COTW 2/24/23: A 6 year old boy presents with elbow pain

A 6 year old boy presents to your emergency department with elbow pain. He was at a birthday party at a trampoline park and unfortunately did not land his double back flip. Well I guess he did kind of land it but rather on his outstretched right hand. His mom gave him some tylenol and motrin at home but he kept complaining and couldnt sleep so they present to your ED at midnight. On exam he has maybe some mild swelling but he is tender at the elbow.

Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 8014

You review the x ray and note that since it is now 1 in the morning radiology has not placed an arrow sign pointing to pathology. You’re kind of unsure if you see anything that would indicate a fracture but you feel like you could be missing something because he is pretty tender at the elbow. Now you could just splint the kid, wait for the read, and call them back in the morning…or you might be able to clinch the diagnosis with ultrasound.

In this case we are evaluating for a garland type 1 supracondylar fracture. Type 2-4 should be easily identifiable…even without radiology placed arrow signs. Remember for type 1 fractures you are looking for the “sail sign” which is displacement of the anterior fat pad into a sail looking thing or the posterior fat pad sign which is where you see the posterior fat pad jutting out. On a normal elbow, the posterior fat pad should not really be visible, thus seeing it is indicative of pathology.

Ultrasound can augment our diagnostic evaluation by essentially looking for effusion at the elbow joint. To do this, have the patient hold their elbow in flexion at 90 degrees and start by scanning in the longitudinal plane.

When looking for an effusion pay attention to the fat pad-effusions should kind of cause some displacement of the fat pad.

When you go to scan your patient you see this instead….

Note the anechoic fluid deep to the fat pad.

This is essentially an ultrasonographic posterior fat pad sign clinching the diagnosis of a type 1 supracondylar fracture. You place your patient in a posterior long arm splint and give him ortho followup.

Fun fact is I stole most of these pictures from the superior fellow’s MSKAID project. Look for the QR codes on the machines and use them so you can scan some joints!




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COTW 3/12/23: 71M with chest pain after a fall

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