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Elbow Fractures

Elbow fractures are of particular importance because they remain one of the most commonly missed fractures by emergency medicine physicians. Though elbow fractures, such as an intra-articular radial head fracture, are not high in volume, we misdiagnose them at such a large rate that they still qualify as one of the most commonly missed fractures. In turn, this leads to misdiagnosed elbow fractures being some of the most highly litigated cases of malpractice affecting emergency physicians. One study remarked that although only about 4% of pediatric fractures tend to occur at the elbow, they accounted for roughly 20% of all malpractice litigation proceedings.(3) Thus, it is important to understand…

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 How to Approach the Pediatric Elbow

Radiographic assessment of acute pediatric elbow trauma requires a firm grasp of developmental anatomy, radiographic landmarks, and common injury patterns. By using a systematic approach to reading elbow x-rays delineated below, you can begin to feel more confident and adept at evaluating the subtle signs of pediatric fractures.

 How to read an elbow x-ray

Fractures lines can be difficult to visualize after acute elbow injury, particularly in children.

 Interpreting Elbow and Forearm Radiographs

Elbow injuries account for 2-3% of all emergency department visits across the nation. Yet, because of the elbow’s complex anatomy and the presence of numerous ossification centers in children, elbow fractures are the third most commonly missed fracture group in the ED. Here are some tools to help ED physicians read elbow x-rays more effectively and hopefully identify abnormalities more easily.

Articles of Interest

A Classic Pediatric Fracture

When the lateral popped up on the screen, it was classic, showing the four signs of a supracondylar fracture. Posterior fat pad sign: A posterior fat pad is always pathologic. An easy way to remember this is that posterior and pathologic begin with a p. Anterior sail sign: A small anterior fat pad is normal, but one that extends so far that the anterior and posterior fat pads make a virtual circle is clearly abnormal. One should never see an anterior fat pad that looks like a sailboat sail. Cortical break: One should carefully search the cortex for discontinuation. Remember that kids can get greenstick fractures, where only one side of the bone's cortex is broken. Abnormal anterior humeral line: A line down the anterior humeral cortex should bisect the middle third of the capitellum in children over 5. The anterior humeral line just has to touch the capitellum to be normal in those under 5.

A Perpetual Red Flag

My eyes had immediately centered on the little avulsed piece of bone, then to the posterior fat pad. The pathologic posterior fat pad confirmed this as an intra-articular fracture. My focus shifted to the radial head, but I was unable to identify a radial head fracture. Still, I pondered the possibility that the assault had caused the terrible triad of elbow injuries.

Can’t Miss Pediatric Elbow Injuries

10% of all pediatric fractures involve the elbow.

How to Avoid Missing a Pediatric Elbow Fracture

Pediatric elbow injuries are among the most challenging musculoskeletal conditions for emergency physicians. Kids can be a challenge to examine, large cartilaginous areas and various elbow ossification centers make X-rays difficult to interpret, and many missed injuries are both subtle and require operative management.

Pediatric Elbow Fractures: A Clinical Review

Though the most common fracture seen in pediatric trauma patients, elbow fractures can be difficult to identify in younger patients. Familiarity with elbow anatomy, ossification centers, and fracture patterns is essential for optimal outcomes.

What's the Diagnosis? Image by Dr. Brandi Knight

Typically secondary to fall on an outstretched hand; head of radius collides axially with capitulum of humerus. Most common type of adult elbow fracture; radial neck fractures more common in children;...

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Bonsecours

There are three types of elbow fractures, an olecranon fracture, radial head fracture, and a distal humerus fracture.

Radiology Key

Elbow fractures account for 6% to 7% of all fractures. Radial head fractures are the most common type of elbow fracture in adults; they account for approximately 30% of all elbow fractures. Olecranon fractures account for an additional 10% to 20%. Distal humeral fractures are uncommon (2% of all elbow fractures), capitellar fractures are even more uncommon (0.5%), and trochlear fractures are rare. Fractures of the radial head and neck generally result from a hard fall on the arm, with the hand outstretched. The wrist is usually in an extended position.