infection is unlikely
Send for crystals and culture
If nonseptic, can inject 20 - 40 mg of steroids
warn patient that fluid may reaccumulate in 3-4 days
If septic, use penicillinae resistant penicillin (oxacillin) or 1st generation cephalosporin
If the patient appears toxic, admit
If diagnosis is unclear, treat as if septic and have patient follow up for culture results, do not give steroids
Posterior takes out the ulna, reduce c Stimson’s and immobilize the elbow in 90 of flexion.
Posterior is the most common.
Better means of reduction. Put hands on humerus with elbow flexed at 90. Put boths thumbs on olecranon and rotate it back into place.
Anteror
Splint and get emergent consult
Check median nerve and brachial artery.
Humeral fxs can box median nerves or brachial artery
Humerus fractures can be placed in sugar tong splint.
X-ray shoulder, elbow and AP/Lat of humerus
Proximal Humerus-greater and lesser tuberosity, surgical neck, anatomic neck
If proximal humerus fracture, should see on shoulder series. Also get AP in internal rotation and Axillary view. Can see pseudo-subluxation 2º to blood in joint
Angle between head and shaft is normally 135º, if less than 90 or greater than 180, this is bad
Proximal humerus c <45 angulation, <50 displacement, <1 cm distraction, can put in sling and send to clinic
ELBOW
Elbow radiographs are notoriously poor in directly detecting fractures.
Indirect signs such as fat pads and bony misalignments are often the only
suggestions of an injury. The normal radiographic anatomy of the elbow is seen
in Figures 9 and 10. A fat pad is a collection of fat tissue adjacent to the
elbow joint capsule, found both anteriorly and posteriorly. These fat pads can
become displaced by an intra-articular effusion such as a hemarthrosis. A
small, lucent anterior fat pad lying anterior to the distal humerus can be
normal. This anterior fat pad is considered abnormal, however, when it becomes
displaced and elevated (called a “sail sign”). In contrast, the presence of any
posterior fat pad, regardless of size and displacement, is pathological.
In addition to fat pads, the other indirect finding to examine in the elbow is
bony alignment. The first alignment is the radiocapitellate line. On both the
AP and lateral views, a longitudinal line drawn through the midshaft of the
radius should bisect the capitellum. Any misalignment suggests a radial head
dislocation. The second line is the anterior humeral line. On a lateral view,
a longitudinal line drawn along the anterior aspect of the humerus should bisect
the capitellum. Extremely important to examine especially in the pediatric
population, an abnormal anterior humeral alignment suggests a supracondylar
fracture.
Figure 9. AP radiograph and diagram of a normal right elbow
Figure 10. Lateral radiograph and diagram of normal right elbow
In the elbow, a radial head “D”islocation, which often
occurs in association with a proximal ulna fracture, is diagnosed by an abnormal
radiocapitellate alignment. This injury will be discussed later in the
Monteggia fracture-dislocation section.
The primary “O”ccult fracture missed in the adult elbow is a radial head
fracture. In the Freeds and Shields study, elbow fractures ranked the second
highest in terms of the “miss rate” at 10.8%. In adults, radial head fractures
comprised the majority of these overlooked fractures. Radiographic findings can
be extremely subtle. Over 80% of elbow fractures had an associated abnormal fat
pad and over 40% had a fat pad sign as the only indicator of a fracture (10).
Figure 11 demonstrates a small nondisplaced radial head fracture with an easily
overlooked cortical break and the presence of both a large anterior fat pad sign
(“sail sign”) and posterior fat pad.
Figure 11. Radial head fracture (lateral view)
The “H”alf injury in the elbow refers to a Monteggia fracture-dislocation
pattern, which is a proximal ulna diaphyseal fracture associated with a radial
head dislocation (Figure 12). When the former is radiographically visualized, a
careful search for the latter must be performed by examining the
radiocapitellate alignment. Monteggia fractures are initially missed
approximately 50% of the time in the pediatric population (14). Always beware
of a discharge diagnosis of an isolated proximal ulna fracture. A complication
from a delayed diagnosis of the associated radial head dislocation includes
paralysis of the posterior interosseous nerve, which normally wraps around the
radial neck.
Figure 12. Monteggia fracture-dislocation of elbow (lateral view)
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