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EMRad: Can’t Miss Pediatric Elbow Injuries

 

Have you ever been working a shift at 3 am and wondered, “Am I missing something? I’ll just splint and instruct the patient to follow up with their PCP in 1 week.” This can be a reasonable approach, especially if you’re concerned there could be a fracture. But we can do better. Enter the “Can’t Miss” series: a series organized by body part that will help identify common and catastrophic injuries. This list is not meant to be a comprehensive review of each body part, but rather to highlight and improve your sensitivity for these potentially catastrophic injuries. We reviewed the approach to the pediatric elbow previously. Now, the “Can’t Miss” pediatric elbow injuries. (more…)

By |2021-04-10T10:24:46-07:00Apr 5, 2021|EMRad, Orthopedic, Pediatrics, Radiology, Trauma|
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SplintER Series: Kitty Nibble: A Case of the Sausage Finger

A 30-year-old female presents with left second finger pain with overlying erythema, warmth, and swelling the day after her cat bit her finger. She cannot fully extend the finger, it is tender and she has pain when it is passively extended. Her hand appears as shown above (Figure 1. Case courtesy of Kristina Kyle, MD).

 

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By |2021-03-31T08:21:17-07:00Apr 2, 2021|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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SplintER Series: A Case of Hip Pain

humeral shaft fracture xray

Figure 1. Image prompt: AP view of the pelvis and left hip. Authors’ own images.

A 70-year-old male presents with left hip pain and inability to ambulate after a mechanical trip and fall. Examination demonstrates that the left lower extremity is shortened, abducted and externally rotated. Hip and pelvis x-rays are obtained (Figure 1).

 

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By |2021-03-16T18:46:18-07:00Mar 31, 2021|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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EMRad: Radiologic Approach to the Pediatric Traumatic Elbow X-ray

This is EMRad, a series aimed at providing “just in time” approaches to commonly ordered radiology studies in the emergency department [1]. When applicable, it will provide pertinent measurements specific to management, and offer a framework for when to get an additional view, if appropriate. We recently covered the adult elbow, here we will cover the approach to the pediatric elbow.

Learning Objectives

  1. Interpret traumatic pediatric elbow x-rays using a standard approach
  2. Identify clinical scenarios in which an additional view might improve pathology diagnosis

Why the pediatric elbow matters and the radiology rule of 2’s

The Pediatric Elbow

  • 10% of all pediatric fractures involve the elbow [2].
  • Missed injuries can cause significant deformity, pain, or functional/neurologic complications [2].

Before we begin: Make sure to employ the rule of 2’s [3]

  • 2 views: One view is never enough.
  • 2 abnormalities: If you see one abnormality, look for another.
  • 2 joints: Image above and below (especially for forearm and leg).
  • 2 sides: If unsure regarding a potential pathologic finding, compare to another side.
  • 2 occasions: Always compare with old x-rays if available.
  • 2 visits: Bring the patient back for repeat films.

An approach to the traumatic pediatric elbow x-ray

  1. Adequacy / Alignment
  2. Effusions or Fat Pads
  3. Bones, Growth Plates, and Ossification Centers
  4. Consider an additional view

1.   Adequacy / Alignment

2.   Effusions or Fat Pads

  • An anterior fat pad can be normal, but is considered pathologic if excessively prominent (usually around ≥20 degrees from the humerus, or “sail sign”).
  • A clearly visualized posterior fat pad is always pathologic.
  • If either the sail sign or posterior fat pad is present, consider a supracondylar fracture or intra-articular fracture (e.g. lateral condyle fracture )

Sail sign

Figure 1: Measurement of apical angle of the anterior fat pad ≥ 20 degrees, concerning for sail sign. There is also a visible posterior fat pad. Case courtesy of Dr. Ian Bickle, Radiopaedia.org. Annotations by Daniel Ichwan, MD.

3.   Bones, Growth Plates, and Ossification Centers

Elbow x-ray

Figure 2: Lateral and AP x-rays of the elbow demonstrating humerus (green), radius (violet), and ulna (blue). Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. Annotations by Daniel Ichwan, MD.

  • Immature bones with open growth plates (physes) are susceptible to injuries (Salter-Harris fractures) with important growth implications.
    • The Salter-Harris classification is as follows below:
      • Salter-Harris Type 1 (“Slipped”) – epiphysis (part of bone between the growth plate and adjacent joint) separates from metaphysis (neck portion of a long bone).
        • Pearl: Can appear radiographically normal, but tender on physical exam.
        • Requires splinting and ortho follow-up.
      • Type 2 (“Above”) – involves metaphysis (“above the physis”).
        • Requires splinting and ortho follow-up.
      • Type 3 (“Lower”) – involves epiphysis (“below the physis”).
        • Consult orthopedics in the department.
      • Type 4 (“Through”) – involves both the metaphysis and epiphysis.
        • Consult orthopedics in the department.
      • Type 5 (“Erasure”) – crushing of physis. May appear normal or focal narrowing of physis.
        • Consult orthopedics in the department

Figure 3: Salter-Harris Classification. Case courtesy of Dr. Matt Skalski, Radiopaedia.org.

  • Pediatric bones have a stronger periosteum than the underlying incompletely ossified bones.
    • Watch out for bowing, torus, greenstick, or avulsion injuries.
  • Trace each bone’s cortex carefully on both AP and lateral views.
  • Pay close attention to all aspects of the humerus, radius, and ulna.
  • Locate each expected ossification center per the patient’s age.
    • If there is one missing or seemingly prematurely present, consider a fracture.

Figure 4: Ossification centers on (a) AP pediatric elbow x-ray (case courtesy of Dr. Leonardo Lustosa, Radiopaedia.org) and (b) lateral pediatric elbow x-ray. Note that not all ossification centers are visible in this view (case courtesy of Dr. Ian Bickle, Radiopaedia.org. Figure 6 (b) annotations by Daniel Ichwan, MD

 

Table 1: Order and timing of appearance of elbow ossification centers. Some people remember this order by using the mnemonic “CRITOE”: capitellum, radial head, internal (medial) epicondyle, trochlea, olecranon, and external (lateral) epicondyle.

4.  Consider an Additional View

Oblique View

  • When: Sometimes included as the 3rd view in a series
  • Why: This is better at seeing the radiocapitellar joint, medial epicondyle, radioulnar joint, and coronoid process. Consider obtaining this view if there is a high suspicion for a subtle lateral condyle fracture or radial head fracture.

Elbow xray

Figure 6: Lateral oblique x-ray of the elbow. Case courtesy of Dr. Craig Hacking, Radiopaedia.org.

X-rays of Contralateral Elbow

  • Given variation among patients, sometimes it might be necessary to image the contralateral extremity to clarify whether the questionable finding is pathologic or actually normal.

References

  1. Schiller, P. et al. Radiology Education in Medical School and Residency. The views and needs of program directors. Academic Radiology, Vol 25, No 10, October 2018. PMID: 29748045
  2. DeFroda SF, Hansen H, Gil JA, Hawari AH, Cruz AI Jr. Radiographic Evaluation of Common Pediatric Elbow Injuries. Orthop Rev (Pavia). 2017;9(1):7030. Published 2017 Feb 20. PMID: 28286625
  3. Chan O. Introduction: ABCs and Rules of 2. In: ABC of Emergency Radiology. John Wiley & Sons, Ltd; 2013:1-10.
  4. Blumberg SM, Kunkov S, Crain EF, Goldman HS. The predictive value of a normal radiographic anterior fat pad sign following elbow trauma in children. Pediatr Emerg Care. 2011 Jul;27(7):596-600. PMID: 21712751
  5. Black KL, Duffy C, Hopkins-Mann C, Ogunnaiki-Joseph D, Moro-Sutherland D. Musculoskeletal Disorders in Children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill; Accessed December 22, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109408415
By |2021-05-15T12:49:15-07:00Mar 19, 2021|EMRad, Orthopedic, Pediatrics, Radiology, Trauma|
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SplintER Series: Venous Thoracic Outlet Syndrome

 

A 29-year-old male presents with right shoulder pain, throbbing, and swelling. He states that a bulge has appeared over his right anterior shoulder recently (Image 1). While he was doing pushups today, he began to have numbness, tingling, and weakness in his right arm. While in the waiting room, his symptoms have completely resolved.

axillary varix

Image 1: Bedside ultrasound of the anterior shoulder at the site of the bulge. AA=axillary artery. AV=axillary vein. Author’s image.

 

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By |2021-03-16T18:12:40-07:00Mar 17, 2021|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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Does the Combination of Parenteral Olanzapine with Benzodiazepines for Agitation in the ED Increase the Risk of Adverse Events?

A previous EM Pharm Pearl focused on the adverse events associated with the use of IV olanzapine for agitation. This pearl addresses concerns around using parenteral (IV or IM) olanzapine with parenteral benzodiazepines.

Background

Olanzapine has two FDA boxed warnings, one for increased mortality when used long-term in older adults with dementia-related psychosis and another pertaining to adverse effects of extended release IM olanzapine. However, there exists a potential risk of excess sedation and respiratory depression when IM/IV olanzapine is administered with parenteral benzodiazepines for agitation. The European Medicines Agency recommends separating the administration of IM/IV olanzapine and parenteral benzodiazepines by at least 60 minutes. The FDA does not have a specific recommendation regarding separation of the 2 medications, but cautions against co-administration citing a lack of data. Currently, IM olanzapine is the only second generation antipsychotic with a precaution listed in its FDA prescribing information. This advisory is the result of 160 post-marketing adverse events, including 29 fatalities, associated with IM olanzapine [1].

Literature

When the above cases submitted to the FDA are thoroughly investigated, the problem appears to be related to polypharmacy rather than an olanzapine/benzodiazepines alone [2, 3]. This FOAMcast podcast provides an excellent summary of the data (Table 1). Additionally, the timing of fatalities after the last dose of olanzapine is prolonged in many cases (Table 2) and many of the causes of death are unattributable to olanzapine [1]. Several ED studies have used IV/IM olanzapine in combination with parenteral benzodiazepines to treat agitated patients without an increased signal of airway compromise [4-6].

Table 1: Summary of Fatalities Associated with Olanzapine (n=29)
Olanzapine AloneOlanzapine

+ Benzodiazepines

Olanzapine

+ Benzodiazepines

+ Other Medications

3/291/2925/29

Adapted from FOAMcast podcast: Olanzapine + Benzodiazepines – What is the FDA warning about? [1]

 

 

Table 2: Timing of Fatalities Following Last Olanzapine Dose (n=29)
≤ 1 hour1-12 hours12-24 hours> 24 hoursUnknown
3/294/298/2911/293/29

Marder [1]

 

Bottom Line

Separating IV/IM olanzapine from parenteral benzodiazepines by 60 minutes is likely a safe practice, if co-administration of these medications is necessary or desired to treat agitated patients. Patients with ethanol on board are at a higher risk of adverse events [7, 8]. Monitoring should be commensurate with the patient situation and medication(s) chosen.

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

  1. Marder SR, Sorsaburu S, Dunayevich E, et al. Case reports of postmarketing adverse event experiences with olanzapine intramuscular treatment in patients with agitation. J Clin Psychiatry. 2010;71(4):433-441. doi: 10.4088/JCP.08m04411gry. PMID: 20156413. 
  2. Williams AM. Coadministration of intramuscular olanzapine and benzodiazepines in agitated patients with mental illness. Ment Health Clin. 2018;8(5):208-213. doi: 10.9740/mhc.2018.09.208. PMID: 30206503.
  3. Khorassani F, Saad M. Intravenous olanzapine for the management of agitation: review of the literature. Ann Pharmacother. 2019;53(8):853-859. doi: 10.1177/1060028019831634. PMID: 30758221.
  4. Chan EW, Taylor DM, Knott JC, Phillips GA, Castle DJ, Kong DCM. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med. 2013;61(1):72-81. doi: 10.1016/j.annemergmed.2012.07.118. PMID: 22981685.
  5. Cole JB, Moore JC, Dolan BJ, et al. A prospective observational study of patients receiving intravenous and intramuscular olanzapine in the emergency department. Ann Emerg Med. 2017;69(3):327-336.e2. 10.1016/j.annemergmed.2016.08.008. PMID: 27823873.
  6. Martel ML, Klein LR, Rivard RL, Cole JB. A large retrospective cohort of patients receiving intravenous olanzapine in the emergency department. Acad Emerg Med. 2016;23(1):29-35. doi: 10.1111/acem.12842. PMID: 26720055.
  7. Wilson MP, MacDonald K, Vilke GM, Feifel D. Potential complications of combining intramuscular olanzapine with benzodiazepines in emergency department patients. J Emerg Med. 2012;43(5):889-896.
    doi: 10.1016/j.jemermed.2010.04.012. PMID: 20542400
  8. Wilson MP, MacDonald K, Vilke GM, Feifel D. A comparison of the safety of olanzapine and haloperidol in combination with benzodiazepines in emergency department patients with acute agitation. J Emerg Med. 2012;43(5):790-797. doi: 10.1016/j.jemermed.2011.01.024. PMID: 21601409.
By |2021-08-19T14:19:38-07:00Mar 13, 2021|EM Pharmacy Pearls, Psychiatry|
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