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Bike accident - September 13, 2005 6:52:00 AM   
Alex Brenner PT MPT OCS

 

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37 year old female fell from her bike and landed on outstretched arm. She has wrist and elbow pains. She was released from local ER with only wrist x-rays which were normal. She was referred to PT for rehab. She complains of global elbow pain and elbow films were ordered. What are the findings? (one elbow view was intentially left out)



< Message edited by Randy J Moore -- July 22, 2007 11:13:46 PM >


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Alex Brenner, PT, MPT, OCS
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Re: Bike accident - September 13, 2005 8:52:00 AM   
ehanso

 

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Alex, Welcome back. I hope your knee is mending.
Elbow films have always been a bit of a mystery to me so I will leave the interpretations to those more knowledgable. Ed

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Re: Bike accident - September 13, 2005 9:06:00 AM   
JLS_PT_OCS

 

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I can see her posterior fat pad, so I know she's got a fracture. I would definitely get her to an Orthopedist right away.
My PT eyes see a fracture of capitulum. In an adult with trauma, radial head is first on my mind, but I don't see it visualized here. (of course the oblique view is required for the radial head, so I guess if you left that out, that might be the cincher on the dx).

I have to admit, I'm not that good at elbow films, I don't see the films often. I know enough to look for fat pad sign and to suspect the radial head.... :)
J

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Re: Bike accident - September 13, 2005 9:22:00 AM   
SJBird55

 

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How come I don't see a fat pad? I don't see anything that concerns me in those views.

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Re: Bike accident - September 13, 2005 9:44:00 AM   
JLS_PT_OCS

 

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Look for the dark area between the posterior distal humerus and the muscle bulk. See how it shows up as if it were air?
My opinion is that it's the posterior fat pad sign in this patient. It gets displaced upward with trauma and is visible that way.
J

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Re: Bike accident - September 13, 2005 10:50:00 AM   
SJBird55

 

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LOL It's all dark on this screen.

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Re: Bike accident - September 13, 2005 1:06:00 PM   
UTDC

 

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I agree with Jason 100%, except for the cpaitulum- I don't see an abnormality. Radial head fracture is most likely.

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Re: Bike accident - September 13, 2005 7:40:00 PM   
jma

 

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Yes, the fat pad is visible. Isn't there another name for it. I heard of something with a triangle in it but I forget if it is related to the elbow. An orthopedist should be consulted here.

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Re: Bike accident - September 13, 2005 7:42:00 PM   
UTDC

 

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jma, it is also called "sail sign"- usually when anterior and posterior pads are visible

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Re: Bike accident - September 13, 2005 7:55:00 PM   
jma

 

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Thanks for the tip. Never heard of that particular name but it does make sense. From my radiology book, they mention a postive fat pad sign.

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Re: Bike accident - September 14, 2005 12:08:00 AM   
FLAOrthoPT

 

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here are some good sites related to this post:
http://www.gentili.net/signs/11.htm
http://www.gentili.net/signs/66.htm

ok good night
Ben

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Re: Bike accident - September 14, 2005 7:23:00 AM   
SJBird55

 

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I see it in Ben's. I wonder if computer screens are different?

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Re: Bike accident - September 14, 2005 11:49:00 AM   
Dr.Wagner


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EVERYONE would have missed this xray, including myself unless she had point tenderness, and if so she STILL would have gone home with ortho follow up.
From my vantage, the anterior humeral line looks good and the radiocapitellar line looks good, making this soooo subtle that if it was in front of you, one would respond "well, it is difficult to say, have it re-evaluated by orthopedics in 2 days" unless there were pronounced physical findings.

This is using the retrospectroscope...if placed in a pile of normal films, this would be missed. In fact, this is so mild the radiologist would hedge on this unless a history was given to them.

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Re: Bike accident - September 14, 2005 12:11:00 PM   
JLS_PT_OCS

 

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So, Wags, what's your call on this?

Do you see the fat pad sign(s) and/or capitulum fx that I do?
Give me some education here, god knows I could use it, as I rarely see these...
Thanks.
J

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Re: Bike accident - September 14, 2005 12:33:00 PM   
UTDC

 

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Wags,
I'm surprised to hear you say this. I have always considered a fat pad at the elbow to be a fracture until proven otherwise. I hear what you are saying about the need for clinical correlation, but the fat pad in itself is an abnormal finding. I assume what you are saying is that the patient would be put in a brace/splint and advised to follow-up with ortho?

Jeff

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Re: Bike accident - September 14, 2005 2:02:00 PM   
chiroortho

 

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Wow am I going to go against the tide here but the fat pad sign says one thing: hemarthrosis. This is not = fracture. Looking at the films there is NO fracture. This is what Alex asked.

It may be an atypical radial head fracture (in that the sail sign is absent) but more likely a small fracture in an unexpected place.

Honestly my guess would be no fracture at all. How's that for taking a position? If I were doing rounds in ortho and Dr. Wagner was my attending (with all facts in hand) he'd be shaking his head but I stand behind my position.

We shall see.

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Greg Priest, DC, DABCO

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Re: Bike accident - September 14, 2005 4:46:00 PM   
UTDC

 

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Hey Greg,
Given the fact that this is an elbow as opposed to a knee, IMHO I think that you could say that hemarthosis does = fracture and be correct 99% of the time. (my own statistic)

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Re: Bike accident - September 14, 2005 9:04:00 PM   
chiroortho

 

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Yes Jeff you're right.

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Re: Bike accident - September 14, 2005 9:23:00 PM   
jma

 

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Hopefully, the image intentionally left out will shed more light into whats going on in the elbow.

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Re: Bike accident - September 14, 2005 10:22:00 PM   
FLAOrthoPT

 

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oh this is an elbow?!

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