1. Skeletal Injuries of the Elbow, Forearm and Wrist
Matthew Deibel
October 30, 2008
Synergy EM

2. Objectives
Know the common injuries associated with the elbow, forearm and wrist
Be able to determine adequacy of above films and identify abnormalities
Know how to read corresponding pediatric films
Avoid common pitfalls with film interpretation

3. Lufkin 1998
Prospective, descriptive study of treating emergency physicians at a high-volume, urban teaching hospital and a moderate-volume nonteaching hospital
Indicated their confidence on plain-film radiographic study interpretations
All radiographs were then reviewed by radiologists
16,410 emergency department radiographic studies were included
ED physicians were confident in 9,599 sets of radiographs out of a total of 16,410 (58%).
Discordant interpretation rates for the “confident” and “not confident” groups were 1.2% and 3.1%, respectively
Review of the 118 discordant interpretations in the confident group demonstrated that 11 were significant (0.1%).
Total radiology review charges for the confident group were $215,338

4. Elbow Mechanism -Fall on outstretched hand -Direct trauma to elbow
Standard exam
-Inability to extend elbow 91% sens and 69% spec for bony injury (Hanksworth 1991)
-Vascular and neuro exam
X-rays
Stardard – AP, Lat
Supplementary – Lat oblique, med oblique, capitellum, olecranon

5. Elbow PA Fully extended Supinated
Adequate – no overlap and fully extended

6. Radiocapitellar line, bone lines

7. Elbow Lat Flexed 90°, midway between supination and pronation
Adequate – flexed 90° and humeral condyles superimposed

8. Anterior and Posterior fat pad.

9. Radiocapitellar line

10. Anterior humeral line

11. Hourglass sign

12. Supplementary Views Lateral Oblique AP, then hypersup 45°
Radial head fx
Medial Oblique
pronate 45°
Medial condyle fx
Capitellum view
Lat, then direct beam 45°
Radial head and capitellum fx
Olecranon view
Flex elbow supinate forearm, beam tangential to olecranon
Olecranon fracture in sagittal plane

13. Ossification Centers CRITOE 1. Capitellum 2. Radial 3. Internal *
4. Trochlea
5. Olecranon
6. External *
* epicondyle

14. Ossification centers CRITOE

15. Complete elbow radiographic exam
Fat pads
Adequacy & Alignment
-radiocapitellar line
-anterior humeral line
Bones
-humerus, radius, ulna
-CRITOE

16. Try this one

17. Supracondylar Fx 1. Anterior fat pad:yes 2. Posterior fat pad:yes
3. Anterior humeral line:abnl
4. Radial head contour: nl
5. Radiocapitellar line: nl
6. Ossification centers: nl
7. Distal humerus: abnl
8. Ulna/Olecranon: nl

18. Supracondylar fx

19. Supracondylar fx

20. Supracondylar Fx 60% of all pediatric elbow fractures
Is intraarticular (transcondylar) runs across condyles and coronoid and olecranon fossa
Complete and incomplete, 99% are post
Loss of normal valgus carrying angle
Can injure brachial artery and median nerve
Volkmann’s ischemic contractures possible if displaced fx not properly treated
Posterior long arm splint

21. Lateral Condylar fx
What is this?

22. Lateral Condylar fx 10-20% peds elbow fractures Salter-Harris type IV
High incidence of nonunion if displaced
Nondisplaced can become displaced by pull of extensor tendons
Can be very subtle, may need oblique views

23. Try this one
Medial Epicondylar Fracture

24. Medial Epicondylar Fracture
Rapid contraction of the forearm flexors
4 types
Avulsion “Little League Elbow”
Avulsion with entrapment
Avulsion with elbow dislocation
SH IV fx of entire med condyle (rare)

25. Try this one

26. Nursemaid’s Elbow Normal x-rays
Annular ligament subluxation – only loosely attached to radius until 5 years old
Lifting a child by the wrist
X-rays not necessary if story compatible
Supination extension, flexion, pronation – what is best?

27. Some studies Schunk 1990, prospective
87 children < 6 years old with radial head subluxation
49% did not have classic pull mechanism
L > R, girls > boys
No difference in method of reduction
Presence of click PPV of 92% and a NPV of 76% for reduction
Most children (76.8%) had return of arm use in less than ten minutes
Schutzman 1995, prospective
178 children < 6 years old with injury or immobility of elbow
Radial head subluxation (RHS) was the most frequent diagnosis (63%; 99 definite and 13 probable), followed by fracture (22%) and soft-tissue injury (STI; 13%)
The mean age of children with RHS was significantly less than that of children with fractures (27±12 months versus 39±19 months)
Arm traction occurred in only 55% of the children with RHS
Arm held at side 95% for RHS, 18% Fx, 29% STI

28. Try this one

29. Does this help?

30. Radial Head Fx

31. Radial head fx toddler

32. Radial Head Fracture Most common adult elbow fracture Associated:
Elbow dislocation (10%)
Other fractures
Essex-Lopresti lesion (radial head fracture and distal radioulnar instability)

33. Radial Head Fracture Mason Classification
Displaced < 2mm
Most common
early mobilization (active and passive range of motion) II
Displaced or depressed >= 2mm
Involve >= 25% radial head
splint 1-2 weeks, then protected range of motion for 7-10 days OR ORIF / excision of the radial head
III
Severely comminuted
excision of the radial head alone or excision with placement of a silicone radial head prosthesis

34. Try this one
Olecranon Fracture

35. Olecranon Fracture 20% of adult elbow fractures (5% kids)
Majority due to direct blow to elbow
Triceps may distract fracture fragments

36. Elbow dislocation 3rd most common adult dislocation
Most common peds dislocation
90% posterior or post-lat
Assoc fractures
Medial epicondyle
Prox radius
Coronoid process
Median nerve entrapment

37. Elbow Reduction
Puller Technique

38. Try this one

39. Monteggia Fx 1. Anterior fat pad:yes 2. Posterior fat pad: yes
3. Anterior humeral line:nl
4. Radiocapitellar line: abnl
5. Radial head contour: nl
6. Ossification centers: nl
7. Distal humerus: nl
8. Ulna/Olecranon: abnl

40. Monteggia Proximal Ulna fx with radial head dislocation

41. Monteggia Fx Results from rotary forces
Disrupted radioulnar articulation makes more difficult to repair

42. Try this one

43. Radial head Fx/Monteggia injury
1. Anterior fat pad:yes
2. Posterior fat pad:?
3. Anterior humeral line:nl
4. Radial head contour: Abnl
5. Radiocapitellar line: Abnl
6. Ossification centers: nl
7. Distal humerus: nl
8. Ulna/Olecranon: Abnl

44. Common Injuries by Age ADULT Radial head or neck 50% Olecranon fx 20%
Elbow dislocation %
Others:
Distal humerus fx
Capitellum fx
Coronoid fx
Monteggia injury
CHILD
Supracondylar fx %
Lateral condylar fx 15%
Medial condylar fx 10%
Radial head/neck fx 10%
Other:
Elbow dislocation
Olecranon fx
Monteggia injury
Complete epiphyseal separation (rare)

45. Commonly Missed Fracture radial head Supracondylar fracture
Joint effusion
Fracture coronoid process (esp. dislocation)
Dislocation of radial head
Entrapped medial epicondyle
Lateral condylar fracture in children

46. Variants
Often variation in appearance of ossification centers between the two elbows
Rickett no additional information provided
Chacon 1992 – diagnostic accuracy not improved
Olecranon and trochlear ossification centers appear irreg and fragmented
Ossification center may remain partially nonunited into adult life

47. Wrist and forearm Vascular and neuro anatomy Standard exam X-ray views
Standard - PA, Lat, Pronation oblique
Supplemental – scaphoid, supination oblique, carpal tunnel

48. PA Wrist

49. PA Wrist
Adequate – long axis 3rd metacarpal parallel with long axis of radius shaft, lunate over distal radioulnar joint (DRUJ)
Alignment – 3 arches
Bones – esp. scaphoid, lunate, prox metacarpals, and distal rad / ulna
Equal intercarpal joint spaces

50. Lateral Wrist

51. Lateral Wrist Adequacy
Dorsal surface of ulnar shaft overlaps 1-2mm dorsal to radius
No flex / ext
Metacarpals parallel to radius
Alignment
Sequence of adjacent C’s
Scaphoid axis 30°-60°
Ulnar styloid points to dorsal surface of triquetrum
Bones – distal radius, dorsal chip triquetrum
Soft tissue – Pronator quadratus fat stripe normal

52. Pronator Oblique View
Adequacy – trapezium and trapezoid joint space with minimal overlap
Bones
Bases I and II MC
Scaphoid distal pole
Triquetrum
Distal radius (oblique fx)

53. Supplementary Views Scaphoid View PA with wrist in ulnar deviation
Full length of scaphoid
Supination Oblique
Wrist 45° semi- supinated
Pisiform fx’s
Fx base 5th MC
Carpal tunnel view
Wrist hyper- extended, beam down tunnel
Fx’s hook hamate, pisiform, volar ridge trapezium

54. What’s This?
Galeazzi Fx

55. Galeazzi Fracture Fx distal 1/3 radius (GR) and ulnar dislocation
Fall on outstretched hand
ORIF

56. Frykman Classification

57. Important Measurements

58. Distal Radius Fractures
Colles Fx – dorsal displace and short
Smith Fx – volar displace
Barton Fx – volar or dorsal, involves distal radial articular surface
Chauffeur’s Fx (Hutchinson) – oblique through radial styloid, often with scapholunate dissociation
Distal Radioulnar Joint Dislocation – sig clinically because radiocarpal and triangular fibrocartilage usually disrupted

59. Other Forearm Fractures
Both Bone Fracture
Careful neuro exam essential
Can get compartment syndrome
Usually requires ORIF
Isolated Ulnar Shaft Fracture
Nightstick
Look for dislocated radial head
ORIF if angulates > 10° or offset > 50%

60. What’s this?
Scaphoid Fracture

61. Scaphoid Fracture
Fall with outstretched palm – 60-80% of carpal fractures
Tubercle, Distal pole, Waist (good prognosis)
Proximal pole (nonunion/osteonecrosis common)
Osteonecrosis of proximal pole fragment
Posttraumatic arthritis
X-ray up to 6 weeks
Bone scans-80% by 24 hr; 95% in 3 days
MRI immediate
Immobilize 8-12 weeks in long arm thumb spica
Displaced – closed or open reduction

62. Other Carpal Fractures
Triquetrum dorsal chip fracture
10-20% of carpal fractures
Fall on outstreched hand
Lunate avascular necrosis (Kienböck disease)
Fracture, repetitive trauma, or ligamentous injury
Pain, swelling, decreased grip strength
Hook of Hamate
Dull pain in volar-ulnar region
Occurs with golf, tennis, racquetball, baseball

63. What is this? Scapholunate Dissociation Scapholunate space > 4mm
Terry-Thomas sign
Rotary subluxation of the scaphoid

64. Dislocations and Ligamentous Injuries
10% of carpal injuries
Perilunate injuries – 4 stages
I – Tear scapholunate lig, scapholunate dissociation
II – Scaphoid and Capitate instability
III – Dorsal perilunate dislocation
IV – Lunate dislocation

65. Perilunate and Lunate Dislocations

66. Common Errors
Failing to consider possibility of significant injury with normal x-rays
Reading negative scaphoid injuries as positive
Missing distal radius fracture

67. References
Chacon D, Kissoon N, Brown T, Galpin R. Use of comparison radiographs in the diagnosis of traumatic injuries of the elbow. Ann Emerg Med Aug;21(8):895-9.
Hawksworth CR, Freeland P. Inability to fully extend the injured elbow: an indicator of significant injury. Arch Emerg Med Dec;8(4):253-6.
Lufkin KC, Smith SW, Matticks CA, Brunette DD: Radiologists' review of radiographs interpreted confidently by emergency physicians infrequently leads to changes in patient management. Ann Emerg Med February 1998;31:
Medpix radiology. April 2004.
Rickett AB, Finlay DB: An audit of comparison views in elbow trauma in children. Br J Radiol 66:123, 1993.
Rosen, Peter. Atlas of Emergency Procedures. Mosby pp
Schwartz, David T. Emergency Radiology pp
Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes.Ann Emerg Med Sep;19(9):
Schutzman SA, Teach S: Upper-extremity impairment in young children. Ann Emerg Med October 1995;26:
Simon RR, Koenigsknecht SJ. Emergency Orthopedics the extremities. McGraw-Hill Fourth Ed
Vanderheide, Stuart. Elbow radiology lecture 2002.