Ultrasonographic evaluation of the elbow in infants and young children after suspected trauma

Bado III Monteggia in children - treatment options and outcome: an ultrasound control study

The Bado III Monteggia lesion is an uncommon fracture in children. Radial head dislocation can occur due to intra- or extra-articular fractures of the olecranon. In extra-articular ulnar fractures, heterogeneous operative methods are proposed in different case reports. The objective of this study is to determine if closed reduction of the ulnar fracture, either without osteosynthesis or by using TEN, is a safe treatment option. In a multicenter study, we retrospectively analyzed 26 children who were treated for an extra-articular proximal metaphyseal ulnar fracture with dislocation of the radial head. These patients underwent a follow-up examination after an average of four years. The investigation included a physical examination, visualization of the elbow anatomy, and specifically, the radial head retention in the joint by ultrasound. Of the 26 patients, 18 were treated by closed reduction and intramedullary osteosynthesis (TEN), 7 were treated by closed reduction and cast immobilization without osteosynthesis, and 1 child was treated by open reduction of the ulna and plate osteosynthesis. In the follow-up examination, 25 children showed an excellent outcome, as well as inapparent sonography. Although this is a retrospective study with different types of treatment, closed reduction of the ulna with or without osteosynthesis appears to be effective. We believe that the correct primary reduction is the key to an excellent long-term outcome. Regarding the invasiveness of the treatment, reduction without or with TEN osteosynthesis should be the preferred approach in extra-articular pediatric Bado III fractures.

Application of ultrasound in the closed reduction and percutaneous pinning in supracondylar humeral fractures

BACKGROUND

Ultrasound examination can be applied to the diagnosis of pediatric elbow fracture. This study aims to analyze the application value of ultrasound in the surgical treatment of supracondylar humeral fractures.

METHODS

64 children with supracondylar humeral fractures were treated with ultrasound-guided closed reduction and percutaneous pinning (CRPP), 31 patients were treated with CRPP under radiography guidence. The reduction effect of supracondylar humeral fractures was determined through the perioperative ultrasound images of the lateral, medial and posterior aspects of the elbow. Percutaneous pinning was performed after supracondylar humeral fractures were well reduced. A follow-up examination was performed and all the patients were evaluated according to Flynn's criteria.

RESULTS

The mean duration of surgery was 58.3 min (42-108 min) in the ultrasound group and 41.5 min (24-63 min) in the radiography group (P < 0.05). The mean carrying angle was 8.2° (0°-15°) in the ultrasound group and 9.4°(3°-16°) in the radiography group; The mean Baumann's angle was 75.5°(60°-85°) in the ultrasound group and 73.4°(62°-82°) in the radiography group; The mean lateral humerocapitellar angle was 38.4° (26°-54°) in the ultrasound group and 41.6°(29°-52°) in the radiography group; No significant differences were observed between the two groups. According to the Flynn's criteria, 49 (76.6%) patients had excellent, 10 (15.6%) patients achieved good, 3 (4.7%) patients showed fair results and 2 (3.1%) patients achieved poor results in the ultrasound group; 22 (70.9%) patients had excellent, 6 (19.4%) patients achieved good, 2 (6.5%) patients showed fair results and 1 (3.2%) patients achieved poor results in the radiography group; No statistically significant difference was noted between the results of these two groups (P > 0.05). After surgery, three patients had pin tract infection. One patient had ulnar nerve neurapraxia in the radiography group. No cases with Volkmann's contracture were reported.

CONCLUSION

Ultrasound-guided CRPP is a safe and reliable surgical treatment of pediatric supracondylar humeral fractures. Trial registration Retrospectively registered.

Monteggia equivalent lesion in children: a narrative review

Background

Monteggia equivalent lesion represents a group of injury or combined injury patterns that resemble the Monteggia lesion in its presentations and mechanisms. Unlike Monteggia lesions, the equivalent ones, which share vague definitions and mostly occur as sporadic single case reports in the literature, have not been thoroughly reviewed since Bado first proposed the term, especially in the pediatric population. The objective of this review was to elucidate the definition by elaborating on its clinical styles and thus analyzing the mechanism, diagnosis, and management through related literature.

Data sources

Based on the terms of ‘Monteggia equivalent’, ‘radial neck fracture’ and ‘pediatric’, all of the related literature was searched on the PubMed and Google Scholar search engine.

Results

The advance of the definitions for pediatric Monteggia equivalent lesion (PMEL) was reviewed. The functional roles of the ulnar and the related mechanism theories in this injury were analyzed. The status of the radiocapitellar joint in this injury was emphasized. According to the previous statements, a new classification model was proposed and proper diagnosis and treatment approaches were suggested.

Conclusions

PMEL should be defined as an ulnar fracture at any level combined with a proximal radial fracture. According to the status of the radiocapitellar joint, it could be divided into three groups. The occult ulnar bowing and delayed radial head dislocation should be a serious concern of orthopedists. Surgical need is usually warranted. Maintaining the ulnar length and securing the radiocapitellar joint are highly recommended.

Standardized sonographic examination of pediatric elbow injuries is an effective screening method and improves diagnostic efficiency

INTRODUCTION

Positive role of ultrasound in the diagnosis of pediatric elbow injuries were confirmed by many papers but no comprehensive, standardized method has been developed for daily clinical practice. The aim of our prospective diagnostic study was to prove the efficacy of a five point sonographic point of care method for detecting different pediatric elbow fractures or dislocations.

METHODS

Between 2016 January and 2017 March 365 children (age 1-14) with suspected closed elbow injury were enrolled in our study. Sonographic point of care examination was carried out by a properly trained resident and two orthopedic surgeons immediately after physical survey. We used a standardized five point sonographic examination. Two plane x-rays were made following sonography according to protocol. Utility of sonographic pictures were analyzed by a radiologist. Cases with images which have not met with standard requirements were excluded. In those cases when primary x-rays were negative and/or any of the ultrasound planes showed positive findings, radiography was repeated after 4 weeks of injury. If we detected callus formation the fracture was considered occult. Cases with images which have not met with standard requirements were excluded. Ultrasonic pictures, evaluation sheets and x-ray results were compared.

RESULTS

Out of the 365 cases we identified 165 with positive findings (45, 2%) by primary x-rays. Distribution of the different injuries were the following: Radial condylar fractures, (n = 29) supracondylar humeral fractures (n = 84 proximal radial fractures, (n = 19) proximal ulnar fractures, (n = 7) fractures with joint dislocations (n = 3) joint dislocations without fractures, n = 2 medial epicondyle fractures (n = 14) fracture combinations (n = 7) We did not find injuries in this series that we could not categorize into these groups. Evaluating the abnormal sonographic dorsal fat pad sign (FPS) as a sole parameter for fracture detection we found sensitivity: 0, 97, specificity: 0,97, positive predictive value: 0,97, negative predictive value: 0,97 Evaluating the effectivity of the four cortical planes we calculated sensitivity 0, 85 specificity 0.96 positive predictive value: 0. 95 negative predictive value 0.87. The overall values of the five planes were the following: specificity0.97 sensitivity 1, positive predictive value 0.97 negative predictive value: 1 Interrater agreements on the cortical plane abnormality were considered good at two examiners and very good at one examiner. (Kappa = 0.79, 0, 81, 0, 79) Agreements on differentiation of elevated, normal fat pad) or lipohaemarthrosis in sonographic pictures were very good in all cases. (Kappa = 0,83, 0,86,0,82) While identification of any displacement or dislocation was possible in 96%, of all cases(n = 59)the exact determination of the type of the injury was possible in only 70,3% (n = 116) CONCLUSIONS: Using the five point ultrasonic examination provides enough information for excluding or confirming the presence of any pediatric elbow fractures or dislocations. The method is quick, simple and can help in the immediate differentiation of the severity of injuries. Sonographic lipohaemarthrosis seems to be more sensitive than elevated fat pad sign for the detection of potential occult fractures. Positive cases should be cleared by x-rays because the exact nature of the fractures are not identifiable only by ultrasound.

Diagnostic accuracy of ultrasound for upper extremity fractures in children: A systematic review and meta-analysis

OBJECTIVE

Ultrasound has an excellent diagnostic accuracy for fractures that is reportedly comparable to plain radiographs. We aim to summarize the diagnostic accuracy of ultrasound for upper extremity fractures in children.

METHODS

Databases were searched from inception through November 2019 using pre-defined index terms, including "ultrasound," "fractures of upper extremities" and "children". The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for fractures was conducted using the random-effects bivariate model. Subgroup analysis of fracture site (elbow vs non-elbow fractures) was also performed. Meta-regression was performed to determine if the site of fracture affected the diagnostic accuracy.

RESULTS

Thirty-two studies were identified in the meta-analysis. Ultrasound for fractures of the upper extremities has a sensitivity: 0.95 (95% CI: 0.93-0.97), specificity: 0.95 (95% CI: 0.91-0.98), positive likelihood ratio: 21.1 (95% CI: 10.8-41.5) and negative likelihood ratio: 0.05 (95% CI: 0.03-0.07), with an area under ROC (AUROC) curve of 0.98 (95% CI: 0.97-0.99). Subgroup analysis for elbow fracture showed ultrasound has a sensitivity: 0.95 (95% CI: 0.86-0.98), specificity: 0.87 (95% CI: 0.76-0.94), positive likelihood ratio: 7.3 (95% CI: 3.7-14.4) and negative likelihood ratio: 0.06 (95% CI: 0.02-0.16), with an AUROC of 0.96 (95% CI: 0.94-0.97). Meta-regression suggested the fracture sites would affect diagnostic accuracy of ultrasound (elbow vs non-elbow, p < 0.01).

CONCLUSIONS

Current evidence suggests ultrasound has excellent diagnostic accuracy for non-elbow upper extremity fractures in children, serving as an alternative diagnostic modality to plain radiographs.

Impact of Transverse Ultrasound Images on the Classification and Treatment of Pediatric Lateral Humeral Condyle Fractures

BACKGROUND

Pediatric lateral humeral condyle fractures (LHCFs) are sometimes misdiagnosed and inappropriately treated on the basis of x-ray radiographs because cartilage cannot be seen on radiographs. However, as a useful technique, transverse ultrasonography can accurately and readily determine the integrity of the cartilage hinge in pediatric LHCFs. The purpose of this study was to assess the reliability of the Jakob classification, the treatment plan, and the necessity for further examination of pediatric LHCFs with the use of x-ray with and without transverse ultrasound images.

METHODS

Five pediatric orthopaedic surgeons with different levels of experience evaluated 62 cases on the basis of the use of x-ray alone and x-ray combined with transverse ultrasound images. These 2 types of evaluations were repeated after an interval of 4 to 6 weeks. At the time of each evaluation, all observers were asked to classify the fractures according to the Jakob classification, to formulate treatment plans, and to determine whether further examinations were required.

RESULTS

After the training of transverse ultrasound image interpretation, the interobserver reliability of the Jakob classification significantly improved from fair (a kappa of 0.54) to moderate (a kappa of 0.71) with the addition of transverse ultrasound images. The treatment plan was changed from conservative treatment to surgical treatment in 7% of the ratings but from surgical treatment to conservative treatment in 15% of the ratings after reviewing the ultrasound images, and the difference was statistically significant (P=0.003).

CONCLUSIONS

The use of the Jakob classification and a treatment plan for pediatric LHCFs can be optimized by the addition of transverse ultrasound images, especially after training for transverse ultrasound image interpretation.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Diagnostic Performance of Ultrasonography for Detection of Pediatric Elbow Fracture: A Meta-analysis

STUDY OBJECTIVE

We evaluate the diagnostic performance of ultrasonography for detection of elbow fracture in pediatric patients with trauma.

METHODS

PubMed and EMBASE databases were searched for diagnostic accuracy studies that used ultrasonography for detection of elbow fracture in pediatric patients. Bivariate modeling and hierarchic summary receiver operating characteristic (ROC) modeling were conducted to evaluate diagnostic performance. The pooled proportions of the false-negative rate were assessed with a DerSimonian-Laird random-effects model. We performed meta-regression analyses for heterogeneity exploration.

RESULTS

Ten articles involving a total of 519 patients were included. The summary sensitivity, summary specificity, and area under the hierarchic summary ROC curve were 96% (95% confidence interval 88% to 99%), 89% (95% confidence interval 82% to 94%), and 0.97 (95% confidence interval 0.95 to 0.98), respectively. The pooled proportion of the false-negative rate of ultrasonography was 3.7%. Among the various potential covariates, ultrasonographic performer (pediatric emergency physician versus others) and presence of extra musculoskeletal ultrasonographic training (trained versus not reported) were associated with heterogeneity of the specificity.

CONCLUSION

Elbow ultrasonography demonstrated high performance in the diagnosis of pediatric elbow fracture, particularly in studies of physicians with extra training in musculoskeletal ultrasonography. Ultrasonography may be performed by trained physicians as a first-line diagnostic tool to diagnose pediatric elbow fracture.

A novel transverse ultrasonography technique for minimally displaced lateral humeral condyle fractures in children

INTRODUCTION

Management of minimally displaced lateral humeral condyle fractures in pediatric patients is controversial. This is primarily because with current imaging modalities it is difficult to accurately and conveniently determine the stability of the fractures by detecting the integrity of the cartilage hinge. Nevertheless, transverse ultrasonography has not been intensively reported in previous studies.

HYPOTHESIS

Transverse ultrasonography can determine the integrity of the cartilage hinge in minimally displaced lateral condyle fractures.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 39 pediatric patients with minimally displaced fractures of the lateral humeral condyle who underwent transverse ultrasonography between 2014 and 2017. Conservative treatment was given to pediatric patients with intact cartilage hinges that had been confirmed by transverse ultrasound images. Surgical treatment was recommended for pediatric patients with disrupted cartilage hinges. Data regarding healing of the lateral humeral condyle fractures were recorded and analyzed.

RESULTS

According to transverse ultrasonography, there were 14 children with intact cartilage hinges and 25 children with disrupted cartilage hinges. Fourteen children with intact cartilage hinges of the fracture were treated conservatively, and none of them showed secondary displacement. There were 16 children in whom there was surgical intervention, and 9 other children decided to have conservative treatment among the 25 children with disruption of the cartilage hinge. Five of these 9 children who underwent conservative treatment were found to have further displacement during an average of 12.6 days after the fracture event, and no other patient was found to have further displacement.

CONCLUSION

Transverse ultrasonography can simply and accurately determine the stability of minimally displaced lateral condyle fractures without sedation, ionizing radiation or invasive techniques. We recommend routine use of transverse ultrasonography to detect stability of the fractures, which can effectively avoid inadequate treatment and unnecessary surgery in pediatric patients with minimally displaced fractures of the lateral humeral condyle.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Significance of the Lateral Humeral Line for Evaluating Radiocapitellar Alignment in Children

BACKGROUND

The radiocapitellar line (RCL) was originally described for evaluation of the alignment of the RC joint on lateral images of the elbow. Although, many authors have translated the utilization of RCL into coronal imaging, previous studies have not been performed to confirm validity. The purpose of this paper was to identify an accurate way of evaluating pediatric RC alignment in the coronal plane.

METHODS

Thirty-seven anteroposterior (AP) radiographs of 37 children were evaluated to determine the position of the RC joint in the coronal plane. All had acceptable magnetic resonance imaging (MRI) studies available for comparison. The lateral humeral line (LHL), consisting of a line along the lateral edge of the ossified condyle of the distal humerus parallel to the axis of the distal humeral shaft, was studied as it related to the lateral cortex of the radial neck. Three children with a confirmed diagnosis of a Bado III, lateral displaced radius, Monteggia fracture were also evaluated.

RESULTS

The LHL passed along the edge of or lateral to the radial neck on all AP radiographs and all MRI studies. The RCL failed to intersect the capitellum on 2 AP radiographs. On MRI, the RCL also passed lateral to the capitellar ossification center in 3 patients. In addition, the RCL was seen passing through the capitellum at a mean of the lateral 30% (range, 0% to 64%) on AP radiographs and 26% (range, 0% to 48%) on MRI. For all 3 children with a Bado III Monteggia fracture, the LHL crossed the radial neck and the RCL did not intersect the capitellum.

CONCLUSIONS

The RCL can fail to intersect the capitellar ossification center on AP radiographs and MRI in pediatric elbows without injury. The LHL consistently lies lateral to the radial neck in normal elbows and medial to the lateral aspect of the radial neck on all Bado III fracture-dislocations. It, therefore, can be used as an adjunct in evaluating the RC joint on AP imaging. The RCL most commonly intersects the lateral one third of the ossification center on both plain radiographs and MRIs.

LEVEL OF EVIDENCE

Level III-diagnostic.

The Use of Magnetic Resonance Imaging in Management of Minimally Displaced or Nondisplaced Lateral Humeral Condyle Fractures in Children

OBJECTIVES

Fractures of the lateral humeral condyle are common in children. Nondisplaced fractures are managed with cast immobilization and frequent radiographic follow-up. Possibility of assessing the displacement and stability of such fractures may be helpful in planning the initial treatment and survey. Magnetic resonance imaging (MRI) could be a useful tool in determining the stability of lateral condyle in children. We propose to investigate the use of MRI in such indication.

METHODS

Fourteen patients presenting with a minimally displaced or nondisplaced fracture were initially treated with a long arm cast and had an MRI within 5 days of injury.

RESULTS

The MRI showed that 10 patients had an incomplete fracture without disruption of the cartilage hinge and 4 patients had a complete fracture with extension of the fracture through the cartilaginous epiphysis into the elbow joint. Three patients with such complete fracture had no evidence of lateral condyle displacement on MRI, and 1 patient had a displacement of the lateral condyle. The patients with incomplete fractures had a conservative treatment. The patient with a complete and displaced fracture had an open reduction and internal fixation. The 3 patients with a complete fracture and no evidence of lateral condyle displacement on MRI had a control MRI, 6 to 10 days after cast application, to detect a secondary displacement of the fracture.

CONCLUSIONS

Because it seems difficult in minimally displaced or nondisplaced fractures to detect further displacement with radiographs, MRI was found mandatory to improve complete fracture visualization during the first phase of conservative treatment. In incomplete fractures, initial MRI investigation was consistent with a stable fracture and avoided further early radiographs or clinical survey. In such cases, we recommend a conservative treatment with late radiographs after long arm cast removal. We propose MRI routine use in the early evaluation of minimally displaced or nondisplaced lateral condyle fractures in children.

Imaging Evaluation of Pediatric Extremity Trauma, Part I: Injury Patterns in the Immature Skeleton and Imaging Modalities

The injury patterns encountered in the extremities of infants and children differ from those seen in adults, predominantly due to significant differences in the composition and structure of the immature skeleton. A variety of fractures occur that are unique to children, and some of them tend to be subtle and easily overlooked. Plain radiographs remain an essential tool for the detection and management of such injuries. In addition, a variety of imaging modalities are available (e.g., CT, MRI, ultrasound) that provide additional information about musculoskeletal injuries which can be helpful in selected cases. This article presents the different types of injuries that can be expected in pediatric extremity trauma and discusses methods to improve detection on plain radiographs. The relative value and indications of other imaging modalities are also discussed.

[Sonographic fracture diagnostics]

BACKGROUND

In clinically suspected fractures taking radiographs is the standard procedure but the indications should be strictly limited. Ultrasound offers a safe and radiation-free alternative for fracture diagnostics.

OBJECTIVES

Sensitivity and specificity of sonographic fracture diagnostics and safety of sonographic algorithms for fracture evaluation.

METHODS

Presentation of useful applications for sonographic fracture evaluation and establishment of sonographic algorithms for safe fracture diagnosis.

RESULTS

In children distal forearm fractures can be diagnosed solely by ultrasound (sensitivity 96 % and specificity 97 %). The sonographic fat pad sign (SOFA) has been proven to be a useful primary screening tool for occult fractures of the pediatric elbow. A positive fat pad sign (SOFA+) is indicative of a fracture and radiographic diagnostics are necessary (sensitivity 97 % and specificity 91 %). Ultrasonography is also useful to exclude subcapital humeral fractures (sensitivity 94 % and specificity 100 %) and for correct estimation of displacement when present.

CONCLUSIONS

Sonographic algorithms for fracture evaluation (SAFE) offer a safe diagnosis and guidance of the therapeutic course of certain pediatric fractures, thereby reducing unnecessary radiation exposure.

Distal Humeral Epiphyseal Separation in a Newborn

Distal humeral epiphyseal separations are rare and treatment strategies are not well defined. The case of a full-term male newborn with a distal humeral epiphyseal separation as the result of a birth trauma was reviewed. A literature review of this topic was undertaken to better understand its occurrence, diagnosis, and treatment options. The patient sustained a distal humeral epiphyseal separation during a vaginal delivery. Deformity and decreased movement in the elbow were observed. Radiographs and subsequent ultrasound were used to make the diagnosis of distal humeral epiphyseal separation. Given the displaced and acute nature of the fracture, a closed reduction and percutaneous pinning was performed. Intraoperatively, this was greatly facilitated by an elbow arthrogram. Immobilization consisted of a posterior plaster splint and swathe. Postoperative follow-up with clinical and radiographic examination showed abundant bony healing and early restoration of function. Ultrasound is useful to confirm the diagnosis of a distal humeral epiphyseal separation for elbow injuries in very young patients. However, once the diagnosis is confirmed, an intraoperative elbow arthrogram helps highlight the fracture fragments and ensures proper reduction and fixation of the fracture. [Orthopedics. 2016; 39(4):e764-e767.].

Transphyseal elbow fracture in newborn: review of literature

Transphyseal elbow fracture is a rare entity in newborns, and in the last century, only case reports or small case series have been published; however, precise epidemiological data lack. Such fractures occur more often in emergency Caesarian section or vaginal delivery. The differential diagnosis with elbow dislocation can be challenging. Radiography, arthrography, magnetic resonance, ultrasound or a combination of these have already been described to make diagnosis, but guidelines for the management of this injury in the neonate are not well established. A review of the literature of the last century about distal transphyseal fracture of the humerus in newborns was performed. A bibliographic search was conducted accessing usual medical databases. The work-up methods, treatments, results at follow-up and the rate of complications were collected. Twenty case reports or small retrospective case series reporting a total of 33 cases were included. A posteromedial displacement of the radioulnar complex was found in 21 elbows (64 %). Four patients (12 %) underwent surgical treatment, whilst 29 (88 %) were managed without surgery. An attempt of reduction was reported in 23 cases (69 %). At follow-up, 88 % recovered completely the carrying angle and 80 % range of motion. A relationship between the type of treatment (conservative or surgical, with attempt of reduction or not) and results at follow-up could not be demonstrated. The most common complication was cubitus varus. Transphyseal elbow fractures are rare among newborns. Regardless of the treatment choice, such lesions are in most cases associated with a good prognosis.

[Sonographic fracture diagnosis in children]

X-rays are the standard imaging procedure for the diagnosis of pediatric long bone fractures. Recent studies show that ultrasound (US) imaging is also qualified to diagnose pediatric long bones fractures. Thus, the diagnosis and decision-making for the treatment of metaphyseal forearm fractures in children can be performed by solely using US. The sonographic fat pad sign has been proven to be a useful primary screening tool for pediatric elbow injuries. If there is a negative fat pad sign, a fracture is unlikely and taking additional radiographs is dispensable at this time. If there is a positive fat pad sign, a fracture is likely and radiographs should be taken. US is also useful to exclude subcapital humeral fractures and to estimate fracture displacement. If a fracture of the subcapital humerus is present, additional radiographs are necessary to avoid overlooking of pathologic fractures. For reliable sonographic fracture diagnosis in childhood, a detailed history und exact clinical examination are required.

Ultrasound assessment of the elbow joint in infants and toddlers and its clinical significance

BACKGROUND

Ultrasound can be used for the diagnosis of elbow injuries in infants and toddlers. However, ultrasound is highly operator-dependent and accurate ultrasound examinations require a complete understanding of the complex anatomy of the elbow joint.

PURPOSE

To report the normal ultrasound anatomy of the elbow, particularly of the humeroulnar joint, in infants and toddlers.

MATERIAL AND METHOD

Thirty subjects aged <3 years with no history of elbow injuries underwent ultrasound examinations of the elbow joint from six directions: (i) lateral to the humeroradial joint; (ii) anterior to the humeroradial joint; (iii) posterior to the humeroradial joint; (iv) medial to the humeroulnar joint; (v) anterior to the humeroulnar joint; and (vi) posterior to the humeroulnar joint.

RESULTS

The appearance of the humeroradial joint observed from three directions was similar and resembled a pair of double fists ("double-breast sign"). The appearance of the humeroulnar joint observed from three directions was different, which is related to the irregular morphology of the medial sides of the humerus and ulna. Anteroposteriorly, the coronoid and olecranon epiphyses and coronoid fossa appear anteriorly and the olecranon and trochlear epiphyses and olecranon fossa appear posteriorly, resembling a "check-mark sign". The medial epicondyle, cubital tunnel and distal humerus appear together ("double-hump sign"). The "anterior hump" is the medial epicondyle and is always higher than the "posterior hump", which is the bony protrusion on the articular surface of the distal humerus. The ultrasound signal of cortical bone in the metaphysis of the distal humerus is continuous with that of the epiphysis of the medial epicondyle.

CONCLUSION

Ultrasound is useful for the diagnosis of elbow injuries in infants and toddlers.

Musculoskeletal ultrasound in childhood

Ultrasonography is one of the first line imaging modalities for the evaluation of musculoskeletal disorders in children. This article provides an overview of the most important pathologic entities in which ultrasonography significantly contributes to the diagnostic workup.

Accuracy of the sonographic fat pad sign for primary screening of pediatric elbow fractures: a preliminary study

PURPOSE

The purpose of this study was to evaluate the diagnostic accuracy of the sonographic fat pad sign (FPS) as a predictor for pediatric elbow fractures.

PATIENTS AND METHODS

This is a prospective study of children under 14 years with suspected elbow fractures. All participants underwent at first ultrasonography focused on a FPS followed by standard elbow radiographs. US findings were compared to final fracture diagnosis.

RESULTS

38 out of 79 children had an elbow fracture. A sonographic FPS predicted an elbow fracture with a sensitivity/specificity of 97.3/90.5 %, positive/negative likelihood ratios (LR) were 10.2/0.03 and correct/false classification rates were 93.7/6.3 %. Primary US findings were later reviewed by a blinded physician giving a congruity of 96.2 %. These secondary US findings predicted an elbow fracture with a sensitivity/specificity of 92.1/92.7 %, positive/negative LRs were 12.6/0.09 and correct/false classification rates were 92.4/7.5 %.

CONCLUSION

The sonographic FPS could serve as a useful screening tool in primary evaluation of pediatric elbow injuries. If a fracture is unlikely after clinical and US evaluation, additional radiographs are dispensable, thereby potentially minimizing the radiation burden in childhood and reducing the length of stay in the Emergency Department.

Distal humeral epiphysiolysis in the newborn: utility of sonography and differential diagnosis

Fracture-separation of the distal humeral epiphysis in newborn is a rare entity, usually the result of a traumatic delivery. It can mimic elbow dislocation and, due to the absence of ossification of the epiphysis at that time, cannot be diagnosed radiographically. However, ultrasound is an important diagnostic tool for this purpose because it is able to clearly visualize the cartilaginous epiphysis. In addition, it allows the differential diagnosis with posterior elbow dislocation whose therapeutic management and prognosis are different. We report the case of a preterm newborn in which a fracture-separation of the distal humeral epiphysis was diagnosed with the help of sonography. The purpose of this report is to emphasize the utility of echography as a cheap, available, and noninvasive tool for the evaluation of the nonossified epiphysis in the newborn elbow.

Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs

BACKGROUND

The radiocapitellar line (RCL) is recommended for evaluating radiocapitellar alignment in skeletally immature elbows, yet its parameters have not been clearly defined. This study systematically assesses the RCL relationship in normal elbows, investigating the impacts of radiographic view, choice of anatomic landmarks, patient age, forearm position, and observer bias on the manner in which the RCL intersects the capitellum.

METHODS

On radiographs of 20 normal elbows (age range, 1 to 8 y), 3 pediatric orthopaedic surgeons, blinded to clinical history, drew lines (RCLs) on anteroposterior and lateral projections, along the radial shaft and neck, and with and without the capitellum visible. Line placement was repeated 2 weeks later. The relationship of each RCL to the capitellum was assessed continuously using the perpendicular distance to the center of the capitellum, normalized to capitellar width [line-capitellar distance (LCD)], and categorically as passing through the middle third, outer two-thirds, or outside the capitellum.

RESULTS

Of the 480 RCLs drawn, 23 (5%) missed the capitellum and 224 (47%) missed the middle third. More radial neck than shaft lines intersected the middle third on both anteroposterior and lateral views (P < 0.05, Fisher exact test), with the lowest LCD values for neck lines on the lateral view (P < 0.05, analysis of variance (ANOVA)). More RCLs intersected the middle third when the capitellum was visible than when it was obscured (P = 0.03, Fisher exact test), suggesting an effect of observer bias. Patient age correlated inversely with LCD (P < 0.001). The angle between the neck and shaft lines correlated positively with LCD (P < 0.001), suggesting an impact of forearm rotation position. Intraobserver and interobserver reliability was moderate-to-substantial (κ = 0.40-0.75).

CONCLUSIONS

The RCL best defines normal radiocapitellar alignment when the line is drawn along the radial neck on the lateral view, although this relationship is affected by bias, patient age, and forearm rotation position. The RCL does not reliably intersect the middle third of the capitellum, arguing against its sufficiency for assessing precise radiocapitellar alignment.

LEVEL OF EVIDENCE

Diagnostic Level 3.

Elbow arthrography in children with an ulnar fracture and occult subluxation of the radial head

The purpose of this study was to investigate the use of elbow arthrography for detecting an occult subluxation of the radial head and for verifying the quality of reduction in children with ulnar fractures. The study involved 15 children who underwent closed reduction (with or without percutaneous pinning) based on arthrography for minimally displaced fractures with or without radial head subluxation. The mean age of the patient at the time of surgery was 6 years (range, 3-12 years). Initial diagnoses based on conventional radiographs were compared with arthrographically confirmed final diagnoses in groups of children with ulnar fractures of the olecranon, proximal, and diaphysis. Arthrography confirmed initial radiographic diagnoses in 10 and altered diagnoses in five patients. We conclude that arthrography can be useful for detecting an occult subluxation of the radial head and for evaluating adequate reduction in children of less than 6 years with ulnar fractures.

Paediatric musculoskeletal US beyond the hip joint

US is a technique particularly suited to the investigation of musculoskeletal disorders in children and adolescents. This review paper describes a range of clinical settings beyond the hip joint where US has a significant role to play, including sports injuries, infectious diseases, inflammatory and degenerative conditions, congenital and developmental disorders, acute trauma of bone and joints, and peripheral nerve injuries. In some circumstances, US can be regarded as the most effective means of diagnostic imaging, whereas in other instances, it is an alternative or supplement to other more comprehensive imaging modalities, like MRI and CT. Although MRI offers superior soft-tissue contrast resolution, US is low-cost, non-invasive and has higher spatial resolution and real-time capability for the assessment of musculoskeletal structures during joint movement and stress manoeuvres.

Traumatic separation of the distal epiphysis of the humerus sustained at birth

We reviewed the clinical and radiological results of six patients who had sustained traumatic separation of the distal epiphysis of the humerus at birth. The correct diagnosis was made from plain radiographs and often supplemented with ultrasonography, MRI and arthrography. An orthopaedic surgeon saw two patients within two days of birth, and the other four were seen at between nine and 30 days. The two neonates underwent unsuccessful attempts at closed reduction. In the remaining patients, seen after the age of eight days, no attempt at reduction was made. All six displaced fractures were immobilised in a cast with the elbow at 90 degrees of flexion and the forearm pronated. When seen at a mean of 58 months (16 to 120) after injury, the clinical and radiological results were excellent in five patients, with complete realignment of the injury. In one patient the forearm lay in slightly reduced valgus with the elbow in full extension. Traumatic separation of the distal epiphysis of the humerus may be missed on the maternity wards and not diagnosed until after discharge from hospital. However, even when no attempt is made to reduce the displaced epiphysis, a good clinical result can be expected.

Ultrasonography for non-displaced and mini-displaced humeral lateral condyle fractures in children

OBJECTIVE

To evaluate the value of ultrasonography in non-displaced and mini-displaced humeral lateral condyle fractures in children.

METHODS

Nine children aged 2-9 years with non-displaced or mini-displaced humeral lateral condyle fractures were examined by high-resolution ultrasonography. The fracture line through the joint surface was visualized by ultrasonography in 6 case, in which closed reduction and percutaneous pinning was performed on 3 patients and other 3 patients did not receive the treatment because of patients'or their parents'refusal. In the remaining 3 children, ultrasonography did not reveal the cartilaginous trochle involvement at the joint surface and conservative treatment was adopted.

RESULTS

The average follow-up period was 8 months. The sonographic findings were confirmed by magnetic resonance imaging in one child who received conservative treatment and another child who received percutaneous pinning. The elbow function and fracture healing were good in cases received closed reduction and percutaneous pinning. Among the three cases who refused to receive closed reduction and internal fixation, re-displacement occurred in 1 case and delayed union in 1 case. All three cases receiving conservative treatment had good results both in elbow function and fracture healing.

CONCLUSION

High-resolution ultrasonography enable to reveal non-displaced and mini-displaced humeral lateral condyle fractures as well as to ascertain whether the cartilaginous trochlea humeri was involved. For these cases, arthrography or magnetic resonance imaging is unnecessary.

Acute elbow trauma in children: role of ultrasonography

BACKGROUND

The diagnosis of occult elbow fracture in children is often challenging due to equivocal or negative repeated radiographic findings.

OBJECTIVE

To evaluate the potential diagnostic role of US in children who have sustained elbow trauma with an elbow joint effusion but no fracture seen on initial radiographs.

MATERIALS AND METHODS

The study included 14 consecutive children (age range 5-15 years) with elbow trauma whose elbow radiographs showed an effusion without fracture who underwent emergency imaging (within the first 72 h) with US and MRI. The aim of US was to demonstrate a lipohaemarthrosis in relation to a cortical fracture. MR imaging was used as the reference to differentiate fracture from bone or muscle contusions.

RESULTS

In seven children US demonstrated a lipohaemarthrosis, and MRI demonstrated a cortical fracture in all these children. Conversely, among the seven children with simple haemarthrosis seen on US, MRI did not identify a cortical fracture in six and demonstrated a cortical fracture in one.

CONCLUSION

Posttrauma elbow joint effusion in children is not always related to a cortical fracture. US appears to be a reliable, accurate, widely available and effective low-cost tool in these cases. The diagnostic clue is the detection of a lipohaemarthrosis in the articular recess.

The assessment of the ulnar nerve at the elbow by ultrasonography in children

We evaluated the morphological changes to the ulnar nerve of both elbows in the cubital tunnel by sonography in a total of 237 children, of whom 117 were aged between six and seven years, 66 between eight and nine years, and 54 between ten and 11 years. We first scanned longitudinally in the extended elbow and then transversely at the medial epicondyle with the elbow extended to 0°. We repeated the scans with the elbow flexed at 45°, 90°, and 120°. There were no significant differences in the area of the ulnar nerve, but the diameter increased as the elbow moved from extension to flexion in all groups. More importantly, the ulnar nerve was subluxated anteriorly on to the medial epicondyle by 1.5% to 1.9% in extended elbows, by 5.9% to 7.9% in those flexed to 45°, by 40.0% to 44% in those flexed to 90°, and by 57.4% to 58.1% in those flexed to 120°, depending on the age group. Sonography clearly and accurately showed the ulnar nerve and was useful for localising the nerve before placing a medial pin. Because the ulnar nerve may translate anteriorly onto the medial epicondyle when the elbow is flexed to 90° or more, it should never be overlooked during percutaneous medial pinning.

MDCT of the Elbow in Pediatric Patients with Posttraumatic Elbow Effusions

OBJECTIVE

The purpose of this study was to determine the performance characteristics of MDCT in the detection of fractures in children with posttraumatic elbow effusions and to assess the effect of MDCT findings on clinical management.

SUBJECTS AND METHODS

Unenhanced MDCT of the elbow was prospectively performed without sedation on 31 children 20 months to 16 years old who had posttraumatic elbow effusions. Two blinded reviewers independently and in consensus characterized all MDCT scans as positive or negative for the presence of fracture. Level of interobserver agreement was determined with the kappa statistic. Sensitivity, specificity, positive predictive value, and negative predictive value of MDCT for fracture detection were determined for the consensus MDCT interpretations with follow-up radiographs as the reference standard. Patients were treated with casts and instructed to return in 2-3 weeks for clinical and radiographic follow-up unless a change in management was indicated on the basis of MDCT findings. The frequency of alteration of management was determined.

RESULTS

Both reviewers detected fractures in 15 (48%) of the patients individually and in 16 (52%) of the patients by consensus. Interobserver agreement for fracture detection with MDCT was excellent (kappa = 0.85). The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT in the detection of fractures were 92%, 79%, 79%, and 92%, respectively. Four (13%) of the children had changes in management based on the MDCT findings.

CONCLUSION

MDCT is a sensitive means of evaluating for radiographically occult fractures in children with posttraumatic elbow effusions. It has a high negative predictive value and a high level of interobserver agreement. MDCT findings may lead to alteration of treatment of children with nondisplaced lateral condylar and radial head fractures.

[Superficial US of superficial bones]

Although bones are not well imaged by US this imaging modality can be helpful in the assessment of bone surface and can be complementary to standard radiographs. A focal irregularity of the hyperechoic cortical line indicates a fracture, a cortical avulsion, a local bulging of the cortex or a foreign body related or not to previous surgery. Subperiosteal collections either purulent or hemorrhagic are easily detected and can be aspirated under US guidance if an infection is suspected. US also allows diagnosis of epiphyseal fractures when involving the distal epiphysis of the metatarsals, radial head, humeral head (Hill-Sachs fracture) growing cartilages... US examination of joints can detect osteophytes and marginal erosions (allowing early diagnosis of rheumatoid arthritis together with visualization of hyperaemic pannus and joint effusion) Cortical continuity in a location where in normal conditions a joint space is found indicates a synostosis. In children US, by directly visualizing the cartilaginous component of the non ossified bones, allows detection and serial follow-up of many congenital malformation (pes equinus...). US may be obtained in all patients where standard radiographs are not diagnostic because of it is efficient, non-invasive and relatively inexpensive.

Use of ultrasound for diagnosis of interposition of soft tissue in bone fracture line

Ultrasound (US) has recently become a favorable diagnostic technique in orthopedics and traumatology, as well as in other medical sciences. We aimed to determine effectiveness of US in diagnosis of soft tissue interposition that impedes or delays the union of fracture. The present study included 55 acute fractures in 39 patients, in whom operation (open reduction and internal fixation) was scheduled because no closed reduction was achieved, in our department between January 1999 and December 2003. Before the operation, the fracture line in all patients was scanned by a 5- to 7-MHz linear probe of the US device. The data obtained by US examination were compared to findings obtained by surgical intervention with the McNemar test. These were calculated as positive predictive value and negative predictive value, with specificity and sensitivity. The difference between the study and control groups was not statistically significant (p = 0.625). These findings demonstrated that sensitivity value, specificity value, positive and negative predictive values were 96.9%, 86.3%, 91.4% and 95%, respectively. US is an efficient, safe and reliable diagnostic technique for detection of interposition of soft tissue in bone fracture line.

Musculoskeletal sonography in the neonate and infant

Babies are ideal subjects for investigation by sonography. They are small and easily examined with the use of high-frequency transducers. Their unique status in US imaging tends to get lost amid the array of other available modalities, such as MRI and CT imaging. Some of the questions posed in pediatric musculoskeletal imaging that are routinely directed to other imaging modalities can be solved quickly at a lower cost by sonography in neonates and infants without sedation or any known clinical risk. These small children not only have thinner soft tissues but they have long bones and midline spine structures whose ends are largely composed of cartilage, which provides an early opportunity to examine these regions by US. And we cannot overestimate the value of new parents being able to stay next to their baby during imaging in a warm, friendly and non-threatening environment.

Radiographic assessment of pediatric proximal radius fractures: interrater and intrarater reliability

Three methods of measuring pediatric proximal radius fracture radiographs were compared using injury films of 32 patients. Angulation and displacement were independently measured by four physicians. One physician measured the films by each method a second time 2 months later. Values for interrater and intrarater reliability were determined using inter- and intra-class coefficients (ICC). Interrater reliability was poor for methods using the axis of the proximal radial fragment or the proximal radial physis as a reference (ICC = 0.47 and 0.42, respectively). Measurement of the angle between a line parallel to the proximal radius articular surface and the radial shaft had the highest interrater reliability (0.76); measurement of displacement had the lowest interrater reliability (0.09). The intrarater reliability was excellent for all methods (0.93-0.99) and was also highest when the proximal articular surface reference was used. Of described methods, use of the proximal radius articular surface and the radial shaft as references had the highest interrater and intrarater reliability.

The role of sonography in detecting radial head subluxation in a child

Injuries around the elbow joint in children can be difficult to diagnose on the basis of findings on physical examination and radiographs. We present the case of a 4-year-old girl with a probable subluxation of the radial head, based on the findings on physical examination and radiographs. Radiography raised the possibility of a radial head subluxation. Sonography demonstrated displacement of the cartilaginous head of the radius away from the capitellum in the affected elbow. The child underwent corrective surgery. During fluoroscopy, results of an ulnar stress test were positive for lateral ligament tears. The patient's arm was put in a cast for 6 weeks. At 1-year follow-up, the patient had full range of motion of the elbow without pain. We present the findings of sonographic studies used to confirm the diagnosis.

Multidetector Computed Tomography of Fracture-Separation of the Distal Humeral Epiphysis

A case of fracture-separation of the distal humeral epiphysis that was diagnosed using unenhanced multidetector computed tomography is reported. Fracture-separation of the distal humeral epiphysis is a rare injury of young children that is difficult to identify on routine radiographs and is frequently misdiagnosed at the time of initial evaluation.

Ultrasound of the elbow

The elbow is an important synovial hinge joint of the upper extremity. This joint represents a common site of musculoskeletal symptomatology, affecting all age groups. The advantages of ultrasound imaging of the elbow include easy availability, multiplanar capability and the ability to assess structures dynamically. Patient symptomatology and site of maximal tenderness can be directly correlated with imaging findings. Comparison is easily made with the contralateral side. Particular strengths include the ability to assess para-articular structures, such as regional tendons and ligaments, in addition to assessment of joint effusions, loose bodies and regional bursae. With operator experience and excellent technique, ultrasound is a valuable imaging tool for assessment of disorders of the elbow joint.

Epiphyseal separation of the distal humerus

A case of epiphyseal separation of the distal humerus is presented, emphasizing the clinical and radiological features of this rare birth trauma. Conservative treatment resulted in complete recovery.

Review article: diagnostic ultrasonography: applications in orthopaedic surgery

Diagnostic ultrasonography of musculoskeletal diseases in the United States has been used most often for detection of rotator cuff tears or developmental dysplasia of the hip. Diagnostic ultrasonography also is useful in imaging the periarticular soft tissues about the knee, hip, ankle, occult pediatric fractures, muscle injury, bone healing, and foreign bodies. Recent technologic improvements have made this imaging modality increasingly more accurate while providing significant benefits over traditional modalities such as magnetic resonance imaging, particularly regarding cost, patient satisfaction, and ease of usage. Increasing use in the future of diagnostic ultrasonography for musculoskeletal conditions is likely as acceptance grows. This review focuses on recent, practical applications of diagnostic ultrasonography of the musculoskeletal system.

Sonography for monitoring closed reduction of displaced extra-articular distal radial fractures

BACKGROUND

Closed reduction and cast immobilization are employed in the primary treatment of most distal radial fractures, and conventional radiographic techniques have been essential and effective in monitoring these reductions. Radiation-free ultrasonography, however, can provide both real-time and dynamic multiple-plane images with a small and simple-to-use transducer that can be operated with only one hand. We therefore wanted to see if the real-time and dynamic multiple-plane observation capabilities of ultrasonography would allow an orthopaedic surgeon to perform a closed reduction without multiple attempts, as are frequently required when only conventional radiographic techniques are used.

METHODS

Sonographically guided closed reduction was performed in twenty-seven consecutive wrists with an acute distal radial fracture. The efficacy of this method was evaluated and compared with that of conventional radiographic techniques.

RESULTS

The sonographic images delineated the fractures as accurately as did the conventional radiographs. All parameters measured on the sonograms and radiographs showed substantial restoration of anatomic alignment after reduction, and all measurements were similar on the two types of images.

CONCLUSIONS

Sonographically guided monitoring compared well with conventional radiographic techniques during closed reduction of extra-articular distal radial fractures. Sonography is an accurate, simple, and radiation-free tool that provides the substantial benefits of dynamic multiple-plane and real-time observation.

Ultrasound of the elbow

This article describes the use of ultrasound (US) in the evaluation of the elbow. US is able to visualize several abnormalities affecting tendons, muscles, ligaments and bursae around the elbow joint as well as to delineate the nature of soft-tissue swelling, such as a space-occupying lesion or synovial enlargement. Occult fractures, osteophytes and intra-articular loose bodies can be depicted with this technique as well. At the cubital tunnel, US allows accurate imaging of the ulnar nerve and to document changes that occur in compressive syndromes. Over other imaging modalities, US offers several key advantages, including cost effectiveness, availability and ability to perform a dynamic examination of tendon movement and joint motion. With continued experience, it is likely that the use of US will increase further with regards to evaluation of soft-tissue abnormalities of the elbow.

Ultrasound in pediatric musculoskeletal disease: techniques and applications

The increased ratio of nonossified cartilage to bone in children makes ultrasound (US) a particularly suitable technique for evaluating pediatric musculoskeletal disorders. US allows the examiner to compare quickly and meticulously an affected to unaffected area of interest in different orthogonal planes without a need for sedation. Developmental dysplasia of the hip is the most common indication for pediatric musculoskeletal US. Sonography is also a cost-effective, useful, and complementary imaging tool for evaluating pediatric musculoskeletal trauma, inflammation-infection, and masses.