Pediatric emergency medicine trisk 3456 3456
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Management . Fracture diagnosis requires plain radiographs of the elbow, with
both anteroposterior and lateral views. Comparison views of the elbow may be
useful in diagnosis of fracture due to the complexity of the joint with its three
points of articulation, numerous growth centers, and variable timing of
ossification ( Table 111.7 ). After initial examination, patients should be splinted
prior to imaging. The lateral view should be with the elbow at 90 degrees of
flexion to avoid a false-positive posterior fat pad sign. In addition, radiographs of
the forearm should be obtained, as there is a 10% to 15% risk of ipsilateral
concurrent distal radius forearm fracture.
Interpretation of the radiographs for occult fracture requires attention to subtle
changes in three regions: the fat pads (anterior and posterior), the anterior
humeral line, and the radiocapitellar line. In the normal lateral radiograph, the
anterior fat pad is readily seen but the posterior fat pad is hidden within the
olecranon fossa ( Fig. 111.16 ). The presence of hemarthrosis and edema in the
joint following trauma will elevate the anterior fat pad creating the “sail sign” and
displace the posterior fat pad from the fossa creating a lucency posterior to the
distal humerus on lateral view ( Fig. 111.17 ). The presence of a posterior fat pad
sign is abnormal and is 75% sensitive for the presence of an occult elbow
fracture. The anterior humeral line is a line drawn along the anterior cortex of the
humerus and should intersect the capitellum in its middle third; however, in the
presence of an extension-type injury this line will pass anteriorly. Finally, a line
drawn along the axis of the radius should pass through the capitellum irrespective
of the degree of elbow flexion or extension on the radiograph. If this is not
visualized, there may be either a lateral condyle fracture or a dislocation of the
radial head (as in a Monteggia fracture) ( Fig. 111.18 ).
