Fat Pad Sign Research Articles

Using The Fat Pad Sign In Pediatric Occult Elbow Fractures: Is It As Reliable As We Think?

Using The Fat Pad Sign In Pediatric Occult Elbow Fractures: Is It As Reliable As We Think?

Frequency of MRI Low Signal Intensity in the Buccal Fat of Fetuses and Speculation as to What It May Reflect.

We aimed to characterize the fetal buccal fat pad (BFP) on magnetic resonance imaging (MRI) to determine the frequency and types of sequences on which the BFP demonstrates low signal intensity and determine any possible correlation with timing of the MRI during fetal development. A retrospective review of all fetal MR studies was performed, and a pediatric radiologist blinded to the referring and final fetal diagnosis as well as outcome evaluated the included cases. A positive buccal fat pad sign (BFS) was recorded as present if a round, symmetric, and bilateral area was seen in the submalar region of the face with the following signal characteristics: T1 hyperintensity, low signal on echo planar imaging (EPI), low signal on true fast imaging with steady-state free precession (TRUFI), and with restriction on diffusion-weighted imaging (DWI). A total of one hundred sixty-seven (167) fetal MRI studies: one hundred fourteen (114) body (68%) and fifty-three (53) neuro (32%) scans were reviewed during the study period. The BFS was most commonly seen on EPI (63%) and TRUFI (49%) sequences. Substantial agreement between TRUFI and EPI (κ = 0.68; p < 0.01); moderate agreement between TRUFI and T1 (κ = 0.53; p < 0.01) as well as T1 and EPI (κ = 0.53; p < 0.01), and fair agreement between EPI and Diffusion (κ = 0.28; p < 0.01) was observed. The median gestational age (GA) was 24 weeks (IQR 22-30 weeks). The fetuses with a positive BFS were significantly older (mean GA of 27 weeks or higher) than those without, for each sequence. The focal low signal in the fetal buccal fat pad, termed the fetal BFS, is a commonly encountered normal finding in the majority of fetal MRI scans on TRUFI and EPI sequences. This finding may be related to the presence and development of brown adipose tissue in the buccal fat pad resulting in T2* effects, but further studies are needed in order to confirm this. Further work can incorporate any of the sensitive sequences demonstrating low signal in brown adipose tissue to map its distribution and development in the fetus and beyond.

THU517 Aggressive Cushing’s: A Rare Case Of Pancreatic ACTHoma In A Young Female

Abstract Disclosure: O.C. Reyes: None. A. Sison: None. M. Villa: None. D. Dimayuga: None. Introduction: Adrenocorticotropic hormone-producing pancreatic neuroendocrine neoplasm (ACTHoma) is a rare type of pancreatic neuroendocrine tumor that causes ectopic adrenocorticotropic hormone syndrome. Cushingoid manifestations and metabolic abnormalities can occur rapidly. High index of suspicion is required for early diagnosis. Case: A 31-year-old Filipino female presented with facial and ankle swelling that occurred 6 weeks before the visit. She also had acne, easy bruising, amenorrhea and frequent mood swings. There was reported weight gain of 3 kg a month prior. She had no history of hypertension and diabetes, and had no unusual family history. At the time of admission, vital signs were blood pressure of 130/80mmHg, pulse of 92/min, respiratory rate 20/min and body temperature of 37.2C. Her body mass index was 28kg/m2. She had muscle atrophy of the upper and lower extremities, facial flushing, posterior cervical fat pad, abdominal violaceous striae, and skin pigmentation. Her external genitalia was normal, Tanner Stage 5 consistent with adult pattern. Neurologic exam was unremarkable. She was examined for Cushing’s syndrome. On initial tests, glucose was 406 mg/dl, HbA1C 10.7%, thyroid stimulating hormone 0.122 (NV: 0.55-4.78), Free T3 0.77 (NV: 2.3-4.2), Free T4 0.58 (NV: 0.89-1.76). Creatinine was 0.86 mg/dL, sodium was 140 mEq/L, potassium was 2.1 mEq/L showing hypokalemia. There was leukocytosis on her blood count, white blood cells 15,310/mm3 (neutrophils 94%, lymphocytes 3%). In the low-dose dexamethasone suppression test (DST), the serum cortisol concentration was 991.03nmol/L. Her adrenocorticotrophic hormone (ACTH) level was elevated at 577pg/mL. After high-dose DST, the serum cortisol concentration was &amp;gt; 1750 nmol/L. No tumor was observed on pituitary magnetic resonance imaging. On abdominal computed tomography (CT), a large, lobulated, heterogeneously-enhancing mass arising from the pancreatic body and tail measuring 7.5cm x 10cm x 10.9cm was seen. The mass had infiltrated the gastric fundus, and encased the splenic artery. Multiple non-calcified subcentimeter pulmonary nodules were observed on chest CT. CT-guided biopsy of the pancreatic mass was done. On microscopic examination, numerous atypical cells arranged with small clusters and sheets and scattered singly were found in the tumor. The cells had small to enlarged, hyperchromatic, ovoid to round nuclei and scant to ample delicate cytoplasm. On immunohistochemical staining, the tumor cells were stained positive for synaptophysin and chromogranin A, which are both neuroendocrine markers, as well as ACTH. However, the patient died prior to any definitive management. Conclusion: ACTHoma is a very rare disease that causes hypercortisolemia. Reporting of similar cases will provide insight into its clinical features, immunohistochemical characteristics, diagnosis, therapy, and prognosis. Presentation: Thursday, June 15, 2023

Effectiveness of ultrasonography performed at the emergency department for pediatric elbow trauma cases

BackgroundTwo-way direct radiography is the first-choice imaging method for pediatric patients presenting to the emergency department with elbow trauma. Although, unlike radiography, ultrasonography (US) is not used routinely, studies show that US can be used in the diagnosis of fractures in pediatric patients. MethodsIn this single-center prospective observational study, patients under the age of 18 who presented to the emergency department after sustaining elbow trauma constituted the population of the study. Findings of the posterior fat pad sign using bedside US and the result obtained by seven-point assessment of the bone cortex were compared with the final diagnosis. ResultsOf the 128 patients enrolled in the study, 6 patients were excluded due to various reasons. Seventy (57.4%) patients were male, and median age was 7.7 years. On examining the final diagnosis of the patients at the emergency department, fracture diagnosis was observed in 39 patients (32%). It was determined that fracture diagnosis for 94.9% of the patients included in the study could be achieved using US (in the presence of at least the fat pad sign and/or direct findings of fracture based on the seven-point assessment). ConclusionUS should be considered as a diagnostic tool in cases of pediatric elbow traumas owing to its high sensitivity and negative predictive value. US, which is reproducible, ionizing radiation-free, and can be performed at the bedside, can considerably reduce unnecessary radiography in low-risk patients when evaluated along with physical examination findings among patients in the pediatric age group presenting with elbow trauma. We believe that the result of our study will contribute to patient care practices.

Validation of the supinator fat pad sign in radial head and neck fractures.

To assess the displacement of the supinator fat pad in radial head and neck fractures and to validate its significance. One hundred two adult patients from the Royal Orthopaedic Hospital, Birmingham, United Kingdomand Sultan Qaboos University Hospital, Muscat, Omanwith confirmed radial head and/or neck fractures were included. Fractures were classified using the Mason-Johnston classification. The displacement of the supinator fat pad from the radius was measured on anterior-posterior (AP) and lateral radiographs and correlated to fracture classification. The supinator fat pad was on average displaced by 10.6 mm and 13.8 mm from the radius on AP and lateral radiographs, respectively. The displacement of the fat pad progressively increased between non-displaced (Mason I) and severely comminuted (Mason III) fractures on both the AP (10.25 to 14.25 mm) and lateral (12.70 to 16.00 mm) projections. The progression of displacement on AP (p = 0.016) and on lateral (p = 0.007) projections was statistically significant. Fracture dislocation was not associated with increased fat pad displacement. The supinator fat pad sign is a useful adjunct in the assessment of radial head and neck fractures.

Occult Fractures in Children with a Radiographic Fat Pad Sign of the Elbow: A Meta-Analysis of 10 Published Studies.

A radiographic fat pad sign after an elbow injury in children may indicate an occult fracture. Different incidences and locations of occult fractures have been reported. The primary objective of this meta-analysis was to assess the overall rate of occult fractures in children with a positive fat pad sign from the data of original studies. Secondary objectives were to assess the fracture types and to identify risk factors for sustaining an occult fracture. A systematic literature search of the Embase, MEDLINE, and Cochrane databases was performed according to PRISMA guidelines. Studies on pediatric populations with a positive fat pad sign identified using a lateral elbow radiograph and with follow-up imaging were included in this meta-analysis. Included studies were assessed for risk of bias with use of the MINORS (Methodological Index for NOn-Randomized Studies) instrument. Ten studies with a total of 250 patients, of whom 104 had an occult fracture, were included. Accounting for heterogeneity between the studies, the overall occult fracture rate was 44.6% (95% confidence interval: 30.4% to 59.7%). The most common fracture locations were the supracondylar humerus (43%), proximal ulna (19%), proximal radius (17%), and lateral humeral condyle (14%). Definitions of a positive pad fad sign were not uniform among studies, and the follow-up imaging modality also varied (radiography, magnetic resonance imaging, or computed tomography). The average MINORS score was 10.1 for the 7 noncomparative studies and 18.7 for the 3 comparative studies, with both averages classified as moderate quality. We were not able to identify risk factors for an occult fracture in the presence of a positive fat pad sign. The occult fracture rate was 44.6% in pediatric elbow injuries with a positive fat pad sign. Supracondylar humeral fractures were the most frequently encountered type. The findings of this meta-analysis underline the potential clinical relevance of a positive fat pad sign in children and denote the opportunity for future studies to create evidence-based guidelines. Level II. See Instructions for Authors for a complete description of levels of evidence.

Late displacement after lateral condylar fractures of the humerus.

Nondisplaced or slightly displaced lateral condyle fractures may subsequently displace if treated with cast immobilization alone, and displacement indicates surgery. In this context, placing the forehand in pronation is sometimes recommended, and the prediction of the late displacement based on the presence of the fat pad sign is useful. However, few studies have quantitatively shown the relationships between forearm position during immobilization and late displacement and between the presence of the fat pad sign and late displacement. We investigated the factors that may affect the late displacement and the features of the consequences during the late displacement. Between October 2003 and July 2020, we observed 62 patients (45 boys and 17 girls). We evaluated the correlation between the factors age, gender, the initial displacement, the presence of a fat pad sign, the flexion angle of the elbow, the forearm position (pronation or neutral), and the late displacement on day 7 after the injury, which means the difference between the displacement on day 0 and that on day 7 in the 62 cases with the minimal displacement. Moreover, of all 62 cases observed, we further investigated those 52 cases that had been treated conservatively for 3 weeks for any resultant effects. We used the Friedman test to evaluate the difference in the late displacement on each day. We acknowledged the P value < .05 as significant. There was no significant correlation between each factor (age, sex, initial displacement, presence of the fat pad sign, flexion angle of the elbow, or forearm position) and displacement on day 7, whereas there was significant progressive displacement until day7. The present study concluded that late displacement would happen until the 7 postoperative dates, regardless of the splint angle, the fat pad sign, the age, or the gender. Therefore, it is important to follow any case, even with mild-displaced lateral condylar humeral fractures, until day 7 because the late displacement might occur.

Diagnostic Value of Lateral Ankle Radiography in Achilles Tendon Rupture.

Achilles tendon rupture (ATR) is a common sports injury, but approximately 20% of acute ATR cases are misdiagnosed as ankle sprains at first presentation. This study aimed to investigate the diagnostic value of lateral ankle radiography in the diagnosis of acute ATR. This was a retrospective case-control study in which the lateral ankle radiographs of patients who presented to the emergency department between January 1, 2015 and December 31, 2019 were examined. The study included a total of 154 patients with acute ATR, who underwent lateral ankle radiography at the presentation and were surgically or magnetic resonance imaging (MRI) confirmed to have ATR in our hospital. The lateral ankle radiographs of the patients were examined by 2 clinicians blinded to clinical data for the following 3 findings: Kager's fat pad sign, tibio-first metatarsal angle, and tibiocalcaneal angle. The same procedure was repeated for 308 controls who underwent lateral ankle radiography and were diagnosed with ankle sprain. Kager's fat pad sign was detected in 133 (86.4%) of the 154 patients with ATR and 26 (8.4%) of the 308 patients in the control group. The Kager's fat pad sign, tibio-first metatarsal angle, and tibiocalcaneal angle sensitivity values for the diagnosis of ATR were 86.4%, 61.7%, and 65.6%, respectively, and their specificity values were 91.6%, 78.9%, and 56.2%, respectively. Interobserver reliability was determined to be good for all 3 radiographic findings. Clinicians should be particularly aware of Kager's fat pad sign when examining lateral ankle radiographs for ankle injury. Level IV: Case control study.

Diagnosis and Treatment of Children with a Radiological Fat Pad Sign without Visible Elbow Fracture Vary Widely: An International Online Survey and Development of an Objective Definition.

Children often present at the emergency department with a suspected elbow fracture. Sometimes, the only radiological finding is a ‘fat pad sign’ (FPS) as a result of hydrops or haemarthros. This sign could either be the result of a fracture, or be due to an intra-articular haematoma without a concomitant fracture. There are no uniform treatment guidelines for this common population. The aims of this study were (1) to obtain insight into FPS definition, diagnosis, and treatment amongst international colleagues, and (2) to identify a uniform definition based on radiographic measurements with optimal cut-off points via a receiver operating characteristic (ROC) curve. An online international survey was set up to assess the diagnostic and treatment strategies, criteria, and definitions of the FPS, the probability of an occult fracture, and the presence of an anterior and/or posterior FPS on 20 radiographs. Additionally, the research team performed radiographic measurements to identify cut-off values for a positive FPS, as well as test–retest reliability and inter-rater reliability via intraclass correlation coefficients (ICC). A total of 133 (paediatric) orthopaedic surgeons completed the survey. Definitions, further diagnostics, and treatments varied considerably amongst respondents. Angle measurements of the fat pad as related to the humeral axis line showed the highest reliability (test–retest ICC, 0.95 (95% CI 0.88–0.98); inter-rater ICC, 0.95 (95% CI 0.91–0.98)). A cut-off angle of 16° was defined a positive anterior FPS (sensitivity, 1.00; specificity, 0.87; accuracy, 99%), based on the respondents’ assessment of the radiographs in combination with the research team’s measurements. Any visible posterior fat pad was defined as a positive posterior FPS. This study provides insight into the current diagnosis and treatment of children with a radiological fat pad sign of the elbow. A clear, objective definition of a positive anterior FPS was identified as a ≥16° angle with respect to the anterior humeral line.

Elbow Injuries in Children

Elbow Injuries in Children

A Woman With Painful Elbow

A 71-year-old woman presented to the emergency department with right elbow pain after a fall. On physical examination, she was conscious and had pain well-localized to the posterior aspect of the elbow without any open wounds or swelling. She was unable to extend her elbow. Other physical examinations were unremarkable. Radiography (Figure 1) and point-of-care ultrasound of the right elbow were performed (Figure 2, Figure 3, Video).Figure 2Point-of-care ultrasound (short-axis view) of the olecranon fossa demonstrating 3 different echogenic bands within the joint fluid, separating into fatty material (arrowhead), serous joint effusion (anechoic collection), and sediment of red blood cells (asterisk). This trilevel appearance of lipohemarthrosis is called the “parfait sign.” O, olecranon fossa.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Point-of-care ultrasound (long-axis view) along the sagittal plane showing an elevated posterior fat pad sign (arrowhead) with heterogeneous echotexture consistent with lipohemarthrosis in the olecranon fossa. O, olecranon fossa.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Occult olecranon fracture with elevated posterior fat pad sign and lipohemarthrosis. Point-of-care ultrasound of the right elbow demonstrated an elevated posterior fat pad sign with lipohemarthrosis. Occult olecranon fracture was diagnosed by computed tomography (Figure 4). The patient was discharged with a splint and started rehabilitation on a 1-week follow-up. Geriatric elbow fractures are not uncommon in the ED after low-energy falls. Diagnosis can sometimes be difficult with radiography because of overlapping bones or inappropriate radiographic positions. Point-of-care ultrasound is an ideal and practical tool for rapidly evaluating traumatic elbow injury.1Okumura Y. Maldonado N. Lennon K. et al.Point-of-care ultrasound: sonographic posterior fat pad sign: a case report and brief literature review.J Emerg Med. 2017; 53: 98-101Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Findings of elevated posterior fat pad sign and lipohemarthrosis on point-of-care ultrasound are highly sensitive predictors of intraarticular elbow fractures.2O'Dwyer H. O'Sullivan P. Fitzgerald D. et al.The fat pad sign following elbow trauma in adults: its usefulness and reliability in suspecting occult fracture.J Comput Assist Tomogr. 2004; 28: 562-565Crossref PubMed Scopus (47) Google Scholar, 3Rabiner J.E. Khine H. Avner J.R. et al.Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children.Ann Emerg Med. 2013; 61: 9-17Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 4Costa D.N. Cavalcanti C.F. Sernik R.A. Sonographic and CT findings in lipohemarthrosis.AJR Am J Roentgenol. 2007; 188: W389Crossref PubMed Scopus (12) Google Scholar Lipohemarthrosis is defined as “2 or 3 different echogenic bands seen within the joint fluid,” separating into fatty material, serous joint effusion, and sediment of red blood cells.1Okumura Y. Maldonado N. Lennon K. et al.Point-of-care ultrasound: sonographic posterior fat pad sign: a case report and brief literature review.J Emerg Med. 2017; 53: 98-101Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar This trilevel appearance is sometimes called the “parfait sign.” Treatment of nondisplaced elbow fractures involves immobilization for a duration of 1 week. https://www.annemergmed.com/cms/asset/2b8d4b36-a95f-43b2-8942-70edc14a2430/mmc1.mp4Loading ... Download .mp4 (0.86 MB) Help with .mp4 files VideoPoint-of-care ultrasound (short-axis view) of the right elbow revealing a trilevel area of joint fluid within the olecranon fossa, known as lipohemarthrosis (asterisk) (visible from 00:00 to 00:04); long-axis view in the same region presented an elevated posterior fat pad sign (arrowhead) (visible from 00:04 to 00:09).

Diagnostic accuracy of ultrasonography for diagnosis of elbow fractures in children.

Elbow injuries and fractures are a common pathology in the pediatric emergency unit. X-ray and CT scan of the elbow are the standard diagnostic procedures, which increase exposure to radiation in children. Previous studies have shown that fractures can also be visualized by ultrasound (US); thus, this study aimed to evaluate the diagnostic accuracy of elbow US compared with radiography for the diagnosis of elbow fracture in children. This was a prospective observational study of patients aged 2-14years that presented to emergency departments with a suspected elbow fracture requiring radiographic evaluation. Elbow US for diagnosing elevated posterior fat pad or lipohemarthrosis was performed. All patients underwent elbow radiography and received clinical follow-up. Initial or follow-up X-ray or CT scan was used as the reference standard for fracture diagnosis. Seventy-five patients with a mean age of 6.51 ± 3.68years were enrolled in the study. Twenty-eight (37.3%) patients had positive results for fracture. The sensitivity, specificity, and accuracy of US in the diagnosis of elbow fractures were 92.9% (95% CI 76.5-99.1%), 89.4% (95% CI 76.9-96.5%) and 90.7% (95% CI 81.7-96.2%). In patients with fracture, US demonstrated a lipohaemarthrosis in 20 patients (71.4%), elevated posterior fat pad in 19 patients (67.9%), cortical disruption in 10 patients (35.7%), and effusion in three patients (10.7%). Our results showed high diagnostic accuracy for the ultrasonography diagnosis of an elbow fracture, which allows us to confirm ultrasonography imaging of the elbow as a safe alternative in the primary evaluation of pediatric elbow injuries.

SOME WORDS ABOUT FRACTURES OF RADIAL HEAD

A visible posterior fat pad on the lateral view of the elbow is a sign of occult intraarticular pathology.&#x0D; Early elbow ROM is needed to prevent stiffness. If you fixed the fracture, but not well enough to move the elbow, you did not fix it.&#x0D; The “safe zone” for placing hardware on the radial head lies in the interval between the radial styloid and Lister’s tubercle.&#x0D; Examine the wrist when examining all elbow injuries; a radial head fracture may be accompanied by a tear of the interosseous membrane and disruption of the distal radioulnar joint.&#x0D; The posterior interosseous nerve (controlling finger and wrist extension) can be damaged by a radial head injury or by the surgery performed to treat the fracture. Therefore, document functional status preoperatively. The severity of these injuries runs the gamut from minimally displaced fractures needing minimal treatment to those with major displacement or comminution, requiring surgical fixation, excision, or replacement.

A simple approach for determining tendon limb length in open Achilles lengthening: technical note.

Estimating the appropriate tendon length and associated skin incision needed to achieve a plantigrade foot without compromising function are essential steps in open Achilles tendon lengthening. Here we describe a technique using basic surgical instruments referencing anatomic landmarks without the need for radiographs. The center of ankle rotation in the sagittal plane is found referencing the tip of the medial malleolus. This point is translated to the plantar surface of the foot, and a straight instrument in line with the foot is used to make a mark at the posterior calcaneal fat pad. The straight instrument is then rotated (representing the plantar surface of the foot) as if dorsiflexing the ankle along the axis of the transposed tibiotalar joint from a plantar-flexed position to the desired final position and a second mark is made at the posterior heel. The distance between the marks is measured, representing the amount of Achilles lengthening required. The skin incision and tendon limb lengths area a sum of the operative correction and the amount of desired tendon overlap, typically 2 cm of tendon overlap is optimal to allow for suture fixation, ensure tendon healing, and maintain the integrity of the repair. A Z-type lengthening is then performed using this tendon limb length. This technique allows an accurate and simple approach to lengthening the Achilles tendon. In this way the ideal tendon limb length is selected to optimize function while minimizing incision length, associated wound complications, inadequate lengthening, and overlengthening. Level of evidence: Technical note, Level V.

Standardized sonographic examination of pediatric elbow injuries is an effective screening method and improves diagnostic efficiency

IntroductionPositive role of ultrasound in the diagnosis of pediatric elbow injuries were confirmed by many papers but no comprehensive, standardized method has been developed for daily clinical practice. The aim of our prospective diagnostic study was to prove the efficacy of a five point sonographic point of care method for detecting different pediatric elbow fractures or dislocations. MethodsBetween 2016 January and 2017 March 365 children (age 1–14) with suspected closed elbow injury were enrolled in our study. Sonographic point of care examination was carried out by a properly trained resident and two orthopedic surgeons immediately after physical survey. We used a standardized five point sonographic examination. Two plane x-rays were made following sonography according to protocol. Utility of sonographic pictures were analyzed by a radiologist. Cases with images which have not met with standard requirements were excluded. In those cases when primary x-rays were negative and/or any of the ultrasound planes showed positive findings, radiography was repeated after 4 weeks of injury. If we detected callus formation the fracture was considered occult. Cases with images which have not met with standard requirements were excluded. Ultrasonic pictures, evaluation sheets and x-ray results were compared. ResultsOut of the 365 cases we identified 165 with positive findings (45, 2%) by primary x-rays. Distribution of the different injuries were the following: Radial condylar fractures, (n = 29) supracondylar humeral fractures (n = 84 proximal radial fractures, (n = 19) proximal ulnar fractures, (n = 7) fractures with joint dislocations (n = 3) joint dislocations without fractures, n = 2 medial epicondyle fractures (n = 14) fracture combinations (n = 7) We did not find injuries in this series that we could not categorize into these groups. Evaluating the abnormal sonographic dorsal fat pad sign (FPS) as a sole parameter for fracture detection we found sensitivity: 0, 97, specificity: 0,97, positive predictive value: 0,97, negative predictive value: 0,97 Evaluating the effectivity of the four cortical planes we calculated sensitivity 0, 85 specificity 0.96 positive predictive value: 0. 95 negative predictive value 0.87. The overall values of the five planes were the following: specificity0.97 sensitivity 1, positive predictive value 0.97 negative predictive value: 1 Interrater agreements on the cortical plane abnormality were considered good at two examiners and very good at one examiner. (Kappa = 0.79, 0, 81, 0, 79) Agreements on differentiation of elevated, normal fat pad) or lipohaemarthrosis in sonographic pictures were very good in all cases. (Kappa = 0,83, 0,86,0,82) While identification of any displacement or dislocation was possible in 96%, of all cases(n = 59)the exact determination of the type of the injury was possible in only 70,3% (n = 116) ConclusionsUsing the five point ultrasonic examination provides enough information for excluding or confirming the presence of any pediatric elbow fractures or dislocations. The method is quick, simple and can help in the immediate differentiation of the severity of injuries. Sonographic lipohaemarthrosis seems to be more sensitive than elevated fat pad sign for the detection of potential occult fractures. Positive cases should be cleared by x-rays because the exact nature of the fractures are not identifiable only by ultrasound.

Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow

IntroductionPulled elbow (PE) is one of the most common injury in children under the age of five years.Diagnosis of PE is usually based on the typical anamnesis and clinical symptoms. A simple reduction maneuver without the need of any imaging modality can eliminate the problem. Certain fractures however can mimic the physical findings of PE and in this cases reduction should not be attempted. The aim of our prospective diagnostic study was to evaluate the accuracy of a sonographic testing method in the differential diagnosis of PE. Methods205 children aged 0–5 with clinical suspicion for PE were enrolled in our study.Inclusion criteria were the typical clinical sign of PE: painful, motionless, extended or slightly flexed and pronated arm following a traumatic event under the age of five. We excluded older children and patients with pronounced elbow swelling and initially flexed and supinated upper arm position.A two plane point of care sonographic examination was carried out at each patient immediately after history taking and primary physical survey.Presence of the elevated dorsal sonographic fat pad sign(FPS) and the synovial fringe enlargement (SFE) were examined from dorsal and ventral longitudinal planes.Children with FPS positivity and/or unsuccessful reduction were x-rayed. Suspected occult fractures with persistent complains were also x-rayed on the 3rd week.Sonographic pictures and x-rays were analyzed and compared to clinical findings. ResultsThe diagnosis of PE was confirmed in 196 cases. (95.6%). 9 children had type I. supracondylar humerus fractures. (4.39%) Out of these 2 proved to be occult fractures.(0.97%). SFE positivity was detected only in the PE group (156 cases, 76%) fractures have not shown this sign. Elevated FPS was negative in all but one PE cases, while all fractures showed FPS positivity without exception.Evaluating the two parameters together both sensitivity, specificity, negative and positive predictive value were 100%. ConclusionsThe two plane sonographic point of care method is an effective tool for confirming the diagnosis of PE and excluding the presence of fractures. It is an easy, standard and objective procedure which can be used as a fast diagnostic test before reduction attempts.

Urgent Surgical Treatment of Blunt Chest Trauma Followed by Cardiac and Pericardial Injuries.

Introduction:Widespread opinion that penetrating chest injuries are more urgent, in terms of treatment and care, contributed to underestimation of the urgency of blunt chest trauma, which in most cases is treated conservatively. It remains an open question frequency when the injuries of the heart and pericardium are not timely diagnosed and surgically treated. Aim:To demonstrate the importance of well-timed surgical treatment of blunt chest trauma, when coupled with cardiac and pericardial injuries.Methods:At the Thoracic Surgery Clinic of the University Clinical Centre Banja Luka, Bosnia and Herzego vina, during period of 10 years (01.01. 2008 – 31.01.2018.), the total of 66 patients were treated for urgent thoracotomy due to clinically and radiologically unclear findings after blunt chest trauma. In general, diagnostic examinations, apart from laboratory analysis, included radiological imaging and Multi Slice Computed Tomography (MSCT) of the chest, followed by an ultrasound of the heart in cases when sternum was injured or when pericardial tamponade was suspected. Results presented in the study where obtained from the retrospective analysis of patients data. This work presents a retrospective observational cross-sectional study, which results in the assessment of the correctness of a particular diagnostic test.Statistical methods used:descriptive statistics, counting measures (frequencies and percentages), central tendency measures (arithmetic mean), variability measures (standard deviation). Results:Sixty six patients were treated with urgent thoracotomy after a blunt trauma of the chest due to the unclear clinical and radiological finding. In the case of 11 patients (10 men and 1 woman), presenting 16.6% of the total sample, pericardial and cardiac injuries were detected and treated intraoperatively. Further, in the case of the one patient, pericardiotomy and suturing of the right heart chamber where performed, with the creation of a pericardial window. Transthoracic echocardiogram was not used as the primary screening module, but rather as a diagnostic test for patients who had unexplained hypotension and arrhythmia. Radiographs of the chest showed cardiomegaly with or without epicardial fat pad sign suggesting a pericardial effusion.Conclusion:Blunt cardiac and pericardial injuries represent a serious therapeutic problem, which, if not treated properly, result in a high mortality rate. Echocardiography is the primary diagnostic method for initial detection of pericardial effusion. Pericardial fluid first accumulates posterior to the heart, when the patient is examined in the supine position. As the effusion increases, it extends laterally and with large effusions the echo-free space expands to surround the entire heart. The size of the effusion may be graded as small ( echo free spaces in diastole <10 mm, corresponding to approxymately 300 ml), moderate (10-20 mm, corresponding to 500 ml), and large ( >20 mm, corresponding to >700 ml). When the ability of the pericardium to stretch is exceeded by rapid or massive accumulation of fluid, any additional fluid causes the pressure with the pericardial sac. Early recognition, pericardiotomy with pericardial window creation and/or ventricular rupture suture remain the “gold standard” in the treatment of blunt cardiac and pericardial injuries.

Inter-Observer Accuracy of “Fat Pad Sign” in Determining Radiological Elbow Joint Effusion with Different Levels of Experience

Abstract Background: Joint Effusion is considered as an important indicator of many joint morbid conditions. In the sitting of trauma, fat pad displacement in lateral elbow radiograph may be the only clue of occult fractures as it is referred to elbow effusion. Likewise, it's a sign of early internal joint morbidity in many articular diseases. The classic lateral radiograph is considered as the primary choice for determining elbow joint effusion because of being simple, available and reasonable tool. Aim of Study: The current study aimed to evaluate the inter-observer accuracy of fat pad signs of elbow lateral radiograph in detecting elbow joint effusion with the impact of observer experience on it. MRI was used as the gold standard. Patient and Methods: The current study is a descriptive validation study in which 52 patients were included prospec-tively in it. Inclusion criteria were positive elbow effusion by MRI with available lateral elbow radiograph within 3 days of the MRI study. Radiographs were read by 2 groups: Group I (2 senior radiology residents of 3 years' experience: Reader A & B), and group II (2 radiologists with MD degree, reader C & D). Each observer provided his readings by either proved effusion, denied effusion or asked for further evaluation. Readers were independently and blinded to the patients' clinical data. Results: The diagnostic accuracy percentages of elbow effusion detection for each reader compared to MRI were calculated as follows: Proper detection were from 59.6% to 61% in low experience, and 76.9% to 82.7% in high experience. Missed cases were (19%) in low experience and (3.8%) to (7.7%) in high experience group. While cases needed further evaluation were 19.2% to 21.2% in low experience and in high experience were ranging from 13.5% to 15.4%. Then agreement between each reader were estimated. The same level of experience showed perfect agreement, (Kappa of 0.922 and 0.965). While lower agreement was detected in different experience group with Kappa of 0.51 to 0.641, which is moderate and substantial agreement. Conclusion: The current study emphasizes that validity of radiographs in detection of elbow effusions widely varied with levels of experience. MRI is important beside lateral radiograph for detection of elbow effusion especially in low experience to avoid missed occult fractures and early morbid joint affection.

Role of the Posterior Fat Pad Sign in Treating Displaced Extension Type Supracondylar Fractures of the Pediatric Elbow Using the Blount Method.

The posterior fat pad sign (PFPS) on the lateral elbow X-ray is useful in the diagnosis of a suspected nondisplaced fracture about the elbow after a subtle injury. However, the presence of a PFPS hallmarks a continuous posterior periosteum-posterior capsule of the distal humerus. This anatomic structure is crucial for the stable anatomic reduction of a displaced extension type supracondylar fracture. Subsequently, the presence of a PFPS may predict the successful nonoperative treatment of a Gartland III-type fracture by means of the Blount method, implying less implant-related morbidity and less intraoperative radiation exposure for the patient and surgeon. Furthermore, it is concluded that a PFPS-positive displaced extension type supracondylar fracture is definitively classified as a Gartland III and not a Gartland IV-type fracture. A retrospective study of 75 displaced extension type supracondylar elbow fractures was performed. All fractures had an initial attempt at a closed reduction under general anesthesia. A stable reduction in 120 degrees of elbow flexion without vascular compromise of the affected limb was achieved in 45 fractures, which were splinted in this position. In the remaining 30 cases, fracture reduction was either inadequate or was achieved with excess elbow flexion, which impaired distal blood flow. These fractures were pinned percutaneously and splinted in 90 degrees of elbow flexion. The two treatment groups were retrospectively compared for the presence of a PFPS. The displaced extension type supracondylar fractures, which were treated successfully by the Blount method, had a statistically significant higher prevalence (chi-square-Yates =4.91, p<0.05) of a positive PFPS (28/45 patients, 62.22%) compared to the fractures treated by closed reduction and percutaneous pinning (10/30, 33.33%). No vascular complications were observed. The long-term outcome did not differ between groups.

What’s New in Orthopaedic Trauma

What’s New in Orthopaedic Trauma