upper extremity trauma: page 1 of 15 elbow & forearm · upper extremity trauma: page 1 of 15...
TRANSCRIPT
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 1 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 1 of 90
TopicsThanks to Carrie Bartels and Shana Jatczak for the 3D processing and
segmentation!
Giving Credit to Famous AuthorsAnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 2 of 90
Charles Monroe “Sparky” Schultz (1922-2000)
Creator of…Charlie Brown1947: Li’l Folks1950: Peanuts2600 newspapers21 languages355 million readers in
75 countriesPublished a total of
17,897 strips
“arguably the longest story ever told by one human being”*
March 1964…wikipedia.org
*Professor Robert Thompson, Syracuse University
AnatomyRadiographsFOPH
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 3 of 90
What’s wrong with Charlie Brown’s arm?
www.gocomics.com 3/6/1964
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 4 of 90
Elbow:3 Bones
[OE] el “forearm” + bow “bend”Humerus
Radius
Ulna
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 5 of 90
RadiusHumerus
Capitellum
Trochlea
LateralEpicondyle
MedialEpicondyle
[L] “small head”round like a ball[Gr] “pulley”
round like a spool
Parts of the Humerus
Ulna
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 6 of 90
Olecranon
Humerus
Parts of the Ulna
Trochlea
[Gr] ōlenē “elbow”+ krānion “head/skull”
“Head of the Elbow”*
*dartmouth.eduUlna
Coronoid[Gr] “crow’s beak”
Coracoid
Mandible
Coronoid
Scapula
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 2 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 7 of 90
Olecranon-Trochlea JointHinge JointExtensionFlexion
Posterior view
Anterior view
OlecranonFossa(deep)
CoronoidFossa
(shallow)
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 8 of 90
“Joint Mice”Loose bodies in joint capsuleBone fragmentCartilage piece
Can limit range of motion (ROM)In coronoid fossaLimits flexion
In olecranon fossaLimits extension
Small fragment off thetip of the coronoid…
… limiting flexion
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 9 of 90
3 BonesHumerus
Ulna
Parts of the Radius
Radial HeadRound & flatLike a diskInside the joint capsule
Radius
Radial NeckOutside the joint capsule
Radial Tuberosity(Biceps Tuberosity)
Insertion of Biceps Brachii Tendon
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 10 of 90
Radiocapitellar JointBall & Socket JointFlex & ExtendRotatePronation &
Supination
#1:Radial head ALWAYS
points to the CapitellumRegardless of how the elbow is bentRegardless of how the x-ray beam is oriented
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 11 of 90
Elbow Radiographs
www.gocomics.com 3/5/1964 Marty Brownage 15½
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 12 of 90
AP View
C,A 34yoF
Elbow raised to shoulder
height
Elbow straight
C
R
Capitellum
aligned
with
Radial head
X-ray beam
Vertical
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 3 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 13 of 90
Lateral View
K,C 33yoF
R
Capitellum
aligned
with
Radial head
CElbow flexed 90°
Coronoid overlaps Radial Head
X-ray beam
Vertical
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 14 of 90
Radial Head View
H,E 22yoFGreenspan. AJR 1982; 138: 1186
Elbow flexed 90°
X-ray beam angled
45°
Eliminates Radial Head Overlap
R
Capitellum
aligned
with
Radial head
C
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 15 of 90
Marty age 8½
HANDS
ULNA
RADIUS
Fall On Out-Stretched Hand (FOOSH)
FOOSH
HyperextendWrist
HyperextendWrist
Upper Extremity Trauma Part 2: Wrist
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 16 of 90
PALMCARPUS
RADIUS
ULNA
HUM
CAPTRO
Fall OnPalmHeel
Axi
al L
oad
Up
Fo
rear
m
Fall On Palm Heel (FOPH)
Fall OnPalmHeel
Axia
l L
oa
d U
p U
lna
Axia
l L
oa
d U
p R
ad
ius
Which load dominates
ulna or radius
determines the pattern
of injury
Marty age 8½
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 17 of 90
CARPUS
RADIUS
ULNA
HUM
CAPTRO
Forearm is a Ring“You can’t break a ring in 1 place”This is not entirely true…Yes, with a fall on the palm heel,
causing an axial load,the forearm ring breaks in 2 places“Both Bone Forearm Fracture”Fracture/DislocationsMonteggiaGaleazziEssex-Lopresti Fall On
PalmHeel
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 18 of 90
CARPUS
RADIUS
ULNA
HUM
CAPTRO
Forearm is a RingYou CAN break a ring in 1 placeWith a direct blow,
like from a stick,the forearm ring breaks in 1 place
“Nightstick fracture”UlnaMid-shaftUncommon fractureUncommon mechanism
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 4 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 19 of 90
About to get a nightstick fracture…
Chicago, 1968
AnatomyRadiographsFOPH
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 20 of 90
Nightstick (isolated ulna) fracture
S,E 9yoM, friend fell on the patient’s arm
After 1 month After 2 months
Treated w/cast
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 21 of 90
CARPUS
RADIUS
ULNA
HUM
CAPTRO
Both Bone Forearm FractureCommon patternChildren75% distal ⅓*Heal, remodel<10yo, <25°
angulation OK**>10yo, >10°
unlikely to correct
AdultMost require
ORIF Fall OnPalmHeel
Axia
l L
oa
d U
p U
lna
Axia
l L
oa
d U
p R
ad
ius
Forearm Ring:
P,Z 12yoM
7months
later
*wheelessonline.com**wheelessonline.com
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 22 of 90
Adult BBFF
K,N 54yoF
Cast not sufficient for such unstable fracture.
So next day…
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 23 of 90
CARPUS
RADIUS
ULNA
HUM
CAPTRO
Monteggia Fracture
Fall OnPalmHeel
Axia
l L
oa
d U
p U
lna
Forearm Ring:Fracture proximal ⅓ ulna+ dislocation radial head
relative to capitellumNot uncommon I see several of these a year
Important not to miss the radial head dislocation!Example of why understanding
injury mechanisms helps to detect fracture patterns
If you see isolated ulna fx…you need to look for the radial head dislocation!
B,J 43yoM
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 24 of 90
Radial Head Points to Capitellum
Monteggia fx/dislocations can be quite
subtle
Need to make sure the radial head points to capitellum…
on all views
#1:
S,A 6yoF
Ulna fx is obvious…
Radial dislocationnot so obvious
Need to look closely at lateral
D,R 10yoF
Lateral--------- Not a True Lateral
True Lateral
Rad HeadCap
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 5 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 25 of 90
Giovanni Battista Monteggia (1762-1815)
books.google.com
1814(same year Colles wrote his article)
768 pages
in Italian
Volume Primo
1 illustration…
AnatomyRadiographsFOPH
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 26 of 90
José Luis Bado (1903-1977)
www.jbjs.org Clin Orthop 1967Jan_Feb 50 71-86
Montevideo, UruguayIstituto Rizzoli,
Bologna, ItalyCreated Instituto de
Ortopedia y Traumatologia, Montevideo
1959, 1967: “The Monteggia Lesion”
FOPH
“Pulled Elbow Syndrome”
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 27 of 90
Bado’s classification of Monteggia fractures
RadioGraphics 2000:20;819-836
Type 1 Type 2 Type 3 Type 4
• Radial Head:Anterior Disloc
• Ulna FractureAnterior Angle
• 60%
• Radial Head:Post. Disloc.
• Ulna FracturePost. Angle
• 15%
• Rad Head:Lat Disloc.
• Ulna FxMetaph.
• 20%
• Rad Head:Anterior Disloc
• Ulna & Rad FxProximal ⅓
• 5%
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 28 of 90
CARPUS
RADIUS
ULNA
HUM
CAPTRO
Galeazzi Fracture
Fall OnPalmHeel
Axia
l L
oa
d U
p R
ad
ius
Forearm Ring:Fracture distal ⅓ radius+ dislocation ulna at Distal
Radio-Ulna Joint (DRUJ)Very uncommon I see these twice
a decade
Ulna dislocationmay be best seenon wrist viewsSometimes DRUJ
dislocation is subtleHelps to compare to
contralateral wrist
DRUJ
L,K 19yoM
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 29 of 90
CARPUS
RADIUS
HUM
CAPTRO
Galeazzi Fracture
Fall OnPalmHeel
Axia
l L
oa
d U
p R
ad
ius
Forearm Ring:
DRUJ
L,R 51yoM
DRUJ Dislocated
ContralateralNormal Wrist
DRUJ Intact
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 30 of 90
Riccardo Galeazzi (1866-1952)
Reported his experience with 18 cases(I’ve seen 4 cases)
He was not the first to describe this pattern…
www.jbjs.boneandjoint.org.uk
Galeazzi, R.: Ueber die Lagebestimmung von Fremdkorpen
vermittelst Roentgen- strahlen. Zentralblatt fur Chirurgie, Leipzig,
1899, xxvi, No. 18, 529.
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 6 of 15Upper Extremity Trauma:Elbow & Forearm
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BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 31 of 90
books.google.compage 497
Sir Astley Paston Cooper (1768-1841)
First published 1822
1842 edition: 576 pages
www.artandarchitecture.org.uk
Cooper’s suspensory ligaments of the breast
jdc.jefferson.edu
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 32 of 90
Monteggia vs Galeazzi
CARPUS
RADIUS
HUM
CAPTRO
DRUJ
CARPUS
ULNA
HUM
CAPTRO
Fracture:ProximalUlna
Dislocation:ProximalRad-Cap
Fracture:DistalRadius
Dislocation:DistalDRUJ
“MU/GR”“I was attacked by a MUGGER”
Monteggia =Ulna fx Galeazzi =Radius fxMU Proximal ½ =
Fx & Disloc are Proximal
GR Distal ½ =Fx & Disloc are
Distal
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 33 of 90
Monteggia vs Galeazzi
CARPUS
RADIUS
HUM
CAPTRO
DRUJ
CARPUS
ULNA
HUM
CAPTRO
COMMONWhenever you see an ulna fx,
ask yourself, “Am I missing a
radial head dislocation?”
RAREYou may never see one
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 34 of 90
Axia
l L
oa
d U
p R
ad
ius
Essex-Lopresti FractureImpaction radial head
into capitellumComminuted radial head fractureProximal migration radial shaftDisruption DRUJ
This is a rare injuryI’ve seen… onePeter Gordon Lawrence Essex-
Lopresti (1916-1951) reported on his series of… two
Forearm Ring:
CARPUS
RADIUS
ULNA
HUM
CAPTRO
Fall OnPalmHeelJ Bone Joint Surg Br May 1951
vol 33-B no 2 244-247
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 35 of 90
Axia
l L
oa
d U
p R
ad
ius
Essex-Lopresti FractureForearm Ring:
CARPUS
RADIUS
ULNA
HUM
CAPTRO
Fall OnPalmHeelL,D 41yoM
Comminutedimpacted
radial head
RH
C
Shortened radius DRUJ disruption
5 days later…Radial head prosthesisrestores radial length
DRUJ restored
Comminuted impacted
radial head fracture
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 36 of 90
Radial Head FracturesRadial head fractures are common
R.C. Murray 1927-37 looked at all 1640 elbow fracturesRadial Head/Neck fractures:
= 44% of all elbow fractures= 5% of all fxs at Liverpool Royal Infirmary10%: Comminuted
Comminuted/impacted head fractures are uncommon14%: Radial Neck (mostly in children)15%: Displaced Radial Head fractures 61%: Non-displaced Radial Head fractures
British J of Surgery 1940 Jul 28 106-119
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 7 of 15Upper Extremity Trauma:Elbow & Forearm
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BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 37 of 90
Radial Head Fractures61%: Non-displaced Radial Head fractures
Most Radial Head fractures arenon-displaced or minimally displacedTreated with sling/splint for a few daysImportant to begin early range of motionTo avoid post traumatic stiffness
How do we detect a Radial Head fxif it is non-displaced?
Fat pads are your friendswww.wheelessonline.com
#2:
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 38 of 90
Fat Pads Live in Fossae
Posterior viewAnterior view
OlecranonFossa(deep)
CoronoidFossa
(shallow)
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 39 of 90
Fat Pads on CT
Lateral view3D CT Sagittal CTR,A 27yoF
Can’t see inside fossae on lat 3D
Can’t see inside fossae on lat view
CAN see inside fossae on sagittal 2D CT
AnteriorFat Pad
PosteriorFat Pad
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 40 of 90
Fat Pads on MR
Sagittal CTR,A 27yoF B,A 35yoM
Sagittal T1(Fat is bright)
T,L 39yoF
Sagittal T1(Fat is bright)
Sagittal T2fs(Fluid is bright)
Normal Fat Pads in Fossae
Normal Fat Pads in Fossae
Fat PadsElevated out
of Fossae
Joint effusion in Fossae
**
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 41 of 90
Elevated Fat PadsFluid within the elbow joint elevates the fat padsPus (septic arthritis)Pannus (rheumatoid arthritis)Synovial fluid (synovitis)BLOOD (acute trauma)Adults: Radial Head FractureIntra-articular fracture
Hemarthrosis
Fat Pad Elevation
R,A 27yoF
Sagittal CT
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 42 of 90
Look for them on lateral viewNeeds to be a good lateral viewCondyles overlap
Easier to see on PACSYou should magnify the imageYou should adjust window/level
Fat Pads Not Easy To See
S,W 32yoM
ElevatedPosteriorFatPad
ElevatedAnterior
FatPad
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 8 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 43 of 90
Elevated Posterior Fat PadIf you can see a posterior fat pad, it’s elevated!Normally you can’t see the posterior fat pad
because it’s tucked inside the deep olecranon fossa
D,T 28yoMH,R 23yoM L,D 55yoF
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 44 of 90
Normal Anterior Fat PadNormally you can see a small anterior fat pad
inside the shallow coronoid fossaBut it should be thin, flat, flush against the bone
C,A 34yoF H,E 22yoF Z,M 44yoM
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 45 of 90
Elevated Anterior Fat PadSticks out like a spinnaker sail“Sail Sign”Not thin, flat, flush to the bone
D,T 28yoMH,R 23yoM L,D 55yoF
wikipedia.org
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 46 of 90
Fat Pads are your Friends#2:Elevated elbow fat pads are telling
you there is something filling the jointIn the setting of acute trauma,
that something is blood (hemarthrosis)In the setting of acute trauma, the blood
came from an intra-articular fractureIf the patient is an adult (skeletally mature),
it’s telling you there’s a radial head fracture……even if you can’t see the fracture61%: Radial Head fractures non-displaced
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 47 of 90
Occult Radial Head Fracture
S,W 32yoM
Lateral View AP View Radial Head View
Fat Pad Elevation
Can’t see the radial head fx
Can’t see the radial head fx
Can’t see the radial head fx
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 48 of 90
Occult Radial Head FractureTreated with slingFollowup 11 days later...
S,W 32yoM
Lateral View
Fat Pad Elevation
Can’t see the radial head fx
Fx!
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 9 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 49 of 90
Elbow Joint Capsule
E,S 23yoF
Contrastflowing intoCoronoidFossa
Needle in Radio-Capitellar joint
Contrastfilling theCoronoidFossa
FluoroscopicGuidedArthrogram
DistalCapsule
Barelyextends to
Radial NeckW,D 56yoM
Contrastfilling theCoronoidFossa
Contrastfilling theOlecranonFossa
Capsuledoesn’t extend to
Radial Neck
Neck fx distal to capsule
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 50 of 90
Radial Neck FracturesWhen Radial Neck is outside capsuleRadial Neck fxs don’t yield hemarthrosisRadial Neck fxs don’t yield fat pad elevation
G,P 41yoM
NeckFx
Normal Flat Ant
Fat Pad
“Fell from bike, landing on bilateral outstretched
arms”
ElevatedFlat Ant Fat Pad
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 51 of 90
Fat Pads are your Friends#2:Elevated elbow fat pads are telling
you there is something filling the jointIn the setting of acute trauma,
that something is blood (hemarthrosis)In the setting of acute trauma, the blood
came from an intra-articular fractureIf the patient is an adult (skeletally mature)RADIAL HEAD FRACTURE!
If the patient is a child (skeletally immature)DISTAL HUMERUS FRACTURE (81%)*
*RadioGraphics 1996; 16: 1446
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 52 of 90
Pediatric Elbow
imgur.comwww.gocomics.com 3/7/1964
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 53 of 90
Elbow Ossification Centers:At birth, none of the elbow
epiphyses are ossified.
As the child matures, they
ossify in a specific order…
L,C 5moF
AP view Lateral view AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 54 of 90
Elbow Ossification Centers: CCapitellum1st to ossifyappears at
~ 1 year old
T,V 15moF
C
C
www.posna.org
AP view Lateral view
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 10 of 15Upper Extremity Trauma:Elbow & Forearm
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Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 55 of 90
Elbow Ossification Centers: CCapitellum1st to ossify~ 1 year oldwell ossified
by 2 years old
F,D 29moF
C
C
www.posna.org
AP view Lateral view AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 56 of 90
Elbow Ossification Centers: C RRadial Head2nd to ossifyappears at
3-4 years old
C,R 5yoFwww.posna.org
R
R
C
C
AP view Lateral view
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 57 of 90
Elbow Ossification Centers: C R IInternal (medial)
epicondyle3nd to ossifyappears at
~5 years old
P,J 5yoMwww.posna.org
I
I
C
C
R
R
AP view Lateral view AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 58 of 90
Elbow Ossification Centers: C R I TTrochlea4th to ossifyappears at
~7 years old
B,A 8yoMwww.posna.org
I
R
CT
C
R
AP view Lateral view
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 59 of 90
Elbow Ossification Centers: C R I T OOlecranon5th to ossifyappears at
~9 years old
R,A 9yoFwww.posna.org
T
O
AP view Lateral view
C
R
R
C
I
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 60 of 90
Elbow Ossification Centers: C R I T O EExternal(lateral)
epicondylelast to ossifyappears at
~11 years old
P,A 11yoMwww.posna.org
RC
T
I
E
O
O
AP view Lateral view
C
R
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 11 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
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Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 61 of 90
Elbow Ossification Centers: C R I T O EApproximate ageCapitellum…...1Radial Head....3Int. epicond... .5
Trochlea……. .7Olecranon….. .9Ext. epicond…11… then go on to
fusewww.posna.org H,J 14yoM
AP view Radial Head view AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 62 of 90
Causes of Pediatric Elbow Pain
www.gocomics.com 3/4/1964
AnatomyRadiographsFOPH
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Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 63 of 90
Fall On Palm Heel (FOPH)Supracondylar Fracture
PALMCARPUS
RADIUS
ULNA
HUM
CAPTRO
Fall OnPalmHeel
Axi
al L
oad
Up
Fo
rear
m
Fall OnPalmHeelMarty age 8½
Axi
al L
oad
Up
Fo
rear
m
FracturingABOVE
Condyles
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 64 of 90
Supracondylar Fracture
5y 8m F
C
R
I
Axi
al L
oad
Up
Fo
rear
m
Negative, No Fracture
S,J 7yoF
Fracture, Above Condyles
Axi
al L
oad
Up
Fo
rear
m
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 65 of 90
Supracondylar Fracture
S,J 7yoF
Axial Load Up Forearm
PushedCondyles
BehindHumerus
AP view: ER AP view: ORClosed reduction & fixation with K-wires
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 66 of 90
Supracondylar FractureTHE most common pediatric elbow fx
60%: Supracondylar24%: Marked displaced32%: Non/Min displaced
7%:Radial Head/Neck(Most common adult elbow fx)
FRACTURES OF THE ELBOW IN CHILDREN
REVIEW OF THREE HUNDRED CONSECUTIVE CASES
Donald J. Maylahn, M.D.
and
John J. Fahey, M.D., Chicago
J.A.M.A. Jan. 18, 1958, Vol. 166, No. 3, p 220-228
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 12 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 67 of 90
Subtle Supracondylar FracturesHard to see on the AP view
F,A 5yoF
Day of Injury After 2 weeks After 5 weeks
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 68 of 90
#2:
Subtle Supracondylar FracturesHard to see on the Lateral view…
…Need to use thes
Fat pads are your friends
Trauma + Elevated Fat Pads = HemarthrosisAdults: Radial Head FracturePeds: Supracondylar Fracture (60%)
Anterior Humeral Line
Passes through middle ⅓ of Capitellum
#3:
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 69 of 90
Subtle Supracondylar FracturesCan’t see fracture on
this AP view.Clues are on Lateral view…
P,B 2yoF
Fx line
ElevatedPosteriorFat Pad
AnteriorHumeralLine (AHL)
Normal Contralateral Side
AnteriorHumeralLine
Normally passes throughMIDDLE ⅓ of Capitellum
Supracondylar fx pushes Capitellum behind AHL
#4:Compare to normal sideAnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 70 of 90
Pediatric Elbow FracturesSupracondylar FractureMost common (60%*)Grossly displacedQuite subtleElevated Fat PadsAnterior Humeral LineCompare with normal side
Lateral Condylar FractureSecond most common12%* - 19%**
*JAMA Jan. 18, 1958, Vol. 166, No. 3, p 220-228**RadioGraphics 1996; 16: 1446
Axi
al L
oad
Up
Rad
ius
PALMCARPUS
RADIUS
ULNA
HUM
CAP
Fracturingjust above Capitellum
Fall OnPalmHeel
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 71 of 90
Lateral Condylar Fractures
S,D 6yoF C,B 6yoF
Normal SideGrossly Displaced Min. Displaced
This piece
BelongsHere
Fracturejust above Capitellum
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 72 of 90
Subtle Lateral Condylar FracturesPresented at RSNA CourseFor practicing
RadiologistsUsed an
Audience Response System
50% of the audience missed this case…
Courtesy of Susan John, MDRadiology Chair, UT Houston
AP View
Negative
Lateral View
ElevatedPosteriorFatPad
ElevatedAnterior
FatPad
Anterior Humeral LineDOESN’T pass throughmiddle ⅓ Capitellum
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 13 of 15Upper Extremity Trauma:Elbow & Forearm
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 73 of 90
Pediatric Elbow FracturesSupracondylar Fracture (55%** - 60%*)Lateral Condylar Fracture (12%* - 19%**)Grossly displaced Quite subtleMost 2 – 8 years oldMechanism: FOPH
Medial Epicondylar Fracture (7%** - 9%*)Majority 8 – 15 years oldMechanism: 1) Elbow Dislocation (54%*)
2) Avulsion, Valgus Stress
*JAMA Jan. 18, 1958, Vol. 166, No. 3, p 220-228**RadioGraphics 1996; 16: 1446
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 74 of 90
Normal Side
Medial Epicondylar FracturesSecondary to Elbow Dislocation
S,K 10yoF
C
R
T
I?
Reduced
R
C
I
R
CT
I
T
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 75 of 90
Medial Epicondylar FracturesSecondary to Elbow Dislocation
S,K 10yoF
AP View
R
C
IT
Lateral View Normal Side
O
O
I
I
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 76 of 90
Subtle Medial Epicondylar FracturesAvulsions from Valgus Stress
H,A 14yoM
Normal Side
IE I
Normal width of growth plate
Abnormally widened growth plate
Valgus StressAVULSION
CommonFlexorTendon
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 77 of 90
What’s wrong with Charlie Brown’s arm?
www.gocomics.com 3/6/1964
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 78 of 90
Little Leaguer’s ElbowBy MAJOR BYRON G. BROGDON, USAF (MC),
and MAJOR NEIL E. CROW, USAF (MC)(residents at) LACKLAND AIR FORCE BASE, TEXASAmerican Journal of Radiology, April 1960, Vol. 83, No. 4, p 671-5
Referencing W.E. Dotters’ 1953 article,“Little Leaguer’s shoulder; fracture of theproximal epiphysial cartilage of thehumerus due to baseball pitching.”Guthrie Clin. Bull., 1953, 23, 68-72
Go on to write, During the past baseball season we haveseen in pubescent pitchers an injury whichwe choose to call “little leaguer’s elbow.”The similarity of these cases is striking.
Photo courtesy of Gil Brogdon, MD
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 14 of 15Upper Extremity Trauma:Elbow & Forearm
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 79 of 90
Little Leaguer’s ElbowCase I. C.S., a well-developed
eleven year old fast-baller, pitched theopening game of the Little LeagueSeason. Despite an inadequate warm-up he pitched a no-hitter and allowedonly one walk! However, by themiddle of the game he wasexperiencing pain over the medialepicondyle of the pitching arm withevery throw and could not really “beardown.” For several days afterwardthere was local tenderness andswelling over the right medialepicondyle and pain on extremeflexion or pronation of the forearm.
He vacationed for one month anddid not pitch or otherwise violently
exercise the elbow. The patient wasbrought to the hospital by his fatherwhen attempted resumption of hispitching career reproduced the initialsymptoms.
Roentgenographic study of theelbow revealed separation andfragmentation of the epiphysis of theright medial epicondyle and loss offascial marking about the elbowsuggesting edema or hematoma.
The patient was forbidden to pitch orotherwise strenuously exercise theelbow. One month later all symptomshad disappeared, but a clandestineexperiment on the part of the patientproved that pitching still elicited pain.
AJR April 1960, Vol. 83, No. 4, p 671
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 80 of 90
Charlie Brown’s Elbow
www.gocomics.com 3/9/1964
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 81 of 90
Charlie Brown’s Elbow“Roentgenographicstudy of the elbowrevealed separationand fragmentationof the epiphysis ofthe right medialepicondyle and lossof fascial markingsabout the elbowsuggesting edemaor hematoma.”*
www.gocomics.com 3/9/1964*AJR April 1960, Vol. 83, No. 4, p 671
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 82 of 90
Little Leaguer’s Elbow in the MediaPeanuts Comic Strip1964: Charlie Brown has it1963: Snoopy was worried about it…
1962: Magazine ArticlesTime: “Medicine: The Dangerous Arm”Life
www.gocomics.com 6/26/1963time.com
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 83 of 90
Gil Brogdon on NBC’s Today 1962
ajronline.org
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
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Supracond.Lat.condyleMed.epicon.
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 84 of 90
Little League Baseball® ResponseIt is estimated that 20 million people were exposed to the story and the role of radiologists, radiology, and the diagnosis of Little League elbow.Little League Baseball® threatened a lawsuit against Brogdon and Crow for copyright infringement for using the term Little League™ without permission.The suit was eventually dropped.
AJR: 192, May 2009
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info
page 15 of 15Upper Extremity Trauma:Elbow & Forearm
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 85 of 90
Little League Baseball® Response
littleleague.org
AnatomyRadiographsFOPH
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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 86 of 90
4 Elbow Radiographs1) Radial Head Point to CapitellumOn All Views
2) Fat Pads are your FriendsIn acute trauma, elevated fat pads = FractureAdults: Radial Head FractureChildren: Supracondylar (or Lateral Condyle) Fx
3) Anterior Humeral LineShould pass through middle ⅓ Capitellum
4) When in doubt, get the other side
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 87 of 90
Giving Credit to Famous AuthorsSchultzMonteggiaBadoGaleazziCooperEssex-LoprestiBrogdonOnly one I’ve personally worked with
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 88 of 90
Gil Brogdon (1929-2014)Emeritus Professor,
U South AlabamaARRS Gold Medal
Recipient
medschoolwatercooleramazon.com
medschoolwatercooler
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 89 of 90
Questions: Forearm/Elbow
rankmytattoos.com
AnatomyRadiographsFOPH
BBFFMonteggiaGaleazziEssex-Lop.
Fat PadsPeds Elbow
Supracond.Lat.condyleMed.epicon.
4
© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info
Upper Extremity Trauma Elbow & Forearm
Slide 90 of 90
Bill Receipt Cheque Spike
M,S 34yoF londonbarandkitchen.com