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Traumatic elbow effusions in pediatric patients: Are occult fractures the rule?
Abstract
Elbow joint effusion with no fracture seen on radiographs of pediatric patients after acute trauma has become synonymous with occult fracture. This study evaluates the incidence of occult fractures in such cases as determined by findings on follow-up radiographs.
Initial and follow-up radiographs were reviewed for 54 children (mean age, 7 years) with a history of trauma who had joint effusion but no identifiable fracture on initial radiographs. The presence of periosteal reaction or bony sclerosis on follow-up radiographs was considered to be evidence of occult fracture. Mean time between initial and follow-up radiographs was 18 days (range, 14-50 days).
Only nine (17%) of the 54 patients showed evidence of a healing occult fracture on follow-up radiographs. However, we found a statistically significant relationship (p = .001) between persistent joint effusion on follow-up radiographs and occult fracture. Seventy-eight percent of cases with occult fracture, versus 16% of cases without occult fracture, had persistent effusions.
Joint effusion without visualized fracture on initial radiographs after trauma does not correlate with the presence of occult fracture in most cases (83%). Therefore, joint effusion as revealed by radiography should not be considered synonymous with occult fracture.
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studien belegen die Rolle des dorsalen Fettkörperzeichens (Fat-Pad-Sign, gleichbedeutend mit einem Gelenkerguss) in der Fossa olecrani [26][27][28][29][30][31]; bei 90 % der Patienten mit einem Fat-Pad-Sign liegt eine Fraktur vor [32], bei isoliertem Fat-Pad-Sign ohne weitere Frakturzeichen noch bei 54-76 % [27,30]; gleichzeitig schließt ein fehlendes Fat-Pad-Sign eine Fraktur zu 98,2 % (negativer prädiktiver Wert) aus [33]. De Maesener konnte schon 1998 zeigen, dass die Sensitivität der Sonografie für den Nachweis des Fat-Pad-Signs höher liegt als die der Röntgendiagnostik, nur übertroffen von der MRT [34]. ...
In this article the basic principles of fracture sonography and meaningful areas of application in children and adults are explained. The sonographic fracture signs are presented and the typical areas of application, i.e. clavicular fracture, acromioclavicular (AC) joint dislocation, proximal humerus fracture, elbow fracture, wrist fracture, metacarpal 5 fracture, palmar plate, femoral bulge fracture, proximal tibia fracture, midfoot V fracture, toddler’s fracture and march fracture, are outlined and known diagnostic algorithms are listed. When used correctly, fracture sonography is a safe, gentle and rapid diagnostic method.
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studien belegen die Rolle des dorsalen Fettkörperzeichens (Fat-Pad-Sign, gleichbedeutend mit einem Gelenkerguss) in der Fossa olecrani [26][27][28][29][30][31]; bei 90 % der Patienten mit einem Fat-Pad-Sign liegt eine Fraktur vor [32], bei isoliertem Fat-Pad-Sign ohne weitere Frakturzeichen noch bei 54-76 % [27,30]; gleichzeitig schließt ein fehlendes Fat-Pad-Sign eine Fraktur zu 98,2 % (negativer prädiktiver Wert) aus [33]. De Maesener konnte schon 1998 zeigen, dass die Sensitivität der Sonografie für den Nachweis des Fat-Pad-Signs höher liegt als die der Röntgendiagnostik, nur übertroffen von der MRT [34]. ...
Die Fraktursonografie ist zunehmend Gegenstand internationaler Forschung. Die Diagnostik kann bei Kindern bis zum 12. Lebensjahr für die distale Unterarmfraktur röntgenfrei erfolgen, am Ellenbogen wird sie als Ausschlussdiagnostik angewandt und für die proximale Humerusfraktur erreicht sie eine 50 %ige Reduktion der Röntgenbelastung. Auch die Suche nach okkulten Läsionen ist eine gute Indikation; Klavikulafrakturen und AC-Sprengungen lassen sich sonografisch teilweise besser als radiologisch beurteilen. Etliche Forschungsgruppen haben in den letzten Jahren wertvolle Studien zu den verschiedenen Bereichen publiziert. Ziel dieses Beitrags ist es, dem Leser einen kompakten Überblick über die Grundlagen und aktuellen Anwendungsgebiete der Fraktursonografie der Extremitäten zu vermitteln.
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studien belegen die Rolle des dorsalen Fettkörperzeichens (Fat-Pad-Sign, gleichbedeutend mit einem Gelenkerguss) in der Fossa olecrani [26][27][28][29][30][31]; bei 90 % der Patienten mit einem Fat-Pad-Sign liegt eine Fraktur vor [32], bei isoliertem Fat-Pad-Sign ohne weitere Frakturzeichen noch bei 54-76 % [27,30]; gleichzeitig schließt ein fehlendes Fat-Pad-Sign eine Fraktur zu 98,2 % (negativer prädiktiver Wert) aus [33]. De Maesener konnte schon 1998 zeigen, dass die Sensitivität der Sonografie für den Nachweis des Fat-Pad-Signs höher liegt als die der Röntgendiagnostik, nur übertroffen von der MRT [34]. ...
Fracture ultrasound has increasingly come into the focus of international research. A growing number of original articles and a meta-analysis show that wrist fractures can be diagnosed without X-ray in children up to 12 years. Further original publications state that elbow fractures can be ruled out by exclusion of intraarticular effusion and in proximal humerus fractures the number of X-rays is reduced by about 50 %, while the quality of diagnosis is improved. Screening for occult fractures is another good indication. Clavicle fractures, and ac-joint sprains can be diagnosed better with US than with X-rays. A number of research groups have contributed valuable research about the different indications. The aim of this paper is to give an overview of the basics and actual fields of application for fracture ultrasound of the extremities.
© Georg Thieme Verlag KG Stuttgart · New York.
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studien belegen die Rolle des dorsalen Fettkörperzeichens (Fat-Pad-Sign, gleichbedeutend mit einem Gelenkerguss) in der Fossa olecrani [26][27][28][29][30][31]; bei 90 % der Patienten mit einem Fat-Pad-Sign liegt eine Fraktur vor [32], bei isoliertem Fat-Pad-Sign ohne weitere Frakturzeichen noch bei 54-76 % [27,30]; gleichzeitig schließt ein fehlendes Fat-Pad-Sign eine Fraktur zu 98,2 % (negativer prädiktiver Wert) aus [33]. De Maesener konnte schon 1998 zeigen, dass die Sensitivität der Sonografie für den Nachweis des Fat-Pad-Signs höher liegt als die der Röntgendiagnostik, nur übertroffen von der MRT [34]. ...
Introduction: Distal torus fractures of the forearm are a common pathology of the growing bone. Literature data hints at simple and reproducible imaging of these fractures by means of ultrasound. Because indication of x-ray examination should be handled restrictively in growing children, this prospective trial was to examine the potential of ultrasound diagnosis compared to radiographic imaging. Methods: In a prospective trial, 32 patients aged 0-12 years with suspected forearm fracture underwent ultrasound and x-ray imaging. The findings and the therapeutic consequences were compared. Results: Diagnoses were identical in 29 of 32 patients, therapeutic recommendations in 31 of 32 cases. Ultrasound imaging has a sensitivity of 0.96 and specificity of 1.0. Discussion: The trial reveals a good presentation of pathologic findings. An ultrasound-based imaging of these fractures seems to be a reasonable alternative.
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studies have provided evidence on the role of the dorsal fat-pad sign (tantamount to articular effusion) in the olecranon fossa [26][27][28][29][30][31]; in 90 % of patients with a fat-pad sign, a fracture is present [32]; in cases of fat-pad sign in isolation with no further signs of fracture, the rate is 54-76 % [27,30]; in a similar vein, where there is no fat-pad sign, there is no fracture in 98.2 % of cases (negative predictive value) [33]. As early as 1998, De Maesener demonstrated that the sensitivity of ultrasound for detection of the fat-pad sign is greater than that of x-ray diagnostics; it is surpassed only by MRI [34]. ...
... Studien belegen die Rolle des dorsalen Fettkörperzeichens (Fat-Pad-Sign, gleichbedeutend mit einem Gelenkerguss) in der Fossa olecrani [26][27][28][29][30][31]; bei 90 % der Patienten mit einem Fat-Pad-Sign liegt eine Fraktur vor [32], bei isoliertem Fat-Pad-Sign ohne weitere Frakturzeichen noch bei 54-76 % [27,30]; gleichzeitig schließt ein fehlendes Fat-Pad-Sign eine Fraktur zu 98,2 % (negativer prädiktiver Wert) aus [33]. De Maesener konnte schon 1998 zeigen, dass die Sensitivität der Sonografie für den Nachweis des Fat-Pad-Signs höher liegt als die der Röntgendiagnostik, nur übertroffen von der MRT [34]. ...
X-rays are the standard imaging procedure for the diagnosis of pediatric long bone fractures. Recent studies show that ultrasound (US) imaging is also qualified to diagnose pediatric long bones fractures. Thus, the diagnosis and decision-making for the treatment of metaphyseal forearm fractures in children can be performed by solely using US. The sonographic fat pad sign has been proven to be a useful primary screening tool for pediatric elbow injuries. If there is a negative fat pad sign, a fracture is unlikely and taking additional radiographs is dispensable at this time. If there is a positive fat pad sign, a fracture is likely and radiographs should be taken. US is also useful to exclude subcapital humeral fractures and to estimate fracture displacement. If a fracture of the subcapital humerus is present, additional radiographs are necessary to avoid overlooking of pathologic fractures. For reliable sonographic fracture diagnosis in childhood, a detailed history und exact clinical examination are required.
... Since the description of this sign, the hypothesis of a possible correlation between the radiological finding of a 'positive fat pad sign' and possible occult fracture has been proposed in several works [1,[4][5][6][7][8]. However, previous studies have either included both the pediatric and the adult group or no description of the trauma mechanism has been provided. ...
... The discussion of the correlation between a positive fat pad sign and occult fracture has waxed and waned [1,4,5,[7][8][9][10]. Despite this, there is still no consensus on the exact percentage of occult fractures when finding a positive sign. ...
... Despite this, there is still no consensus on the exact percentage of occult fractures when finding a positive sign. According to the literature, it varies considerably between 17 and 89% [4,[7][8][9][10][11], but we found 23% occult fractures. ...
Unlabelled:
In 1954, Norell described the 'fat pad sign' for the first time. This refers to the radiological visualization of the elbow fatty tissue. This is a prospective study with the aim of clarifying the relation between the presence of a positive fat pad sign on the lateral radiograph and the type of injury verified on MRI. From January to December 2010, 31 children were diagnosed primarily with a positive fat pad sign. An above-the-elbow cast was applied and all patients were referred for an MRI within a few days. All patients were recommended a clinical follow-up and informed about the MRI results. After revision, five patients were found to have a negative fat pad sign and were excluded. This resulted in a total of 26 patients, 10 men and 16 women, mean age 10±2.62 years. The time between the injury and the initial radiological examination was 0.8±0.27 days and the MRI was obtained on an average of 6.6±3.84 days. A total of 12 patients had an injury of the left side and 14 of the right side. The MRI showed a posterior positive sign in all except five cases and six occult fractures, which accounts for 23%. Nineteen patients (73%) had a bone bruise. All patients except one had a normal range of movement with no pain on the last clinical examination after 2-3 weeks. The presence of a positive fad pad sign is not synonymous with occult fractures. Finding occult fractures on MRI does not alter the final treatment of these patients. On the basis of this study and review of other similar studies, pediatric patients who presented with elbow effusion verified on conventional radiographs could be treated with a cast for 2-3 weeks and extra clinical or radiological controls did not seem to be indicated.
Level of evidence:
Level III, development of diagnostic criteria on the basis of consecutive patients.
... Conversely, categorising doubt cases as negative fracture detection led to an increase in PPV (93%) but a notable drop in sensitivity, decreasing from 91.5% to 80.5%. As an occult fracture is defined to be invisible on conventional radiographs and may only be detectable through indirect fracture signs such as joint effusion or on follow-up images by signs of fracture healing [12]; the annotation "doubt" is particularly confusing in the elbow considering the relatively high frequency of occult fractures in that location. The only previous study which evaluated BoneView in the setting of an external assessment did not report the confidence scores [8]. ...
Research into artificial intelligence (AI)-based fracture detection in children is scarce and has disregarded the detection of indirect fracture signs and dislocations.
To assess the diagnostic accuracy of an existing AI-tool for the detection of fractures, indirect fracture signs, and dislocations.
An AI software, BoneView (Gleamer, Paris, France), was assessed for diagnostic accuracy of fracture detection using paediatric radiology consensus diagnoses as reference. Radiographs from a single emergency department were enrolled retrospectively going back from December 2021, limited to 1,000 radiographs per body part. Enrolment criteria were as follows: suspected fractures of the forearm, lower leg, or elbow; age 0–18 years; and radiographs in at least two projections.
Lower leg radiographs showed 607 fractures. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were high (87.5%, 87.5%, 98.3%, 98.3%, respectively). Detection rate was low for toddler’s fractures, trampoline fractures, and proximal tibial Salter-Harris-II fractures. Forearm radiographs showed 1,137 fractures. Sensitivity, specificity, PPV, and NPV were high (92.9%, 98.1%, 98.4%, 91.7%, respectively). Radial and ulnar bowing fractures were not reliably detected (one out of 11 radial bowing fractures and zero out of seven ulnar bowing fractures were correctly detected). Detection rate was low for styloid process avulsions, proximal radial buckle, and complete olecranon fractures. Elbow radiographs showed 517 fractures. Sensitivity and NPV were moderate (80.5%, 84.7%, respectively). Specificity and PPV were high (94.9%, 93.3%, respectively). For joint effusion, sensitivity, specificity, PPV, and NPV were moderate (85.1%, 85.7%, 89.5%, 80%, respectively). For elbow dislocations, sensitivity and PPV were low (65.8%, 50%, respectively). Specificity and NPV were high (97.7%, 98.8%, respectively).
The diagnostic performance of BoneView is promising for forearm and lower leg fractures. However, improvement is mandatory before clinicians can rely solely on AI-based paediatric fracture detection using this software.
... Conversely, categorising doubt cases as negative fracture detection led to an increase in PPV (93%) but a notable drop in sensitivity, decreasing from 91.5% to 80.5%. As an occult fracture is defined to be invisible on conventional radiographs and may only be detectable through indirect fracture signs such as joint effusion or on follow-up images by signs of fracture healing [12]; the annotation "doubt" is particularly confusing in the elbow considering the relatively high frequency of occult fractures in that location. The only previous study which evaluated BoneView in the setting of an external assessment did not report the confidence scores [8]. ...
In forensic investigations, characteristics such as gender, age, ethnic origin, and height are important in determining biological identity. In this study, we developed a deep learning-based decision support system for gender recognition from wrist radiographs using 13,935 images collected from individuals aged between 2 and 79 years. Differences in all regions of the images, such as carpal bones, radius, ulna bones, epiphysis, cortex, and medulla, were utilized. A hybrid model was proposed for gender determination from X-ray images, in which deep metrics were combined in appropriate layers of transfer learning methods. Although gender determination from X-ray images obtained from different countries has been reported in the literature, no such study has been conducted in Turkey. It was found that gender discrimination yielded different results for males and females. Gender identification was found to be more successful in females aged between 10 and 40 years than in males. However, for age ranges of 2-10 and 40-79 years, gender discrimination was found to be more successful in males. Finally, heat maps of the regions focused on by the proposed model were obtained from the images, and it was found that the areas of focus for gender discrimination were different between males and females.
... Furthermore, sonographic evaluation can find some indirect signs of elbow fractures such as elevated posterior fat pad and lipohemarthrosis. Indeed, an elevated posterior fat pad as a sign of intracapsular fractur can be better diagnosed via ultrasonography (9)(10)(11). In spite of the results of previous studies regarding the benefits of ultrasonography for diagnosis of elbow fractures in children, the exact accuracy of this imaging modality is still under debate, mostly on account of its dependency on the operator's experience. ...
Introduction
In spite of the results of previous studies regarding the benefits of ultrasonography for diagnosis of elbow fractures in children, the exact accuracy of this imaging modality is still under debate. Therefore, in this diagnostic systematic review and meta-analysis, we aimed to investigate the accuracy of ultrasonography in this regard.
Methods
Two independent reviewers performed systematic search in Web of Science, Embase, PubMed, Cochrane, and Scopus for studies published from inception of these databases to May 2023. Quality assessment of the included studies was performed using Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Meta-Disc software version 1.4 and Stata statistical software package version 17.0 were used for statistical analysis.
Results
A total of 648 studies with 1000 patients were included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95% CI: 0.93-0.97) and 0.87 (95% CI: 0.84-0.90), respectively. Pooled positive likelihood ratio (PLR) was 6.71 (95% CI: 3.86-11.67), negative likelihood ratio (NLR) was 0.09 (95% CI: 0.03-0.22), and pooled diagnostic odds ratio (DOR) of ultrasonography in detection of elbow fracture in children was 89.85 (95% CI: 31.56-255.8). The area under the summary receiver operating characteristic (ROC) curve for accuracy of ultrasonography in this regard was 0.93. Egger's and Begg's analyses showed that there is no significant publication bias (P=0.11 and P=0.29, respectively).
Conclusion
Our meta-analysis revealed that ultrasonography is a relatively promising diagnostic imaging modality for identification of elbow fractures in children. However, clinicians employing ultrasonography for diagnosis of elbow fractures should be aware that studies included in this meta-analysis had limitations regarding methodological quality and are subject to risk of bias. Future high-quality studies with standardization of ultrasonography examination protocol are required to thoroughly validate ultrasonography for elbow fractures.
... Another limiting factor was that radiographs were used as our gold standard, as they are currently the imaging standard in clinical practice [14]; however, they are not perfect. For example, on radiographs that are positive for joint effusion but with no evidence of a clear fracture, there are occult elbow fractures in 17% to 50% of cases [15][16][17]. We were unable to employ a more sensitive gold standard in this study, such as MRI or CT, due to logistical difficulties and radiation dose, respectively. ...
Supracondylar fractures are common injuries in children. Diagnosis typically relies on radiography, which can involve long wait times in the ED, emits ionizing radiation, and can miss non-displaced fractures. Ultrasound (US) has the potential to be a safer, more convenient diagnostic tool, especially with new highly portable handheld 2D point of care US (POCUS). This study aimed to determine the reliability of 2D POCUS for the detection of supracondylar fractures and elbow joint effusions, to contrast the accuracy of 2D POCUS vs. 3DUS vs. radiographs, and to determine whether blinded image interpretation could produce similar results to non-blinded real-time imaging. Fifty-seven children were scanned with 2D POCUS and 3DUS on the affected elbow. US scans were then read by three blinded readers, and the results were compared to gold-standard radiographs. Compared to a gold standard of 30-day radiographic diagnosis, readers of 2D POCUS detected supracondylar fracture and effusion with sensitivities of 0.91 and 0.97, respectively, which were both higher than with 3DUS. Inter-rater reliability of fracture detection was moderate for 2D POCUS (k = 0.40) and 3DUS (k = 0.53). Consensus sensitivities, although high, were lower than reports from some non-blinded studies, indicating that clinical presentation serves as an important factor in detection rates. Our results from consensus US diagnosis support the validity of using 2D POCUS in children for supracondylar fracture and elbow effusion diagnosis.
... Вопросы травматологии дений у взрослых [1][2][3][4]. При визуализации и диагностике множественных переломов у детей характерна фокусировка внимания на доминирующее повреждение и недооценка тяжести последствий сопутствующих повреждений [19][20][21][22][23]. ...
Introduction Diagnosis and treatment of children with multiple injuries of the bones that form the elbow joint is a relevant problem in pediatric traumatology. Due to the high variability of the cases encountered, it is necessary to differentiate the volume, timing and sequence of surgical interventions, as well as the duration of fixation of the injured limb with immobilizing means. The aim of the work was to study the dependence of long-term anatomical and functional treatment results in children with multiple fractures around the elbow joint on the type of injury. Materials and methods The medical records of 82 pediatric patients with multiple injuries of the bones forming the elbow joint were studied. The patients involed in the study were divided into two groups. Group 1 were patients with multiple fractures of the bones that make up the elbow joint (35 children), and group 2 were patients with intra-articular fractures of the distal end of the humerus and fracture-dislocations of the forearm bones in the elbow joint (47 children). The results were evaluated using the DASH questionnaire and the Broberg-Morrey rating scale. Results In the first group of patients with multiple fractures of the bones that make up the elbow joint, the anatomical and functional results of treatment were significantly better, and the process of restoring the function of the elbow joint was shorter. The treatment results of patients in the second group largely depended on the severity of the injuries. The use of the Ilizarov method with rational arrangements of the apparatus enables to preserve the function of the elbow joint in the course of transosseous osteosynthesis. In hybrid fixation (the use of pins and apparatus or plaster immobilization and apparatus), patients frequently developed immobilization contracture of the elbow joint and the anatomical and functional results turned out to be worse, since the fixed elbow joint needed long-term rehabilitation. Discussion Multiple injuries of the bones of the elbow joint are highly variable. The treatment of patients with multiple injuries of the elbow joint remains a difficult clinical task, partly because there is no differentiated approach to rehabilitation measures depending on the nature of the injury, and, accordingly, a rational approach to the treatment of this group of patients has not been developed. Due to the fact that most dislocations are usually associated with fractures, accurate diagnosis of the severity of injuries and rational surgical intervention in terms of timing and volume are necessary to achieve good anatomical and functional results. Conclusion Accurate and timely diagnosis of skeletal injuries of the elbow joint and rational determination of treatment tactics are of great importance in pediatric emergency traumatology. They determine the anatomical and functional outcomes of rehabilitation.
... The diagnosis of fracture of medial condyle of humerus in childhood is still difficult, including the following points: (1) The limitation of MRI for children, which is expensive, time-consuming, noisy and According to the literature, ultrasound supports the role of dorsal fat pad sign (equivalent to joint effusion) in olecranon fossa in children under 12 years of age with elbow injury. The symptom of absence of fat pad can rule out 98.2% of fracture (negative predictive value) [18][19][20][21][22]. In 1998, de Maesener proved that the sensitivity of ultrasonography in detecting fat pad signs was higher than that of X-ray, and only MRI was more accurate than ultrasound [21]. ...
Background
Medial epicondyle fractures are one of the more common humerus fractures, but humeral medial condyle fracture (HMCF) is rare. Nonunion of medial humeral condyle fractures due to functional exercise is less common.
Case presentation
We report a 5-year-old patient with a nonunion HMCF due to excessive functional exercise, who bruised the elbow 1 year ago and had no positive findings on all imaging studies. On this physical examination, there was a snapping and palpable lump in the elbow joint during movement, but the patient did not feel any discomfort and the range of motion of the joint was normal. X rays and computed tomography (CT) showed that the left HMCF was discontinuous, the broken ends were dislocated, and the joint alignment was poor. Open reduction (OR) and screw fixation was used during the operation, and the patient recovered well at 3-month follow-up.
Conclusions
The rarity and low radiographic appearance of displaced HMCF are easily overlooked and can eventually lead to nonunion HMCF, especially when radiographically difficult to visualize before age 5 years. Therefore, regardless of whether there are signs or imaging abnormalities in the growth process of adolescents, they should be vigilant, shorten the time interval for re-examination, and early detection and timely treatment can avoid some complications caused by this.
... All studies included only children; the study population totaled 250, and the age range was 1 to 18 years for radiographic follow-up, 2 to 15 years for MRI, and 1 to 16 years for CT. Patients were recruited in the emergency room in 8 studies, and data were extracted from a hospital register 7 and from an unknown database 6 in the remaining 2 studies. The follow-up time ranged from 7 to 50 days for radiography, ranged from 1 to 16 days for MRI, and was 2 days for CT. ...
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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 of evidence:
Level II. See Instructions for Authors for a complete description of levels of evidence.
... Donnelly et al., [16] reported that only 54% of cases with an isolated joint effusion with no detected fracture on initial presentation, had evidence of a healing fracture on follow-up later on. This because occult fracture can be easily missed at initial radiograph, but can be detected easily as healed fracture. ...
... Several factors make the radiographic detection of pediatric elbow fractures challenging: the preponderance of radiopaque cartilage, the variable appearance of ossification centers during skeletal growth, and the unique and sometimes subtle fracture patterns when compared to skeletally mature patients [3][4][5][6]. Studies have demonstrated that elbow joint effusions without radiographic evidence of a clear fracture represent underlying occult elbow fractures anywhere from~17% to greater than 50% of the time [7][8][9]. As such, pediatric patients with elbow joint effusions without clear fractures are often casted given concern for underlying occult fracture [10]. ...
Background
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.
Objective
To assess the added value of digital tomosynthesis on the detection and diagnostic confidence of pediatric elbow fractures.
Materials and methods
A retrospective study was performed between January 2016 and December 2017 in pediatric patients (≤18 years) 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: 8.1 years, range: 1 year to 17 years) 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.
Results
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).
Conclusion
The addition of digital tomosynthesis with conventional elbow radiographs improves diagnostic confidence and performance for the detection of pediatric elbow fractures.
... However pediatric elbow trauma remains a diagnostic challenge for radiologists and orthopedists given the intricate elbow joint anatomy with overlapping structures, as well as the added complexity in children of dynamic ossification and apophyseal fusion about the elbow. Pediatric patients also experience distinct and sometimes subtle elbow fracture patterns that do not typically occur in adults [3][4][5][6], including radiographically occult fractures with only an effusion to indicate underlying fracture [7][8][9][10][11]. Therefore pediatric elbow fractures sometimes require additional views, imaging of the opposite asymptomatic elbow, or crosssectional imaging for further clarification [12,13]. ...
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.
... Our study further suggests that a complete proximal radius fracture, displacement or a substantial joint effusion independently portend a higher likelihood of an additional elbow fracture. Unfortunately, a joint effusion can be a nonspecific finding in the setting of elbow injury with variable associations with occult fracture reported in the literature and has only fair agreement between observers [9,18,19]. Suboptimal agreement in the radiographic assessment for elbow joint effusions seen in this study may arise from discrepancies in what constitutes a joint effusion, which we defined as requiring a posterior fat pad sign, as well as impaired conspicuity of joint effusions on poorly positioned lateral views or in patients with substantial overlying soft-tissue swelling. ...
Background:
Additional fractures occur in association with proximal radius fractures, but the extent of these secondary injuries has not been systematically assessed.
Objective:
To ascertain the frequency and nature of additional fractures associated with proximal radius injuries in a large pediatric cohort.
Materials and methods:
Radiographs meeting search criteria for proximal radius fracture during a 5-year period were reviewed. Fracture characteristics and the coexistence of additional elbow fractures were recorded and analyzed. The retrospective review was compared with initial interpretation and a blinded review by two pediatric musculoskeletal radiologists.
Results:
Four hundred ninety-four proximal radius fractures were included. The radial neck was the most common fracture site (89%). Neck fractures occurred in younger patients (mean: 7.3 years) than head fractures (mean: 13.3 years) (P<0.001). Additional elbow fractures occurred in 39%, most commonly at the olecranon (22%). Additional fractures occurred in younger patients (mean: 7.2 years) than isolated proximal radius fractures (mean: 8.5 years) (P<0.001). Elbow joint effusion and complete or displaced radius fractures were each associated with additional elbow fractures (P<0.001). When compared with initial interpretation, 25% of additional fractures were not identified on initial radiographs, of which 44% were occult retrospectively. Fracture identification demonstrated excellent inter-reader reliability (interclass correlation coefficient [ICC]: 0.88, 0.94), but joint effusion interobserver agreement was only fair (ICC: 0.52, 0.41).
Conclusion:
Proximal radius fractures in children often occur in association with other elbow fractures, most commonly involving the olecranon. Enhanced awareness of these fracture patterns, especially in the setting of joint effusion or complete and displaced radius fractures, may improve detection to guide appropriate management.
... 8 Approximately 70%-90% of children with an elbow effusion will have a visible fracture; however, there is wide debate in the literature about the presence of radiographically occult fractures in the setting of a joint effusion at presentation -radiographic follow-up by Donnelly et al reported 54% of patients showing healing fractures. 9 More recent studies looking at MRI and MDCT show occult fractures in the majority of patients, although they do stress that these investigations did not significantly alter management. 10,11 . ...
The evaluation of X-rays of the paediatric elbow in the setting of trauma is challenging. The difficulty arises from the complex developmental anatomy of the elbow, with its multiple ossification centres and the differences in the pattern of injuries between adults and children. It is essential to evaluate the radiographs systematically. This review will provide an overview of the developmental anatomy, the range of soft tissue and skeletal findings, and demonstrate tips and pitfalls in radiographic interpretation in paediatric elbow trauma.
Introduction
In this study, we aimed to compare the performance of a convolutional neural network (CNN)-based deep learning model that was trained on a dataset of normal and abnormal paediatric elbow radiographs with that of paediatric emergency department (ED) physicians on a binomial classification task.
Methods
A total of 1,314 paediatric elbow lateral radiographs (patient mean age 8.2 years) were retrospectively retrieved and classified based on annotation as normal or abnormal (with pathology). They were then randomly partitioned to a development set (993 images); first and second tuning (validation) sets (109 and 100 images, respectively); and a test set (112 images). An artificial intelligence (AI) model was trained on the development set using the EfficientNet B1 network architecture. Its performance on the test set was compared to that of five physicians (inter-rater agreement: fair). Performance of the AI model and the physician group was tested using McNemar test.
Results
The accuracy of the AI model on the test set was 80.4% (95% confidence interval [CI] 71.8%–87.3%), and the area under the receiver operating characteristic curve (AUROC) was 0.872 (95% CI 0.831–0.947). The performance of the AI model vs. the physician group on the test set was: sensitivity 79.0% (95% CI: 68.4%–89.5%) vs. 64.9% (95% CI: 52.5%–77.3%; P = 0.088); and specificity 81.8% (95% CI: 71.6%–92.0%) vs. 87.3% (95% CI: 78.5%–96.1%; P = 0.439).
Conclusion
The AI model showed good AUROC values and higher sensitivity, with the P-value at nominal significance when compared to the clinician group.
Suprakondylové zlomeniny distálneho humeru u detí patria k častým a závažným poraneniam detského skeletu s frekventnou nutnosťou operačnej liečby. Táto práca prináša komplexný prehľad súdobej dostupnej literatúry ohľadne managementu a liečby takéhoto pacienta. V praktickej časti má práca za ciel zistiť kvalitu poskytovanej zdravotnej starostlivosti u detí so suprakondylovou zlomeninou na Klinike detskej chirurgie v Detskej fakultnej nemocnici v Banskej Bystrici prostredníctvom retrospektívnej analýzy 349 pacientov za obdobie rokov 2015-2022. Zistené výsledky preukazujú vysokú kvalitu poskytovania zdravotnej starostlivosti, porovnateľnú s výsledkami zahraničných prác publikovaných v tejto oblasti, čím preukazujú dostatočné skúsenosti lekárov s uvedenou problematikou na špecializovanom pracovisku pre liečbu zlomenín detského skeletu.
The pediatric population is prone to unique upper extremity injuries that are not typically seen in adults. The normal dynamic maturation pattern of ossification centers and open physis can potentially confuse radiologists who are not familiar with the pediatric patients. In this review article, we discuss the normal anatomy and commonly encountered acute and chronic upper extremity injuries such as supracondylar distal humeral fracture and osteochondritis dissecans, in pediatric patients. Diagnosing the correct type of fracture (e.g., buckle vs Salter-Harris) is important for proper management of the injury. With an increasing number of adolescents participating in competitive sports, specific sports related injuries such as little league shoulder, gymnast wrist, and medial epicondyle apophysitis, are also discussed in this review. We examine late complications of injuries, such as physeal bar formation of fishtail deformity of the distal humerus.
1.1 Indication: Primary sonographic evaluation of childhood elbow injuries.
Introduction
Positive 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.
Methods
Between 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.
Results
Out 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)
Conclusions
Using 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.
Objective:
The purpose of this study is to determine whether a deep convolutional neural network (DCNN) trained on a dataset of limited size can accurately diagnose traumatic pediatric elbow effusion on lateral radiographs.
Materials and methods:
A total of 901 lateral elbow radiographs from 882 pediatric patients who presented to the emergency department with upper extremity trauma were divided into a training set (657 images), a validation set (115 images), and an independent test set (129 images). The training set was used to train DCNNs of varying depth, architecture, and parameter initialization, some trained from randomly initialized parameter weights and others trained using parameter weights derived from pretraining on an ImageNet dataset. Hyperparameters were optimized using the validation set, and the DCNN with the highest ROC AUC on the validation set was selected for further performance testing on the test set.
Results:
The final trained DCNN model had an ROC AUC of 0.985 (95% CI, 0.966-1.000) on the validation set and 0.943 (95% CI, 0.884-1.000) on the test set. On the test set, sensitivity was 0.909 (95% CI, 0.788-1.000), specificity was 0.906 (95% CI, 0.844-0.958), and accuracy was 0.907 (95% CI, 0.843-0.951).
Conclusion:
Accurate diagnosis of traumatic pediatric elbow joint effusion can be achieved using a DCNN.
This is a 5-year-old boy who fell off a trampoline and injured his left elbow. Radiographs, including stress views, were negative for fracture or effusion (not shown).
Children's fracturesThe epiphysesUpper limb injuriesLower limb injuriesThe axial skeletonSummaryReferences
Emergency radiology is a relatively new subspecialty. It is a blend of organ systems and modalities, with dedication to the immediate evaluation of patients with acute conditions. Emergency radiologists provide time-critical support to trauma surgeons and other acute-care providers, using the full gamut of imaging modalities to provide the best care. Emergency radiologists also constitute the core of worldwide tele-radiology services, providing off-hour coverage to institutions that lack sufficient staff to provide these services. Emergency radiology is also a new academic discipline, with emergency radiology faculty who are dedicated to research and the teaching of emergency imaging to medical students, residents and fellows.
Paediatric and adolescent elbow injuries are common and at times clinically challenging problems. The majority of these are the supracondylar fractures of the humerus. A variety of other fractures around the elbow and elbow dislocations occur in young patients which are associated with a variety of classic complications, post-traumatic deformities and functional limitations. We discuss developmental anatomy and biomechanics, the process of assessment and investigation, and recommended principles and options for treatment.
This chapter deals with general considerations for obtaining adequate radiographs. Included are “which views to obtain” and the value of comparative views. Soft tissues and joint fluid are emphasized as they often aid in directing one to the bony injury. The role of MR is briefly cited.
The chapter talks about pediatric orthopedic injuries, which have specific mechanisms of injury, pathophysiology, and healing. There are five basic types of fractures in children: plastic deformation, buckle fractures, greenstick fractures, complete fractures, epiphyseal and apophyseal injuries. Elbow fractures are common in children and account for 10% of all pediatric fractures. Apophyses in the pelvis arethe weak link in muscle contraction related injury. Avulsion fractures are commonly seen about the pelvis in adolescents. Patellar sleeve avulsion fractures are uniqueto children between 8 and 12 years of age. Imaging modality for the diagnosis of fractures or musculoskeletal trauma includes radiographs, Computed Tomography (CT), Magnetic Resonance (MR) imaging and ultrasound. The chapter briefly touches upon musculoskeletal manifestations in non-accidental trauma.
The three most common elbow fractures classically reported in pediatric orthopedic literature are supracondylar (50-70%), lateral condylar (17-34%), and medial epicondylar fractures (10%), with fractures of the proximal radius (including but not limited to fractures of the radial neck) being relatively uncommon (5-10%). Our experience at a large children's hospital suggests a different distribution.
Our goals were (1) to ascertain the frequency of different elbow fracture types in a large pediatric population, and (2) to determine which fracture types were occult on initial radiographs but detected on follow-up.
Review of medical records identified 462 children, median age 6 years and interquartile range for age of 4-8 years (range 0.8-18 years), who were diagnosed with elbow fractures at our institution over a 10-month period. Initial and follow-up radiographs were reviewed in blinded fashion independently by two experienced pediatric musculoskeletal radiologists to identify fracture types on initial and follow-up radiographs.
The most common fractures included supracondylar (n = 258, 56%), radial neck (n = 80, 17%), and lateral condylar (n = 69, 15%). Additional fractures were seen on follow-up exams in 32 children. Of these, 25 had a different fracture type than was identified on initial radiographs. The most common follow-up fractures were olecranon (n = 23, 72%), coronoid process (n = 4, 13%) and supracondylar (n = 3, 9%). Olecranon fractures were significantly more common on follow-up radiographs than they were on initial radiographs (n = 33, 7%; P < .0001). Twenty-six children had more than one fracture type on the initial radiograph. The most common fracture combinations were radial neck with olecranon (n = 9) and supracondylar with lateral condylar (n = 9).
Supracondylar fractures are the most frequent elbow fracture seen initially, followed by radial neck, lateral condylar, and olecranon fractures in a distribution different from what has been historically described. The relatively high frequency of olecranon fractures detected on follow-up speaks to their potentially occult nature. Careful attention to these areas is warranted in children with initially normal radiographs.
OBJECTIVE. The objective of this study is to evaluate the frequency and significance of unrecognized bone or soft-tissue injury in pediatric patients with elbow trauma assessed with radiographs alone.
SUBJECTS AND METHODS. Fifty children (32 boys and 18 girls; mean age, 7.3 years; age range, 2-12 years) with acute elbow trauma were examined with radiography and MR imaging. Radiographs were categorized into those showing normal findings, an effusion, an equivocal fracture, or an unequivocal fracture. MR examinations were assessed for an effusion, fracture, transphyseal fracture extension, physeal injury, bone bruising, and ligament or muscle injury. Average clinical follow-up was 1.6 years (range, 6-28 months) after injury.
RESULTS. Radiographs showed normal findings in seven children (14%), an effusion only in 17 children (34%), and an unequivocal or equivocal fracture in 26 children (52%). MR imaging showed an effusion in 48 children (96%); unequivocal fracture in 37 children (74%), including transphyseal fracture in seven children (14%) and other physeal injury in three children (6%); bone bruising in 45 children (90%); ligament injury in six children (14%); and muscle injury in 19 children (38%). A less severe spectrum of injury occurred in children with normal findings on radiographs than in those with an effusion or fracture seen on radiography. Follow-up radiographs did not help in the detection of radiographically occult fractures. MR findings had no appreciable effect on patient treatment and no value in predicting duration of convalescence or clinical outcome at an average of 1.6 years after injury.
CONCLUSION. In children with elbow trauma, MR imaging reveals a broad spectrum of bone and soft-tissue injury beyond that recognizable radiographically. However, the additional information afforded by MR imaging has little bearing on treatment or clinical outcome.
Purpose:
The purpose of this study was to evaluate the diagnostic accuracy of the sonographic fat pad sign (FPS) as a predictor for pediatric elbow fractures.
Patients and methods:
This is a prospective study of children under 14 years with suspected elbow fractures. All participants underwent at first ultrasonography focused on a FPS followed by standard elbow radiographs. US findings were compared to final fracture diagnosis.
Results:
38 out of 79 children had an elbow fracture. A sonographic FPS predicted an elbow fracture with a sensitivity/specificity of 97.3/90.5 %, positive/negative likelihood ratios (LR) were 10.2/0.03 and correct/false classification rates were 93.7/6.3 %. Primary US findings were later reviewed by a blinded physician giving a congruity of 96.2 %. These secondary US findings predicted an elbow fracture with a sensitivity/specificity of 92.1/92.7 %, positive/negative LRs were 12.6/0.09 and correct/false classification rates were 92.4/7.5 %.
Conclusion:
The sonographic FPS could serve as a useful screening tool in primary evaluation of pediatric elbow injuries. If a fracture is unlikely after clinical and US evaluation, additional radiographs are dispensable, thereby potentially minimizing the radiation burden in childhood and reducing the length of stay in the Emergency Department.
OBJECTIVE. The purpose of this study was to evaluate whether a detectable abnormality was present on MR imaging without a visible fracture on conventional radiography in the setting of trauma. A recent retrospective study based on the presence or absence of periosteal reaction on follow-up radiographs concluded that fractures were not always present. The discrepancies in the literature over the usefulness of joint effusions as an indicator of fracture caused us to evaluate whether fractures were present more often than identified by conventional radiography. To do this, we used MR imaging.
MATERIALS AND METHODS. Thirteen consecutive patients (age range, 4-80 years; seven children and six adults), whose posttrauma elbow radiographs showed an effusion but no fracture, underwent screening MR imaging.
RESULTS. All patients showed bone marrow edema. Four of the seven children had fractures on screening MR imaging, and all adults had some identifiable fractures.
CONCLUSION. Preliminary data using screening MR imaging suggests that an occult fracture usually is present in the setting of effusion without radiographically visualized fracture.
Purpose
Elbow fractures are a common pathology in any pediatric emergency unit. X-ray of the elbow is the standard diagnostic procedure. Previous studies have shown that fractures can also be visualized by ultrasound (US). The aim of our study was to evaluate the diagnostic accuracy of US in comparison to X-rays in diagnosing pediatric elbow fractures.
Methods
Sixty-seven patients aged 1–13 years with clinically suspected elbow fracture were first examined by US followed by standard two-plane radiographs. US examination was done with a 12-MHz linear probe from seven longitudinal positions across the distal humerus and additionally from longitudinal positions across the radial head and olecranon. The sonographic and radiological findings were compared in a contingency table, and sensitivity, specificity, and positive and negative predictive values of the US diagnostic procedure were calculated.
Results
With X-ray, we found 48 patients with an elbow fracture and 19 patients with no fracture. With US, we found 46 patients with an elbow fracture and 21 patients with no fracture. In comparison to X-ray diagnosis, we calculated for US diagnosis a sensitivity of 97.9 %, a specificity of 95 %, a negative predictive value of 95 %, and a positive predictive value of 97.9 %.
Conclusion
Typical elbow fractures in children could also be visualized by US. A positive fat pad sign, in particular, serves as a strong indicator for elbow joint fractures and can be identified very sensitively by US. We confirm US as a valuable primary screening tool for elbow injuries in children. In the absence of US signs of fracture and in sonographically confirmed non-displaced fractures, standard X-rays are dispensable, thereby minimizing the X-ray burden in children without loss of diagnostic safety.
This is the second of a two part series to address simple elbow injuries in children. The first in this series described the assessment of the injured elbow and identification and management of a pulled elbow. The focus of this paper is the differences between children's and adults' bones and the radiographic features that are unique to the paediatric elbow. Using a case study the features of supracondylar fractures and the management of this injury will be described.
Background
Conventional radiography has limitations in the detection of physeal fractures before the closure of the physis occurs. Fracture detection may be improved by using magnetic resonance imaging (MRI).PurposeTo evaluate the usefulness of MRI for the detection of occult fractures involving the physis when radiography results are negative.Material and Methods
In this prospective study, 24 children (age range, 3-15 years; mean age, 10.7 years) received MRI if they met the following criteria: acute joint trauma, swelling and tenderness around the joint, limitations in bearing weight, an open physis, and negative radiography results for fractures. Fractures revealed by the MRI were classified according to the Salter-Harris classification system. Joint effusion, bone marrow edema, and periosteal alterations were graded on a three-point scale. The non-parametric Wilcoxon test and Fisher's exact test were used for the statistical evaluation.ResultsFrom a total of 24 MR data-sets, 23 were evaluated (one patient was excluded due to poor MR image quality). Elbow injuries were present in 10 patients (43.5%), distal tibia injuries in 10 patients (43.5%), and distal femur injuries in three patients (13%). MRI results excluded physeal fractures in 15 (65.2%) of the 23 children. An occult physeal fracture was detected with MRI in eight (34.8%) patients; of these, five (21.7%) had fractures of the elbow, two (8.7%) had fractures of the distal tibia, and one (4.3%) had a fracture of the distal femur. All of the patients with fractures and 11 of the 15 patients without fractures demonstrated bone marrow edema.Conclusion
The frequency of occult fracture, as detected by MRI, was 34.8%. Thus, MRI is a useful additional imaging method for the detection of occult fractures when radiography is negative.
As advanced practices and role extension within the healthcare sector continues unabated, increasingly practitioners seek ways to widen their professional remit and develop and add to their skills. Interpreting Trauma Radiographs provides a unique guide to enable radiographers and trained healthcare professionals to confidently and competently interpret and report on radiographic images. Designed specifically for radiographers, casualty (accident and emergency) medical officers and trainees, and other health professionals who regularly encounter trauma radiography as part of their work, this book brings together expert contributions on the clinical, medical, legal and scientific aspects of radiographic interpretation and reporting, promoting a thorough understanding of both the general framework of reporting and the detail of image interpretation. The book is divided into two sections. The first section deals with the overall framework of image reporting and interpretation: the radiologist's perspective, the legal aspects, scientific background and the psychological nature of perception and interpretation. The second section focuses on image interpretation of regional anatomy, presented to support both reporting practitioners in training and those more experienced in reporting practice. Interpreting Trauma Radiographs is an invaluable companion for qualified radiographers, radiographers in training, casualty medical officers, and other healthcare professionals, such as nurse practitioners, aspiring to interpret and report on radiographic images.
Diese Arbeit soll einen kurzen Überblick über die Besonderheiten des Kindesalters in der Traumaradiologie vermitteln. Neben
einer kurzen Beschreibung der pathophysiologischen Unterschiede zum Erwachsenen werden die daraus resultierenden unterschiedlichen
Verletzungsarten und Traumafolgen überblickartig dargestellt. Die daraus resultierenden Anforderung an die Bildgebung beinhalten
neben strahlenhygienischen Aspekten eine fundierte Kenntnis der für das Kindesalter typischen Verletzungen und Frakturarten
und eine Anpassung der bildgebenden Untersuchungsprotokolle an die kindlichen Umstände. Neben dem Vorschlag einiger standardisierter
Untersuchungssequenzen bei typischen und häufigen Fragestellungen/Konstellationen werden auch die Möglichkeiten moderner bildgebender
Methoden wie des Ultraschalls, der Spiral- und Multidetektor-CT sowie der MRT andiskutiert. Insgesamt soll die Arbeit eine
Hilfestellung für den Allgemeinradiologen eines peripheren Spitals bei der für ihn/sie doch selteneren Konfrontation mit pädiatrischen
Traumapatienten anbieten, um im Sinne unserer kleinen Patienten ein sicheres und doch schonendes Vorgehen zu ermöglichen.
The aim of this review article is to familiarise the reader with the specific paediatric conditions in trauma radiology. The
article briefly describes the major pathophysiologic differences in childhood and the consecutive altered injury pattern.
The standard radiological imaging protocol for various involved body regions and different trauma settings/varying queries
is described, with suggestion for standardised diagnostic flowcharts in some typical settings. Special regard is given to
radiation protection and the potential of newer imaging modalities such as ultrasound, multi-detector- and spiral CT as well
as MRI in paediatric trauma patients. As such the paper hopefully provides some basic guidelines for general radiologists
in peripheral hospitals who less often have to deal with paediatric queries.
Objective:
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.
Conclusion:
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.
The purposes of this study were to describe the characteristics of a normal anterior fat pad (AFP) and to determine the association between a normal AFP and the absence of fracture.
A prospective cohort of children aged 1 to 18 years with elbow trauma underwent radiographic examination. All patients received standard orthopedic management and follow-up 7 to 14 days after injury. A pediatric radiologist evaluated all radiographs for the presence or absence of fracture and documented whether the AFP was normal or abnormal on the lateral view. The radiologist also recorded specific measurements of the AFP including the apical angle, which is formed by the intersection of the humerus and the superior aspect of the AFP. The interpretation of the AFP on the initial lateral radiograph was compared with the final patient outcome (fracture/no fracture).
Two hundred thirty-one patients had elbow radiographs; 34 patients (15%) were lost to follow-up. A total of 56 fractures were identified: 49 (87%) on the initial radiograph and an additional 7 (13%) on follow-up radiographs. This latter group was defined as occult fractures. Among the 197 patients available for analysis, 113 (57%) had a normal AFP on the initial radiograph. Of these, 2 children had a final diagnosis of fracture. The sensitivity of a normal AFP was 96.4% (95% confidence interval, 86.6%-99.4%), and the negative predictive value was 98.2% (95% confidence interval, 93.1%-99.7%). There was a significant difference in mean AFP angle when the AFP was read as normal (14.7 [SD, 3.3] degrees) compared with when it was read as abnormal (27.0 [SD, 6.8] degrees) (P < 0.01).
Our data suggest that a normal AFP is highly associated with absence of elbow fracture and that the determination of a normal AFP can be aided by measuring the apical angle of the AFP.
Capitellum fractures account for less than 1% of all elbow fractures. Their appearance on plain radiographs may be subtle. It is this combination of features that make these injuries easy to misdiagnose. Misdiagnosis of a nondisplaced capitellum fracture is significant because the capitellum does not have soft tissue attachments and can convert to a displaced fracture that will need surgery. Although a prior study has reported a high incidence of occult elbow fractures when elevated fat pads are present, it did not demonstrate an impact on management. Our case illustrates that because of the capitellum's propensity to displace, detecting fat pads and immobilizing the elbow may have a significant impact on outcome.
Elbow injuries, both acute and chronic, continue to rise as both the young and elderly increase their participation in athletic activities. The role of imaging is to provide supportive data as to the cause of the patient's symptoms and to guide treatment options for the referring physician. Understanding the anatomy and biomechanics of this sophisticated joint, various injury patterns, and the implication of injury to the static and dynamic stabilizers will result in improvement in diagnostic accuracy. Each of these topics are discussed to provide a foundation and overview of key concepts necessary to understand common elbow injuries.
The radial head-capitellum (RHC) view was performed in 125 patients following acute elbow trauma in which an elbow fat-pad effusion was visible on the standard antero-posterior and lateral projections. Seventy-four fractures were identified of which 63 (85%) involved the radial head. In only one case (1%) did the RHC view reveal a radial head fracture not seen on the standard two views. In eight cases (11%) the RHC view did not confirm a radial head fracture seen on the standard radiographs. Magnification blurring and the vertical orientation of the radial head fractures missed on the RHC view are responsible for this confusing situation. Routine use of the RHC view even in acute elbow trauma significant enough to produce an effusion is generally unhelpful and potentially misleading.
The dorsal fat pad of the elbow joint lies within the olecranon fossa and is not radiographically visible under normal circumstances. An effusion into the elbow joint will displace the fat pad dorsally and it will become visible on a lateral radiograph of the elbow.
Visualization of a dorsal fat pad in cases of trauma should alert the radiologist to the probability of a fracture even if one is not apparent. The author found 8 patients in whom a fracture had been missed. The initial radiographs had shown a dorsal fat pad but the small fractures had been overlooked, though they were seen retrospectively. Their presence was confirmed by later films showing periosteal reaction.
The author's study suggests that a fat pad may be found in the absence of a fracture, being due to a joint effusion only. However, this is difficult to prove because a tiny intracapsular fracture may escape radiological detection.
The radiographs and clinical records of 128 patients with joint trauma and radiographic evidence of intraarticular fluid but no visible fracture were reviewed. The patients were divided into two groups: 63 with follow-up films and 65 with no follow-up films. Clinically, the latter group had less serious injuries and generally were instructed not to return unless symptoms worsened abruptly or if pain persisted for longer than 1 week. The group with follow-up films consisted of those patients with more serious injuries, and mandatory repeat radiographs were obtained 10-14 days after initial injury. Findings suggest that if a fracture was not seen on the first study, chances of its being present and missed in the ankle and elbow were small (7% and 15%) but were high (67%) in the wrist.
Sixty-two patients with post-traumatic radiologically visualized effusion in the elbow joint, apparently without bony damage, were randomized to either 1 week of immobilization in a plaster or immediately instructed in active exercises without any immobilization. They were reexamined by an orthopaedic surgeon weekly until recovery. New radiographs were taken after 1 week. Reevaluation of the radiographs by a radiologist revealed seven 'false-positive' effusions, i.e. neither effusion nor fracture, and 21 missed fractures. All but five missed fractures, continued in the study. Thirty patients started immediate active exercises instructed by the surgeon and 27 were immobilized. The 'active exercise' group had a significantly shorter recovery time (one week vs two weeks, P < 0.05). The presence of missed fractures did not influence the result and all patients recovered fully. Also four of the excluded patients with missed fractures recovered fully. One patient with missed fracture dropped out from follow-up. We recommend that an apparently isolated post-traumatic effusion in the elbow joint is treated with immediate active exercises followed by a clinical reexamination after one week supplemented with new radiographs if there is unsatisfactory clinical progress.
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