How to solve the maze of diagnosis of the elbow fractures 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

1 Take a proper AP and Lateral view

Taking a proper AP view in an injured elbow is a challenge. In an injured elbow It may not be possible to extend the arm. The reduction of supracondylar fracture is done with elbow flexed making it necessary to take a Jones view

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

Displased supracondylar fracture and complete physeal separation

Displaced Lateral condyle Elbow Dislocation fracture

What happens in injured elbow

Conditions where the radial line passes through centre of capitellum
a. b. c. d. Normal elbow Supracondylar fracture Complete physeal separation Undisplased lateral condyle fractures

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

Conditions where humero ulnar relationship is maintained

a. b. c. d. Normal elbow All lateral condyle fractures Monteggia fracture dislocation Isolated radial head dislocation

Conditions where humero ulnar relationship is disrupted

a. Supracondylar fracture b. Complete physeal separation c. Elbow 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

Ulno humeral relationship N D D N N D N

3.Draw the anterior humeral line

What is normal
Normally the anterior humeral line passes through middle of capitellum

What happens in in jured elbow

In extension type supracondylar fracture it passes anterior to center of capitellum In flexion type supracondylar fractures it passes posterior to the capitellum

Normal

Extension type supracondylar fracture

Flexion type supracondylar fracture

4.Measure the Bowmann angle

In the flexed elbow it is difficult to determine the carrying angle of elbow The Baumann an gle which is the angle between line through lateral condyle physis and a perpendicular to humerus axis represents the carrying angle Bowmann angle

What is normal
Baumann angle of 65-80 is normal with a mean of 75

What happens in injured elbow

Baumann angle more than 80 suggests cubitus varus and less than 65 represents cubitus valgus This is useful in assessing quality of reduction in supracondylar fractures

Bowmann angle 75 Normal alignment

Bowmann Angle 85 Cubitus Varus

Bowmann angle 75 Normal alignment

5. Look at the fat pad

The fat pad sign is a sign that is sometimes seen on lateral radiographs of the elbow following trauma. Elevation of the anterior and posterior fat pads of the elbow joint suggests the presence of an occult fracture. A small anterior fat pad may be

present in normal pediatric elbows.

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

6. Know the ossification centres

The numerous ossification centers, which appear at different tines and fuse with each other at different times, are confusing in a diagnostic setting because they can often be mistakenly interpreted as fractures

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

7. Take xray of the opposite side

The timing of appearances of the epiphyseal ossification centres can vary Whenever in doubt it is always better to take xray of the opposite side to compare. This is specially helpful in fractures of medial condyle v/s epicondyle, fractures of olecranon apophyses and intraarticular fractures

Injured elbow

Normal elbow comparison view helps to know the degree of displacement

8. Take a traction view

In rotated and overlapped lateral condyle and supracondylar fractures it becomes very difficult to diagnose the level of fractures due to overlap of the fragments In these cases a traction view can greatly help. This view also helps when the fracture line is oblique

The rotated fragment gives impression of lateral condyle fracture

The traction view shows that it is a supracondylar fracture

9 Take stress views

Stress views are important to differenciate between type 1 and 2 lateral condyle fractures. They also help to know the degree of ligamentous injury in an epicondyle fracture

The stress views suggest unstable lateral condyle fracture which needs fixation

10 Take oblique xrays

Internal oblique view accurately shows the profile and displacement of a lateral condyle fracture. Similarly internal and external oblique column views are important to assess reduction in supracondylar fractures

On AP view one gets impression of an undisplaced fracture but Internal oblique view shows the correct degree of displacement of lateral condyle fractre

11 Visualize the unossified bone and articular surface by MRI or ultrasound

In medial condyle fractures , some lateral condyle fractures, complete physeal separation in neonate and complex elbow trauma it may become necessary to see the radiologically unseen anatomy by doing an MRI or ultrasound. It also may be indicated when differentiating between traumatic and post infective physeal separations

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.