Joined: March 1, 2004
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 >
Joined: January 31, 2005
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
Joined: January 31, 2005
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
Joined: January 25, 2003
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.
Dr. Wagner DO Moderator of Medical Complexity Forum
Joined: December 22, 2003
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?
Joined: February 19, 2004
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.