Pediatric Elbow Trauma Research Articles

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.

Not all that looks fractured is broken—multipartite humeral epicondyles in children

ObjectiveMultipartite epicondyles may mimic fractures in the setting of pediatric elbow trauma. This study examines the prevalence of multipartite epicondyles during skeletal development and their association with pediatric elbow fractures.Materials and methodsIn this retrospective analysis, 4282 elbow radiographs of 1265 elbows of 1210 patients aged 0–17 years were reviewed. The radiographs were analyzed by two radiologists in consensus reading, and the number of visible portions of the medial and lateral epicondyles was noted. For elbows in which epicondylar ossification was not yet visible, the epicondyles were already fused with the humerus or could not be sufficiently evaluated due to projection issues or because osteosynthesis material was excluded. In total, 187 elbows were included for the lateral and 715 for the medial epicondyle analyses.ResultsNo multipartite medial epicondyles were found in patients without history of elbow fracture, whereas 9% of these patients had multipartite lateral epicondyles (p < 0.01). Current or previous elbow fractures increased the prevalence of multipartite epicondyles, with significant lateral predominance (medial epicondyle + 9% vs. lateral + 24%, p < 0.0001). Including all patients regardless of a history of elbow fracture, multipartite medial epicondyles were observed in 3% and multipartite lateral epicondyles in 18% (p < 0.0001). There was no gender difference in the prevalence of multipartition of either epicondyle, regardless of a trauma history.ConclusionMultipartite medial epicondyles occur in patients with current or previous elbow fractures only, whereas multipartite lateral epicondyles may be constitutional. Elbow fractures increase the prevalence of multipartite epicondyles on both sides, with significant lateral predominance.Key Points• Multipartite medial epicondyles should be considered of traumatic origin.• Multipartite lateral epicondyles may be constitutional.• Elbow fractures increase the prevalence of multipartite epicondyles on both sides with lateral predominance.

Usefulness of CT as additional imaging examination after X-ray for pediatric elbow trauma

Usefulness of CT as additional imaging examination after X-ray for pediatric elbow trauma

Applying CRITOE in pediatric elbow trauma: is that a fracture or an ossification center?

Applying CRITOE in pediatric elbow trauma: is that a fracture or an ossification center?

Initial Evaluation by a Non-Surgeon Provider Does Not Delay the Surgical Care of Pediatric Forearm and Elbow Trauma in a Walk-In Orthopaedic Clinic.

IntroductionWalk-in and after-hours clinics are being increasingly utilized in orthopedics and are especially beneficial for patients with simple sprains, fractures, or overuse injuries that might otherwise require an emergency room visit. To meet the increased patient load, additional staffing often is required, which might include a family medicine physician, nurse practitioner, or physician assistant. Few studies have evaluated the performance of these non-surgeon providers in an orthopedic clinical setting. This study compared the time to definitive care of pediatric patients with forearm and elbow injuries between non-surgeon providers in a walk-in clinic, orthopedic surgeons in a walk-in clinic, and a pediatric orthopedic surgeon in a regular clinic.MethodsChildren who had closed reduction and fixation of an elbow or forearm injury from January 2010 to December 2017 were identified. The patients were divided into groups: patients initially evaluated in a walk-in clinic by a non-surgeon provider; patients initially evaluated in a walk-in clinic by an orthopedic surgeon; and patients initially seen by a fellowship-trained, pediatric orthopedic surgeon in a regular clinic (control group). Neither type of provider (non-surgeon or surgeon) in the walk-in clinics definitively treated any injury but rather transferred care of the patient to a pediatric orthopedic surgeon. The number of clinic visits until surgery, the number of providers seen, the days before evaluation by a pediatric orthopedic surgeon, and the number of days before definitive surgical treatment were documented.ResultsOf the 162 patients identified, 36 (22%) were initially seen by an orthopedic surgeon and 62 (38%) by a non-surgeon provider in a walk-in clinic. The remaining 64 (40%) (control group) were initially seen in a regular office visit by a pediatric orthopedic surgeon. There were no significant differences noted for patients treated by orthopedic surgeon and non-surgeon providers in days before a referral visit to the pediatric orthopedic surgeon (3.7 vs. 3.9, respectively; p = 0.63) or days to surgery for definitive treatment (5.2 vs. 4.8, respectively; p = 0.62). The average number of providers seen (1.58 vs. 1.63, respectively; p = 0.69) and average number of clinic visits before surgery (2.08 vs. 2.06, respectively; p = 0.76) also were similar when comparing the two groups. The control group had significantly fewer days from evaluation to surgical treatment than the surgeon walk-in group (3.3 days vs. 5.2 days, p < 0.05) and the non-surgeon walk-in group (3.3 days vs. 4.8 days, p < 0.05).ConclusionThere was no difference in the number of days to transfer patient care to a pediatric orthopedic surgeon between non-surgeon providers and orthopedic surgeons in the walk-in clinic. However, there was a one-day delay reaching definitive treatment when initial evaluation occurred in a walk-in clinic, regardless of whether the patient was initially seen by a surgeon or non-surgeon, when compared to an initial evaluation by a pediatric orthopedic surgeon.

Improved diagnostic confidence and accuracy of pediatric elbow fractures with digital tomosynthesis.

Pediatric elbow fractures are common but remain challenging to accurately diagnose. Digital tomosynthesis is a technique that has shown promise in difficult adult fracture patterns but has not been formally studied in the pediatric population. To assess the added value of digital tomosynthesis on the detection and diagnostic confidence of pediatric elbow fractures. A retrospective study was performed between January 2016 and December 2017 in pediatric patients (≤18years) to assess the ability of conventional elbow radiographs and digital tomosynthesis to detect elbow fractures. One hundred twenty-one pediatric patients with concern for pediatric elbow trauma (64 males, 57 females; mean age: 8.1years, range: 1year to 17years) were imaged with both conventional elbow radiographs and digital tomosynthesis. Two blinded pediatric radiologists identified fractures and indicated their diagnostic confidence. Observer agreement was assessed with Cohen's Kappa coefficient and a nonparametric Wilcoxon rank sum test was used to compare the degree of diagnostic confidence between standard radiographs alone and standard radiographs with digital tomosynthesis. McNemar's test was used to assess the difference in the rate of fracture detection between the two methods and sensitivity, specificity, precision, accuracy and diagnostic odds ratios were calculated. Compared with standard radiographs alone, standard radiographs with digital tomosynthesis improved inter-rater agreement, sensitivity, specificity, accuracy, precision and the diagnostic odds ratio for fracture detection and increased diagnostic confidence (Rater 1: P=0.01, Rater 2: P=0.003). The addition of digital tomosynthesis with conventional elbow radiographs improves diagnostic confidence and performance for the detection of pediatric elbow fractures.

Digital tomosynthesis of the pediatric elbow.

Imaging pediatric elbow trauma in the acute setting remains diagnostically challenging given difficult patient positioning, multiple ossification centers of the pediatric elbow, overlapping structures, and complex joint anatomy. Digital tomosynthesis is a technique where the X-ray source travels across a limited arc angle, obtaining a series of low-dose exposures that are in turn digitally reconstructed to produce high in-plane resolution at a relatively low overall radiation dose. Digital tomosynthesis is now more commonly integrated into standard radiographic machines and offers a new and exciting way to assess the pediatric elbow. In this review article we discuss the clinical applications of digital tomosynthesis in pediatric elbow trauma along with challenges related to technique, patient positioning and artifacts.

Reliability and Effectiveness of Smartphone Technology for the Diagnosis and Treatment Planning of Pediatric Elbow Trauma.

Mobile imaging, such as viewing radiographs as text messages, is increasingly prevalent in clinical settings. The purpose of this study was to determine whether remote diagnosis of pediatric elbow fractures using smartphone technology is reliable. In addition, this study aimed to determine whether the assessment regarding the decision for operative treatment is affected by evaluation of images on a mobile device as opposed to standard picture archiving and communication system (PACS). Standard anteroposterior and lateral radiographs of 50 pediatric elbow trauma cases were evaluated by 2 fellowship-trained pediatric orthopaedic surgeons and 2 senior orthopaedic residents. Raters were asked to classify the case as any of 6 diagnoses: supracondylar humerus, lateral condyle, medial epicondyle, radial neck fracture, positive posterior fat pad sign, or normal pediatric elbow. Raters were asked to choose operative or conservative treatment. After 1 week, photographs of the same images were taken from a standardized distance from a computer monitor with an iPhone 5 camera and transmitted by multimedia messaging to each rater. The same questions were again posed to raters. Interobserver and intraobserver reliabilities were calculated by Cohen κ-statistics with bootstrapped 95% confidence intervals. Intraobserver reliability of classification of injuries on PACS compared with smartphone images was excellent, with an overall κ of 0.91. Treatment decision also demonstrated excellent intraobserver reliability (PACS vs. smartphones) with a κ of 0.86 for all raters. Diagnosis of pediatric elbow injuries can be made equally reliably based on either PACS or transmitted multimedia messaging images taken with an iPhone camera from a computer screen and viewed on a smartphone. Treatment decisions can also be made reliably based on either image modality. Using smartphones to transmit and display radiographs, which is common in current clinical practice, is effective and reliable for diagnosis and treatment planning of pediatric elbow injuries.

Pediatric Bone Imaging: Imaging Elbow Trauma in Children???A Review of Acute and Chronic Injuries

Pediatric elbow trauma is challenging because of the complex nature of the growing skeleton. The objectives of this article are to review the anatomy and radiographic landmarks and to discuss common acute and chronic injuries sustained. Radiographic evaluation of elbow trauma in the acute setting requires a firm understanding of developmental anatomy, radiographic landmarks, and the common injury patterns. Both radiography and MRI are vital tools for diagnosing chronic elbow overuse injuries in adolescent athletes.

Outcome of treatment of the mismanaged pediatric elbow trauma: A series of 73 cases

Purpose. To analyze the outcome of the management of pediatric elbow trauma referred to our hospital after initial intervention by traditional bone setters.Method. Retrospective study of 73 patients, presenting to the hospital with a complication attributable to the initial mismanagement of their injuries.Results. The mode of presentation was directly related to the type of initial intervention on the basis of which we were able to quantify bone setters into two groups. The first group using a rather rough method of trauma treatment involving the application of tight local bandages, massage and manipulation and a second group having a relatively less rough approach, applying splints to the injured extremity without tight bandages and manipulation. The result of treatment of these injuries was determined by the delay in presentation and the type of injury.Conclusion. This study highlights the importance of dealing with the unchecked and unsupervised practice of bone setting in the developing world. We believe that training these people on the pattern of traditional birth attendants can at the very least lower the occurrence, if not entirely eliminate the problem of mismanaged trauma in this part of the world.

Pediatric Elbow Trauma: An Orthopaedic Perspective on the Importance of Radiographic Interpretation

Radiographic interpretation of pediatric elbow trauma presents a daunting task for both the radiologist and treating orthopaedic surgeon. Proper radiographic diagnosis and appropriate intervention requires a thorough understanding and appreciation of developmental anatomy. As the pediatric elbow matures, it transitions from multiple cartilaginous anlagen through a predictable pattern of ossification and fusion. When children sustain trauma to the elbow, they may have a limited capacity to communicate specific complaints and are sometimes difficult to examine reliably. Furthermore, the presence of multiple growth centers, and their variability, makes radiographic evaluation of pediatric elbow injuries particularly challenging. These variables, coupled with the known adverse long-term sequelae of pediatric elbow trauma (painful nonunion, malunion, elbow stiffness, growth disturbance, etc.) highlight the importance of accurate radiographic interpretation, which facilitates appropriate treatment. By using an orderly, systematic approach based on well-defined anatomical relationships and accepted radiographic markers, the radiologist may effectively interpret and communicate pertinent findings to the treating orthopaedic surgeon. Furthermore, using common classification systems may facilitate interdisciplinary communication. Finally, it is crucial that caregivers of children consider the possibility of child abuse in suspect cases.

Magnetic resonance imaging in pediatric elbow fractures

Magnetic resonance imaging (MRI) evaluation of pediatric elbow trauma with or without a visible fracture on radiography. MRI was performed in the acute phase in 25 children with an elbow injury. Nine patients with an elbow effusion only on radiographs and 16 with a fracture or luxation seen on radiographs underwent subsequent MRI. No sedation was used. MRI revealed eight occult fractures (89%) in seven out of nine patients who had only an effusion on radiographs. Based on MRI findings, septic arthritis was suspected in one patient. Two patients out of five with a supracondylar fracture on the radiograph had a cartilage lesion in the humerus. MRI depicted a 3-mm gap on the articular surface in two patients with a lateral condyle fracture, a more accurate fracture location in two patients than the radiographs, and an additional occult fracture in two patients. MRI showed a fracture not seen on radiographs in two of three patients with prior luxation. MRI is a sensitive and accurate method in the diagnosis of pediatric elbow injuries, especially when only an effusion is present on radiographs. Occult fractures are more common in pediatric patients with elbow injury than reported earlier.

The prevention of traditional bone setter’s gangrene

The Journal of Bone and Joint Surgery. British volumeVol. 87-B, No. 9 CorrespondenceFree AccessThe prevention of traditional bone setter’s gangreneA. AGARWAL, R. AGARWALA. AGARWALSearch for more papers by this author, R. AGARWALSearch for more papers by this authorPublished Online:1 Sep 2005https://doi.org/10.1302/0301-620X.16755AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Sir,We read with interest the article in the January 2005 issue by Eshete1 entitled ‘The prevention of traditional bone setter’s gangrene’. We appreciate the concern shown by Dr Eshete and his colleagues towards their community. Shah2 also reported encouraging results from an effort to bridge the gap between orthodox and unorthodox medical practitioners in Nepal. Although most reports of traditional healers originate from African countries, their impact is felt in all developing countries. In India, it is estimated that there are about 70 000 traditional healers and bone setters who treat 60% of all trauma patients.3 Little or nothing is known of how well these patients recover, although incidences of failure reported to health centres are damaging to the bone setters’ reputation.Bone setters will continue to exist. With their unscientific methods and without knowledge of anatomy, physiology or radiography, complications will inevitably occur. However, education plays a key role in influencing their method of treatment. They should be urged to adopt the fine example of Chinese healers, who refer complicated cases to orthopaedic experts in equipped centres. Interaction with traditional healers should not necessarily be one-sided. Some healers are experienced and have a sound knowledge of regional resources. For example, the Puttur bandage, which is a type of forearm bandage used in southern India, is considered superior to the normal ‘collar and cuff sling’ used by orthopaedic surgeons.4 This bandage supports the arm at the wrist and angle of thumb and palm, preventing wrist-drop.4Integrating the services of traditional bone setters into primary health care also requires a strong political commitment. They should be permitted and encouraged to attend as orthopaedic assistants in primary trauma departments of district hospitals.5 A particular village can be adopted by a teaching medical institution as part of a rural health scheme to provide education and to address the health problems of that particular region. This should be supplemented by legislation to regulate these traditional practices so as to limit them to what is considered safe. References 1 Eshete E. The prevention of traditional bone setter’s gangrene. J Bone Joint Surg [Br] 2005;87-B:102–3. Link, Google Scholar2 Shah RK. Comments. Trop Doct 1992;22:121. Google Scholar3 Church J. Regional news. World Orthopaedic Concern Newsletter Jan 1998;74. Google Scholar4 Shankar D. Traditional bone setting. http://planningcommission.nic.in/reports/sere-port/ser/seeds/seed_helth.pdf. (accessed 05/04/05). Google Scholar5 Onuminya JE, Obekpa PO, Ihezue CH, Ukegbu ND, Onabowale BO. Major amputations in Nigeria: a plea to educate traditional bone setters. Trop Doct 2000;30:133–5. Crossref, Medline, ISI, Google ScholarFiguresReferencesRelatedDetailsCited byComplications of paediatric elbow trauma treatment by traditional bonesetters1 April 2009 | Tropical Doctor, Vol. 39, No. 2Outcome of treatment of the mismanaged pediatric elbow trauma: A series of 73 cases7 July 2009 | Disability and Rehabilitation, Vol. 31, No. 5 Vol. 87-B, No. 9 Metrics History Published online 1 September 2005 Published in print 1 September 2005 InformationCopyright © 2005, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

PEDIATRIC ELBOW TRAUMA

This article provides a summary of the acute management of pediatric elbow trauma. Treatment options are reviewed for all pediatric fractures, specific recommendations are outlined, and complications are addressed. Particular emphasis is placed on the common, but often complicated supracondylar fracture of the distal humerus.

MR Imaging of Pediatric Elbow Trauma.

Magnetic resonance imaging (MRI) of the pediatric elbow is important because it allows delineation of fracture type in a joint with complex anatomy, made more complex by the variable appearance of ossification centers of the distal humerus.1-4 Acute and chronic injuries can be evaluated with MRI using several classification systems. Accurate diagnosis of pediatric elbow trauma with MRI has management implications. For example, a Salter-Harris II fracture can be differentiated from a Salter-Harris IV physeal fracture by delineating intra-articular fracture extension and displacement, which requires open reduction internal fixation. The former is treated with closed reduction if nondisplaced, and the latter, with open reduction and internal fixation. The rate of complications in this age group is high and the treatment for these deformities thereafter can be difficult. There is also a useful role for MRI when the clinical history is unobtainable or absent as in a case of child abuse, for example. The multiplanar capability of MR allows for good preoperative planning to delineate fragment displacement. The main fracture classifications are presented.

Pediatric elbow trauma

Acute pediatric elbow trauma is commonly seen in the emergency department (ED). Reports confirm that, compared to other fractures, children's elbow fractures are commonly misdiagnosed in the ED. In addition, missed orthopedic injuries are one of the leading causes of malpractice claims in emergency medicine. Radiologic diagnosis of these injuries is challenging, as a large portion of the pediatric elbow is composed of radiolucent cartilage. Knowledge of the normal anatomy and ossification centers around the elbow is essential for correct diagnosis. Acute neurovascular injury is frequently associated with these injuries, but is often difficult to assess in an apprehensive child. Immediate orthopedic consultation is indicated for any child with an elbow injury in whom neurologic or vascular compromise is suspected. Consultation should be strongly considered for children with displaced supracondylar fractures and/or significant echymosis and swelling about the cubital fossa.