Imaging in Pediatric Elbow Trauma Guidelines

Updated: Jul 20, 2017
  • Author: Richard M Shore, MD; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
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Guidelines

Guidelines Summary

The American College of Radiology Appropriateness Criteria for chronic elbow pain includes the following [7] :

  • Initial evaluation of chronic elbow pain should begin with radiography.
  • Chondral and osteochondral abnormalities can be further evaluated with MRI or CT. The addition of arthrography is helpful, especially for detecting intra-articular bodies.
  • Radiographically occult bone abnormalities can be detected with MRI, CT, or bone scintigraphy.
  • Soft-tissue abnormalities (tendon, ligament, nerve, joint recess, and masses) are well-demonstrated with MRI or US.
  • Dynamic assessment with US is effective for diagnosing nerve or muscle subluxation.

Supracondylar fractures may be complete or incomplete and have a wide range of severity. The Gartland classification as modified by Wilkins and expanded by Leitch defines extension supracondylar fractures as follows [23, 24] :

  • Type 1 - Fractures with no or minimal posterior displacement or angulation of the distal fragment such that the anterior humeral line still intersects part of the capitellum
  • Type 2 - Fractures with more posterior displacement or angulation, but with an intact posterior cortex; type 2 fractures have been divided into type 2A, with no rotation or translation, and type 2B, with some rotation or translation in addition to posterior displacement and angulation
  • Type 3 - Fractures with displacement and complete cortical disruption (see the image below)
  • Type 4 - Fractures with displacement, complete cortical disruption, and complete loss of the periosteal hinge anteriorly and posteriorly leading to multidirectional instability

A staging system for displacement of lateral condyle fractures is as follows [36] :

  • Stage I fractures have an intact articular surface. These may have some angulation but no true displacement of the fracture fragment and no shift of the olecranon.
  • Stage II fractures extend through the articular surface, allowing for a small amount of displacement of the distal fragment and olecranon shift.
  • Stage III fractures have significant displacement, usually laterally and proximally, leading to translocation of the olecranon and radial head. In addition, traction from the common extensor muscles leads to rotation so that the cartilage-covered articular surface of the fractured lateral condyle is in contact with the metaphysis, leading to nonunion if not corrected.

The Milch classification scheme for lateral condylar fractures defines a type I fracture as one that passes through the distal humeral epiphysis lateral to the lateral crista of the trochlea, in most cases passing through the ossified capitellum. For these fractures, the lateral crista of the trochlea is intact, maintaining stability of the elbow joint. However, the adjacency of fracture margins for the metaphysis and capitellum poses the risk of focal physial closure. The more frequent Milch type II fracture follows dense collagenous fibers through the epiphyseal cartilage into the trochlea medial to the lateral crista. In this case, the lateral crista is part of the distal fracture fragment, leading to instability of the elbow joint. [35]