Radiographic evaluation of Paediatric elbow injury

paediatric elbow injury

1. Radiographic evaluation of common pediatric elbow injures. Dr. Saikat Ghosh Resident, Phase B MS ( Orthopaedics ) Chittagong Medical College.

2. Normal Variations in anatomy in the skeletally immature patient may be mistaken for fracture or injury due to the presence of secondary centers of ossification. Variations in imaging exist from patient to patient based on sex, age, and may even vary from one extremity to the other on the same patient. Despite differences in the appearance of bony anatomy there are certain landmarks to distinguish normal from abnormal. Abstract

3. Pediatric elbow fractures represent up to 10% of all fractures that occur in Children. The most common fractures are supracondylar humerus fractures, radialneck fractures, lateral condyle fractures , and medial epicondyle fractures. Interpretations of pediatric elbow radiographs is complicated by the cartilaginous nature of the immature elbow. Introduction

4. It is critical to identify subtle fractures and dislocations because missed injuries can be associated with deformity, pain and neurologic complication . Because of the challenges presented when evaluation pediatric elbow radiographs, systematic assessments of numerous radiographic measurements are useful. Introduction

5. Elbow fractures represent 9% to 10% of all upper extremity fractures in children. Of all elbow fractures, 85% occur at the distal humerus 55% to 75% of these are supracondylar . Most occur in patients 5 to 10 years of age, more commonly in boys There is seasonal distribution for elbow fractures in children, with the most occurring during the summer and the fewest during the winter. Epidemiology

6. Radiographic evaluation of the skeletally immature elbow requires knowledge of the normal sequence and appearance of the secondary ossification centers of the elbow in order to correctly distinguish pathology from normal anatomy. At birth the elbow joint is completely c artilaginous and cannot be reliably evaluated via plain radiography. Normal anatomy and development

7. The appearance of secondary ossification centers of the elbow are predictable, however may vary from patient to patient based on sex, maturity, and may even vary from one extremity to the other, making imaging of the contra lateral elbow useful in identifying subtle abnormalities. The mnemonic device CRITOL can be used to remember the chonologic order of ossification Normal anatomy and development

8. ( capitellum , radial head, medial epicondly , trochlea , olecranon ,, lateral epicondyle . This can also be remembered as CRITOE ( capitellum , radial head, internal ossification center, trochela , olecrannon , external ossification center. Ossification begins at 1 year old and each ossification center sequentially appears at about every years thereafter.

9. Secondary Ossification Center of the elbow.

10. Normally, the capitellum is anteverted approximately 40 degree, froming an angle of 130 degree with the humeral shaft. With age fusion of the capitellum occurs, frequently to the trochela and lateral epicondyle first, followed by fusion ton the distal humerus by approximately age 14 years. Secondary ossification Centers

11. The capitellum serves as a critical landmark when evaluating pediatric elbow x-ray. For example, the radial head should align with the capitellum in all views in order to rule out dislocation. The radial head ossifies at around age 3-4 years. As it ossifies, the metaphysis of the radial neck may appear angulated with a notch at the lateral cortex, which fills in with time, however, this may be mistaken for a fracture. Secondary ossification Centers

12. The medical epocondyle ossifies between 3-6 years of age, It is varible in its ossification pattern and is often the last center to fuse at approximately 17 years of age. The trochlea exhibits multiple ossification centers beginning around age 7-8 years. Its tragmented appearance should not be confused with pathological condition, such as fracture or avascular nerosis . Secondary ossification Centers

13. The olecranon begins to ossify around age 9 years via two or more ossification centers. Its ossification begins distally before migrating proximally to form a concentric articulation with the distal hurnerus . As the physis colses , it has sclcrolic margins that appear different than a fracture, with final closure occurring by age 14-15 years. Lastly the lateral epicondyle begins ossifying around age 11 years. Secondary ossification Centers

14. Antero posterior view Lateral view Internal and External oblique view Stress view Greenspan (radio capitellar ) Coyle’s view Inferiosuperior view Elbow acute flexion ap view Supracondylar ap view Jones view. Different X-ray Views

15. 1. Lines: Anterior Humeral line (AHL) Middle Humeral Line (MHL) Radio Capitellar Line Coronoid line 2. Angles: Baumann’s angle Carrying angle Capiteller angle Metaphyseo diaphyseal angle Radiographic Parameters

16. 3. Signs: Fat pad sign Tear drop sign Crescent sign Fish tail sign Radiographic Parameters

17. Knowledge of normal radiographic relationships within the pediatric elbow is important for diagnostic evaluation. Assessment of the radiocapitellar joint is erformed by drawing a line down the middle of the radial neck or shaft on standard anteroposterior (AP), ogblique and lateralradiographs . This line should interest the capitellum at approximately its middle third on all radiographic views. Radiographic relationships

18. The anterior humeral line (AHL) is an important radiopraphic landmark used to assess the alignment of the distal humerus and is often used to evluate the anterior posterior displacement of supracondylar humerus fractures. This line is drawn on the lateral projection of the elbow along the anterior cortex of the humerus and should intersect the middle third of the capitellum in most normal elbows. Radiographic relationships

19. Midhumeral Line

20. Anterior Coronoid line (ACL)

21. Baumann’s angle (or the humerocapitellar angle) is another radiographic measurement that may be used to assess the normal relationships of the distal humerus and is measured on the AP projection of the elbow. It is used to evaluate for the presence of a supracondylar or other types of distal humerus fracture. Radiographic relationships

22. The metaphyseal-diaphyseal angle formed between the long axis of the humerus and a line connecting the lateral and medial epicondyles .

23. Teardrop or figure eight sign

24. Supracondylar humerus (SCH) fractures are the most common type of elbow fracture in children. Anterior humeral line which should intersect the middle third of the capitellu . In an extension type supracondylar fracture the capitellum lies posterior to the anterior humeral line. Supracondylar Humerus

25. Peak age: 6 years Hall mark of Radiology: Posteriorly based metaphyseal fragment. In case of minimally displaced fractures internal oblique view & contralateral films & CT, MRI, arthrogram may be helpful. Lateral condyle fractures

26. Peak age: 9-14 yns . More Common in male. These fractures occurs up to 50% with elbow dislocation. Widening in irregularity of the physis may be the only radiographic sign is minimally displaced fractures. Medial epicondyle fractures

27. Peak age: <2 yns Often associated with child abuse. X-ray: Relation between Primary ossification center of the distal Humerus & the proximal radius & Ulna. It is distinguished from elbow dislocation by measuring the Radio- copiteller line. It is distinguished from supracondylar fracture as metaphysis maintain a smooth border where in supracondylar fracture this is irregular. Distal humeral physeal injury

28. Monteggia fractures are complex injuries involving a fracture of the ulna asociated wit proximal radioulnar joint dissociation and radiocapitaller . This fractures should be evaluated with standard AP and lateral radiographs of the forearm and elbow. Any ulnar shaft fracture warrants a radiograph of the elbow Disruption of the ulna, even minor bowing, should alert the observer to assess the proximal radioulnar joint for disruption. Monteggia fracture

29. Capitellar ostcochondritis dissecans (OCD) is a pathologic entity with an unknown etiology ad can be confused with panner’s disease (osteochondrosis of the capitellum ). Capitellar OCD typically affects children older than 10 years of age, Is associated with overuse syndromes. Panner’s disease affects those younger than 10 years old is not necessarily associated with overuse, and has a self-limited benign clinical course. Capitellar osteochondritis dissecans

30. Peak age: 7-12 yns Isolated injury only 50% . Sometimes associated with proximal ulnar injury. X-ray: Oblique view of Elbow. Radial neck fractures with unossified radial head is difficult to detect. In that occasion the only sign may be irregularity of proximal metaphysis . Radial neck fractures

31. Pediatric elbow fractures are commonly encountered by pediatricans , orthopedists and emergency physicians representing up to 10% of all fractures that occur in children. Diagnostic radiology is an essential component of proper evaluation. Understanding these radiographic findings and relationships in the pediatric elbow is important to avoid pitfalls in diagnosing these relatively common injuries. Conclusions

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