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.
The Pediatric Elbow
10% of all pediatric fractures involve the elbow .
Missed injuries can cause significant deformity, pain, or functional/neurologic complications .
With many ossification centers, subtle injuries, and significant consequences, the pediatric elbow x-ray can be challenging but important to interpret.
Non-accidental trauma is, unfortunately, a not uncommon reality. Have a high suspicion for it, especially when there are inconsistencies in the story, mechanism, or the child’s developmental stage. There are certain highly suspicious fracture patterns to be aware of that will be highlighted when appropriate.
Type I (non-displaced): Long arm splint/cast and prompt ortho follow-up within 2-7 days.
Type II (displaced with intact posterior cortex): ED orthopedic consultation.
Type III (complete displacement): ED orthopedic consultation.
Figure 1: A) Median nerve assessment. B) Simulation of anterior interosseous nerve neurapraxia.
Figure 2: Lateral and AP X-rays of type 1 supracondylar fracture with posterior fat pad (blue arrows), anterior cortical disruption (red arrows) and displacement of anterior humeral line (green dotted line). Case courtesy of Dr. Frank Gaillard, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
Figure 3: Lateral X-ray of (a) type 2 supracondylar fracture with anterior cortical disruption (red arrow) without posterior cortical disruption. Case courtesy of Dr. Mohamed Walaaedlin, Radiopaedia.org. Annotations by Daniel Ichwan, MD. (b) type 3 supracondylar fracture with complete displacement. Case courtesy of Dr. Benoudina Samir, Radiopaedia.org.
Epidemiology : Second most common pediatric pediatric elbow fracture. The peak is at approximately age 6 years old.
A missed fracture is a common cause of nonunion
Other known complications:
Tardy ulnar nerve palsy.
Physical Exam: Tenderness/edema of the lateral elbow.
Diagnostic Imaging: Can be a subtle, small bone fragment next to capitellum.
Pearl: An internal oblique view should be obtained if the index of suspicion is high.
Displacement is measured on the internal oblique view.
Because of well-known complications, discuss fracture with orthopedics . Weiss Classification:
Type 1 (<2 mm displacement on internal oblique view): long arm casting/splint and close follow-up within 1 week for repeat films .
Type 2 (2-4 mm displacement on internal oblique view): ED orthopedics consult.
Type 3 (>4 mm displacement on internal oblique view): ED orthopedics consult.
Figure 4: AP, internal oblique, and lateral X-rays of lateral humeral condyle fracture (red arrows) with associated “sail sign” (blue arrow). Case courtesy of Dr. Maulik S Patel, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
Pearl: Check for an associated ulnar fracture that occurs due to the proximal and distal radioulnar joints (“Monteggia fracture-dislocation”, more commonly a bowing ulna fracture in pediatrics) or entire elbow dislocation.
Treatment: Reduction with sling and ortho follow-up [6, 7].
Consult orthopedics if irreducible, unstable, neurovascular compromise, or associated fracture .
Figure 6: Lateral view of elbow demonstrating radial head dislocation and displacement of radiocapitellar line (red line). Case courtesy of Dr. Matt Skalski, Radiopaedia.org.
Figure 7: Lateral and AP X-rays views demonstrating radial head dislocation and corresponding displacement of the radiocapitellar line (red line). Case courtesy of Dr. Gerry Gardner, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
Epidemiology: <5% of pediatric elbow injuries .
Physical exam: Tenderness/edema over the posterior elbow. Special attention should be given to the ulnar nerve.
Diagnostic Imaging: Best seen on the lateral view.
Pearl: Frequently displaced and associated with radial neck fracture or elbow dislocation.
Treatment: If minimal displacement (<4mm): Long arm splint/cast and ortho follow-up in 24 hours. Otherwise, ED orthopedics consult .
Figure 9: Lateral and AP X-rays views demonstrating an olecranon fracture (red arrows) and posterior fat pad (blue arrows) in a 4-year-old. Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
Pearl: Can have associated lateral/medial epicondyle fracture or radial neck fractures in children .
If no associated fracture: closed reduction with immobilization x1-2 weeks and orthopedic follow-up .
If complex / associated / unstable fracture: ED orthopedics consult .
Figure 10: Lateral and AP X-rays views demonstrating an elbow dislocation (red arrows), displaced anterior humeral line (green dotted line), and associated medial epicondyle fracture (blue arrows). Case courtesy of Dr. Maulik S Patel, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
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