Ultrasound is a fast and simple modality to incorporate into the evaluation of elbow pain after trauma in pediatric patients.The negative and positive predictive values range from 86 - 100%, and 95.2 - 100%, respectively. Across various studies, the sensitivity and specificity of ultrasound in diagnosis ranges from 88 - 100%, and 93.5 - 100%, respectively. The strongest indicator of an occult elbow fracture is a positive posterior fat pad sign on ultrasound. In the elbow with an occult supracondylar fracture, the posterior fat pad will be elevated above the bony prominences in both orthogonal planes Accuracy of ultrasound in elbow traumaįew studies have demonstrated greater accuracy for ultrasound when comparing ultrasound and X-rays for diagnosis of pediatric elbow fractures-particularly for supracondylar fractures. In the elbow with an occult supracondylar fracture, the posterior fat pad will be elevated above In an elbow without injury, the fascial line that connects bony prominences in the olecranon fossa is flat and slightly below each bony ridge. Most importantly, you are evaluating for the presence of an effusion/lipohemarthrosis within the posterior aspect of the elbow joint, which results in an elevation and displacement of the posterior fat pad. You are looking to identify any obvious cortical irregularity along the humeral cortex. Scan in both orthogonal planes as depicted below (longitudinal and transverse views). Use a high frequency linear transducer for more superficial structures and higher resolution. Position the elbow in a 90-degree, flexed position this may also often be the position of comfort for the patient. However, plain radiographs may still miss these findings, and ultrasound can supplement your workup and assessment – pointing you to the appropriate treatment plan. One should also be sure to look at the anterior humeral line on the lateral view to ensure it intersects the middle third of the capitulum in children greater than five years of age if it does not, it may also indicate a supracondylar fracture. Rather, occult elbow fractures are often diagnosed by the presence of an enlarged triangularly shaped anterior fat pad known as the “sail sign” and/or the presence of a posterior fat pad. They are often subtle and may be missed on plain radiographs as a fracture line may not be detected. Garland Type I are non-displaced supracondylar fractures. These will require close reduction, orthopedic surgical consultation, and likely surgical pinning. Garland Type II to IV fractures are displaced and fairly obvious on radiographs. Supracondylar fractures in pediatrics are a common diagnosis in the emergency department. What are the findings and scanning technique used when evaluating the elbow joint with point-of-care ultrasound? The Traumatic Pediatric Elbow You notice an ultrasound machine by the bedside. She is otherwise neurovascularly intact, and the rest of the examination is unremarkable. The patient is able to actively pronate with only mild discomfort. On physical exam there is isolated tenderness of the left elbow, without any swelling, bruising, or open wounds. She has her left arm held in a fixed and adducted position. A 4- year-old girl comes in with her parents for evaluation of acute left arm pain after a fall from monkey bars.
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