Upper Extremity Trauma: page 1 of 15 Elbow & …©Ken L Schreibman, PhD/MD 6/4/15 Upper Extremity...

15
©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info page 1 of 15 Upper Extremity Trauma: Elbow & Forearm Anatomy Radiographs FOPH BBFF Monteggia Galeazzi Essex-Lop. Fat Pads Peds Elbow Supracond. Lat. condyle Med. epicon. 4 © 2013 Ken L Schreibman, PhD/MD www.schreibman.info Upper Extremity Trauma Elbow & Forearm Slide 1 of 90 Topics Thanks to Carrie Bartels and Shana Jatczak for the 3D processing and segmentation! Giving Credit to Famous Authors Anatomy Radiographs FOPH BBFF Monteggia Galeazzi Essex-Lop. Fat Pads Peds Elbow Supracond. Lat. condyle Med. epicon. 4 © 2013 Ken L Schreibman, PhD/MD www.schreibman.info Upper Extremity Trauma Elbow & Forearm Slide 2 of 90 Charles Monroe “Sparky” Schultz (1922 - 2000) Creator of… Charlie Brown 1947: Li’l Folks 1950: Peanuts 2600 newspapers 21 languages 355 million readers in 75 countries Published 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 Anatomy Radiographs FOPH BBFF Monteggia Galeazzi Essex-Lop. Fat Pads Peds Elbow Supracond. Lat. condyle Med. epicon. 4 © 2013 Ken L Schreibman, PhD/MD www.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 Anatomy Radiographs FOPH BBFF Monteggia Galeazzi Essex-Lop. Fat Pads Peds Elbow Supracond. Lat. condyle Med. epicon. 4 © 2013 Ken L Schreibman, PhD/MD www.schreibman.info Upper Extremity Trauma Elbow & Forearm Slide 4 of 90 Elbow : 3 Bones [OE ] el “forearm” + bow “bend Humerus Radius Ulna Anatomy Radiographs FOPH BBFF Monteggia Galeazzi Essex-Lop. Fat Pads Peds Elbow Supracond. Lat. condyle Med. epicon. 4 © 2013 Ken L Schreibman, PhD/MD www.schreibman.info Upper Extremity Trauma Elbow & Forearm Slide 5 of 90 Radius Humerus Capitellum Trochlea Lateral Epicondyle Medial Epicondyle [L] “small head” round like a ball [Gr] “pulley” round like a spool Parts of the Humerus Ulna Anatomy Radiographs FOPH BBFF Monteggia Galeazzi Essex-Lop. Fat Pads Peds Elbow Supracond. Lat. condyle Med. epicon. 4 © 2013 Ken L Schreibman, PhD/MD www.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.edu Ulna Coronoid [Gr] “crow’s beak” Corac oid Mandible Coronoid Scapula

Transcript of Upper Extremity Trauma: page 1 of 15 Elbow & …©Ken L Schreibman, PhD/MD 6/4/15 Upper Extremity...

©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.

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© 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

BBFFMonteggiaGaleazziEssex-Lop.

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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

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Upper Extremity Trauma Elbow & Forearm

Slide 4 of 90

Elbow:3 Bones

[OE] el “forearm” + bow “bend”Humerus

Radius

Ulna

AnatomyRadiographsFOPH

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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

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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

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Upper Extremity Trauma Elbow & Forearm

Slide 7 of 90

Olecranon-Trochlea JointHinge JointExtensionFlexion

Posterior view

Anterior view

OlecranonFossa(deep)

CoronoidFossa

(shallow)

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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

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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

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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

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Upper Extremity Trauma Elbow & Forearm

Slide 11 of 90

Elbow Radiographs

www.gocomics.com 3/5/1964 Marty Brownage 15½

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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

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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

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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

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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

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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

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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

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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

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Upper Extremity Trauma Elbow & Forearm

Slide 19 of 90

About to get a nightstick fracture…

Chicago, 1968

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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

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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

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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

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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

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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

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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…

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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

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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

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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.

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© 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

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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

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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

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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

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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

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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

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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

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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

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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:

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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.

4

© 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

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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

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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.

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 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.

Fat PadsPeds Elbow

Supracond.Lat.condyleMed.epicon.

4

© 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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© 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

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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.

4

© 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

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 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.

4

© 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

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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.

4

© 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

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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.

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© 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.

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© 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.

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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 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.

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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.

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© 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

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© 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

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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

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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

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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

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© 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

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© 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

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© 2013 Ken L Schreibman, PhD/MDwww.schreibman.info

Upper Extremity Trauma Elbow & Forearm

Slide 89 of 90

Questions: Forearm/Elbow

rankmytattoos.com

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© 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