Analysis of initial injury radiographs of occult femoral neck fractures in elderly patients: a pilot study

Diagnosis of occult hip fractures by initial radiographs remains challenging in the emergency department. Previously, the gold standard for accurate diagnosis of occult hip fractures was magnetic resonance imaging. This study used initial radiographs obtained in the emergency department to evaluate specific signs and measurements as diagnostic references for occult femoral neck fractures in elderly patients.Initial negative radiographs were reviewed for 2 groups of patients: a group with occult femoral neck fractures (n=16) and a group without fractures (n=32). Reviews of initial radiographs and all imaging studies were performed by a senior orthopedist (C-C.C.) and a radiologist (H-T.W.). Diagnostic signs included lateral, medial, anterior, and posterior signs; measurements included elevation of the fat pad and external rotation of the femur. The prevalence of occult femoral neck fracture was 3.3%. Initial radiographs of occult femoral neck fractures were not routinely negative; 14 (87.5%) of 16 patients with fractures had at least 1 radiographic sign. Using the positive lateral or posterior sign as the diagnostic reference, the sensitivity was 0.875 and the specificity was 0.906. When elevation of the fat pad was ?1.5 mm, the sensitivity was 0.867 and the specificity was 0.857 for the diagnosis of occult femoral neck fracture.The lateral and posterior signs and elevation of the fat pad ?1.5 mm on initial radiographs are recommended as diagnostic references for occult femoral neck fracture. These references are clearly defined and may offer important information for all clinicians and radiologists in the emergency department.     

Abnormal scaphoid fat pad: is it a reliable sign of fracture scaphoid.

In a retrospective study, initial radiographs of 40 proven cases of scaphoid fractures and 40 cases where fractures of scaphoid were eventually excluded were examined in a 'blinded' fashion. In none of these radiographs was a fracture line demonstrated by people who did not know the outcome. In 4 patients with proven fracture, normal scaphoid fat pads were demonstrated; a 10% 'false negative' result and in 9 patients without fracture, abnormal scaphoid fat pads were seen; a 23% 'false positive' result. The authors conclude that the scaphoid fat pad sign is a poor predictor of scaphoid fracture, even though a positive scaphoid fat pad sign indicates that an underlying fracture is likely.     

Ultrasound diagnosis of supracondylar fractures in children

Purpose

The objective of our study was to evaluate the safety and accuracy of ultrasound (US) compared to standard radiographs in diagnosing supracondylar fractures (SCFs) of the humerus in children.

Patients and methods

A total of 106 children (aged between 1 and 13 years) with clinically suspected SCF of the humerus were primarily examined by US followed by standard two-plane radiographs of the elbow. US was conducted with a linear scanner viewing the distal humerus from seven standardized sectional planes. US fracture diagnosis was established either by a cortical bulging or cortical gap, or by a positive dorsal fat pad (dFP) sign. X-ray diagnosis was stated by an independent pediatric radiologist and, afterwards, compared to our US findings. Sonographic and radiographic findings were collected in a contingency table. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for US fracture diagnosis were calculated according to the radiographs. In addition, by identifying significant angulation and/or disrupture, SCFs were classified as non-operative/stable and operative/instable SCFs according to the AO Pediatric Fracture Classification System.

Results

By US, a SCF could be excluded in 43 patients and in 63 patients, a fracture was diagnosed. In contrast, by radiographs, an SCF could be excluded in 46 patients and in 60 patients, a fracture was diagnosed. For US fracture diagnosis in comparison to radiographs, we calculated a sensitivity of 100 %, a specificity of 93.5 %, an NPV of 100 %, and a PPV of 95.2 %. Thirty-nine SCFs were sonographically classified as stable grades 1/2 SCFs and confirmed in 37 patients by X-rays. All four operative/instable SCFs were correctly identified by US.

Conclusion

By identifying a positive dFP sign and/or cortical lesions of the distal humerus, SCFs can be detected very sensitively by US. Even the estimation of fracture displacement seems to be possible. We suggest US as an applicable alternative method in the primary evaluation of suspected SCF in children, guiding further diagnostics, where appropriate. After minor injuries, if clinical assessment for an elbow fracture is low and US examination is negative for fracture, additional radiographs are dispensable. Thereby, the amount of X-ray burden during childhood can be reduced, without loss of diagnostic safety.     

Musculoskeletal Ultrasound in Pediatric Trauma

Abstract Background and Purpose: The radiologic evaluation of musculoskeletal injuries in young children is difficult due to the absent ossification of several secondary ossification centers, which therefore cannot be seen directly on plain radiographs. When relying on conventional radiographs, even severe cartilaginous or soft tissue injuries cannot be visualized, as there is no possibility to differentiate them from bruises or sprains. It is the aim of this review to present clinically relevant applications of ultrasound imaging in pediatric musculoskeletal trauma. Methods: Currently used ultrasound techniques for evaluation of typical pediatric fractures or joint dislocations, techniques for differentiation between stable and unstable intraarticular fractures, the use of sonography for monitoring reduced bone length in long bones after fracture, sonographic guidelines for evaluation of tendon injuries or lesions, and sonographic imaging techniques in arthritis and osteomyelitis are described. Conclusion: Musculoskeletal sonography—despite its inability to view through intact cortical bone and its accuracy being dependent on skill and experience of the investigator—provides important information about soft tissue, bony or cartilaginous injuries in children.     

Elbow fat pad sign: implications for clinical management.

The significance of the radiological fat pad sign indicating elbow joint effusion after trauma when a fracture is not visible remains controversial. This retrospective analysis of 45 cases examines the need for routine repeat radiography at 2-week review. At follow-up, 29 had normal repeat radiographs, two had undisplaced radial head fractures, three had no radiographs but were clinically well and 11 failed to attend. The incidence of fracture in those having repeat radiography was 6%. We conclude that routine repeat radiography is unnecessary.     

The posterior fat pad sign in association with occult fracture of the elbow in children.

BACKGROUND: An elevated posterior fat pad visible on a lateral radiograph of a child's elbow following trauma is generally considered to be suggestive of an intracapsular fracture about the elbow. However, in previous studies, the prevalence of fracture in elbows with an elevated posterior fat pad and no other radiographic evidence of fracture has ranged from only 6 percent (two of thirty-one) to 29 percent (nine of thirty-one). We are not aware of any prospective studies, limited to children, on the value of an elevated posterior fat pad as an indicator of an occult fracture about the elbow. While it is common practice to manage children who have radiographic evidence of an elevated posterior fat pad as if they have a fracture, scientific evidence for this approach is lacking. METHODS: Forty-five consecutive children who had an average age of four and a half years, a history of trauma to the elbow, and an elevated posterior fat pad without other radiographic evidence of a fracture were enrolled in the study. At an average of three weeks after the injury, anteroposterior, lateral, and two oblique radiographs were made and evaluated for evidence of fracture-healing. If there was evidence of new-bone formation on any of these four radiographs, it was considered to indicate a fracture of the elbow. RESULTS: Thirty-four (76 percent) of the forty-five patients had evidence of a fracture. Eighteen (53 percent) of the thirty-four had a supracondylar fracture of the humerus; nine (26 percent), a fracture of the proximal part of the ulna; four (12 percent), a fracture of the lateral condyle; and three (9 percent), a fracture of the radial neck. CONCLUSIONS: This prospective study demonstrated that the posterior fat pad sign was predictive of an occult fracture of the elbow following trauma in thirty-four (76 percent) of forty-five children who had no other evidence of fracture on anteroposterior, lateral, and oblique radiographs after the injury. This finding is in contrast to those of previous studies, in which the highest prevalence of fracture in elbows with an elevated posterior fat pad and no other radiographic evidence of fracture was 29 percent (nine of thirty-one elbows). Our results support the practice of managing children who have a history of trauma to the elbow, an elevated posterior fat pad, and no other radiographic evidence of fracture as if they have a nondisplaced fracture about the elbow.     

The usefulness of ultrasound and the posterior fat pad sign in pulled elbow

IntroductionA pulled elbow is a common cause of acute elbow pain that is generally managed by a reduction maneuver without radiographic examination. However, children with atypical presentation with no history of abrupt longitudinal traction should undergo elbow imaging. This study aimed to investigate plain radiography findings and determine the usefulness of ultrasonography (US) in atypical pulled elbow.Materials and methodsWe retrospectively reviewed the medical records and images of 37 (22 males) consecutive patients with pulled elbow who presented with an atypical history or failed reduction between April 2015 and September 2018. Mean age at presentation was 4.34 years (range, 1.25–9.5 years). Of the 37 elbows, 20 were left elbows. The injury mechanism, incidence of the posterior fat pad sign on plain radiographs, and characteristic US findings, pre- and post- reduction, were investigated.ResultsThe original mechanisms of injury included slipping (n = 14), rolling over the arm (n = 7), vague history (n = 6), falling down (n = 6), abrupt longitudinal traction (n = 2), and direct injury (n = 2). On plain radiographs, six of the 37 elbows (16%) showed the posterior fat pad sign. Before the reduction, an entrapped supinator, a pathognomonic sign of pulled elbow, was identified on US in all cases. After reduction, the characteristic US findings showed a disentangled and swollen supinator (100%) and restored annular ligament (100%) in all successful cases. Although a click was not felt in three cases, the reductions were considered successful because the annular ligament was restored on US with free elbow motion.ConclusionPulled elbow may be caused by atypical mechanisms of injury, such as slipping and rolling over the arm. Clinicians should be aware of the possibility of the posterior fat pad sign on plain radiographs of pulled elbow to prevent unnecessary immobilization. In such circumstances, US is a useful method for detecting an entrapped supinator and confirming adequate reduction via restoration of the annular ligament in children with atypical pulled elbow.     

Subcapital femoral neck fracture following successful trochanteric fracture treatment with a dynamic hip screw: a report of five cases

A subcapital femoral neck fracture complicating a healed trochanteric fracture is rare. Such cases are managed in a rather heterogeneous manner, i.e. there exists a mixture of cases treated by either fixed angle devices or dynamic compression screws. We describe 5 patients who developed subcapital femoral neck fractures after healed trochanteric fractures treated with dynamic compression screws. The subjects' clinical data, operative records, and radiographs have been studied retrospectively and the literature reviewed. The risk factors for such a complication include being of advanced age, female, osteoporotic, and having a small femoral head and neck, and a basicervical type of fracture.     

Subcapital fractures associated with extensive osteonecrosis of the femoral head

The authors reviewed 10 patients with subcapital fractures associated with extensive osteonecrosis of the femoral head and distinguished these fractures from traumatic femoral neck fractures The mean age of the patients was 52 years (range, 36-68 years). Nine patients were younger than 60 years. Eight patients had risk factors for osteonecrosis. Necrosis was extensive and involved nearly the whole femoral head. Fracture occurred at the junction between a necrotic bone and reparative bone and extended downward through the reparative interface to the healthy inferior cortex of the femoral neck. Patients experienced hip pain that was aggravated gradually during a period of 1 to 24 weeks before diagnosis of the fracture. In all patients, the opposite femoral head was involved with osteonecrosis. In two femoral heads, slight collapse or subchondral fracture (crescent sign) also was observed. No patient had a history of precipitating trauma. In patients younger than 60 years with a subcapital fracture, fracture associated with extensive osteonecrosis of the femoral head should be suspected when a history of trauma is not obvious, when the opposite hip shows findings of osteonecrosis, and when the patient has a risk factor of osteonecrosis. In these fractures, osteosynthesis rarely should be considered because of the high failure rate caused by additional progression of extensive osteonecrosis and the probability of nonunion.     

Standard radiographs and computed tomographic scan underestimating pediatric acetabular fracture after traumatic hip dislocation: report of 2 cases

Posterior wall acetabular fractures are rare in the pediatric patient but require proper management to prevent significant complications. Plain radiographs and computed tomography scans are standard diagnostic imaging used with clinical examination of hip stability to determine if the injury requires open reduction and internal fixation. Two cases are presented of adolescent traumatic hip dislocations and posterior wall fractures in which radiography underestimated the extent of the posterior wall fracture. In one case, a magnetic resonance imaging study more clearly characterized the injury. Because the ossification of the posterior wall occurs throughout adolescence, magnetic resonance imaging may be a useful tool in characterizing these fractures and assisting with surgical planning.     

Fat suppression imaging in epidural lipomatosis: case report

A case of epidural lipomatosis associated with steroid use in rheumatoid arthritis is presented to describe the role of fat suppression imaging as a diagnostic tool. The plain radiographs revealed several vertebral compression fractures and the magnetic resonance imaging (MRI) showed a large extradural mass. A fat suppression MRI was obtained, which confirmed the diagnosis of epidural lipomatosis. A fat suppression MRI scan is a special imaging technique that is used in particular to either suppress the signal from adipose tissue or detect adipose tissue. An MRI scan is the imaging tool of choice to examine soft tissue lesions of the spine, and fat suppression imaging will provide additional information about any fatty soft tissue lesion, as in the case of epidural lipomatosis. This imaging modality is particularly useful in those patients who are morbidly obese or taking exogenous corticosteroids, because these conditions can proliferate adipose tissue leading to epidural lipomatosis.     

Osteochondral fractures of the dome of the talus

Twenty-four patients who had an osteochondral fracture of the dome of the talus were examined by plain radiography, magnetic resonance imaging, computerized tomography, and, when indicated, scintigraphy. When plain radiographs of the ankle are relied on for the diagnosis of an osteochondral fracture of the talus, many lesions remain undiagnosed. Stage-I osteochondral fractures show no diagnostic changes on plain radiographs, and Stage-II lesions are usually subtle and, therefore, are often overlooked by both radiologists and clinicians. The use of scintigraphy as a screening procedure and of magnetic resonance imaging for patients who have positive scintiscans showed that osteochondral fractures are more common than has previously been indicated in the literature. Scintigraphy should be used to assess patients when there is clinical suspicion of an osteochondral fracture but the plain radiographs appear to be negative. Patients who have positive scintiscans should be assessed by magnetic resonance imaging. Patients who have abnormal plain radiographs will derive no major benefits from magnetic resonance imaging; for all but one of these patients, computerized tomography was adequate for staging the fracture.     

The value of T1-weighted coronal MRI scans in diagnosing occult fracture of the hip

A delay in establishing the diagnosis of an occult fracture of the hip that remains unrecognised after plain radiography can result in more complex treatment such as an arthroplasty being required. This might be avoided by earlier diagnosis using MRI. The aim of this study was to investigate the best MR imaging sequence for diagnosing such fractures. From a consecutive cohort of 771 patients admitted between 2003 and 2011 with a clinically suspected fracture of the hip, we retrospectively reviewed the MRI scans of the 35?patients who had no evidence of a fracture on their plain radiographs. In eight of these patients MR scanning excluded a fracture but the remaining 27 patients had an abnormal scan: one with a fracture of the pubic ramus, and in the other 26 a T(1)-weighted coronal MRI showed a hip fracture with 100% sensitivity. T(2)-weighted imaging was undertaken in 25?patients, in whom the diagnosis could not be established with this scanning sequence alone, giving a sensitivity of 84.0% for T(2)-weighted imaging. If there is a clinical suspicion of a hip fracture with normal radiographs, T(1)-weighted coronal MRI is the best sequence of images for identifying a fracture.     

Talus Fracture of the Medial Tubercle of the Posterior Process: Interposition of the Flexor Hallucis Longus Tendon

Talus fracture of the medial tubercle of the posterior process is rare. This type of fracture can be easily missed, because it is difficult to identify on plain radiographs of the ankle. Oblique radiographs with external rotation, computed tomography, and magnetic resonance imaging (MRI) of the ankle are useful for making an accurate diagnosis. However, even with an early diagnosis, the treatment guidelines for talus fractures of the posterior medial tubercle have not yet been established. The flexor hallucis longus (FHL) tendon, which passes through the groove between the medial and lateral tubercles of the posterior process of the talus, can interpose between the fracture sites and interrupt fracture reduction. MRI might be the best imaging modality for the identification of the interposed FHL tendon. We report a case in which talus fracture of the posterior medial tubercle was treated by open reduction and internal fixation owing to an interposed FHL tendon that was confirmed by MRI. MRI is the recommended imaging study of choice for talus fractures of the posterior medial tubercle owing to the possibility of an interposed FHL tendon.     

The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures

BACKGROUND: Computed tomographic (CT) scanning is sensitive in detecting pelvic fractures in the pediatric patient. Pelvic fractures in the pediatric population rarely require emergent intervention, thus providing time to obtain the optimal imaging study. The objective of this study was to compare pelvic radiographs and abdominal pelvic CT scans of all pediatric trauma patients with pelvic injury to determine the role of pelvic imaging in the immediate trauma resuscitation. METHODS: A retrospective review was performed of pediatric patients (age < 18 years) with a pelvic fracture identified from the registry of a Level I pediatric trauma center for the period 1993 to 2001. Patients with a documented pelvic injury and both a pelvic CT scan and pelvic radiograph available for review were extracted for analysis. For this study, all films were re-reviewed by an attending pediatric radiologist, and the abnormalities were categorized by the area of injury. The data were comparatively analyzed according to the area of injury and the soft tissue findings. RESULTS: For the 8-year period, 130 pediatric patients with a pelvic fracture were identified, including 103 patients with both a pelvic CT scan and radiographs. Of the 151 fractures identified by pelvic CT scan, 81 were also identified by the pelvic radiograph (54%). There were 38 soft tissue hematomas noted by pelvic CT scan and only 2 identified by the pelvic radiograph. The greatest discrepancy was noted in comparison of the sacral region (16 abnormal pelvic CT scans vs. 3 abnormal radiographs); the least discrepancy was noted in the evaluation of the hip (6 abnormal pelvic CT scans vs. 5 abnormal radiographs). CONCLUSION: The pelvic radiograph lacked the sensitivity of the pelvic CT scan for detecting pelvic fractures in all anatomic areas evaluated. Pelvic CT scan also offers additional information regarding soft tissue injury not available on most pelvic radiographs. In the trauma patient that will undergo abdominopelvic CT scanning as part of the trauma evaluation, a pelvic radiograph may be superfluous. Screening pelvic radiography should be reserved for the rare unstable patient or the patient in whom an abdominopelvic CT scan is not otherwise indicated.     

Fettpolsterzeichen und Supinatorfettlinie bei Kubitaltraumen

The fat pad sign and the supinator fat line (SFL) are valuable diagnostic aids in the evaluation of bony cubital injuries. A total of 377 lateral X-rays of the elbow joint-including 121 fractures-were investigated. The supinator fat line exhibited bar-like and bird-like configurations in 55.9% and 41.8% of healthy test subjects, respectively. In the presence of a fracture, a wavy configuration, directed downwards from, or running parallel to, the upper edge of the radius, was seen in 95% of the cases. If in the event of an injury to the elbow a wavy configuration is seen in association with a positive anterior and/or posterior fat pad sign, bony involvement of the joint-forming elements may justifiably be suspected.     

Treating Displaced Distal Forearm Fractures in Children

Abstract Purpose:  Distal forearm fractures are among the most common fractures in children. In the past few years the option of percutaneous pinning has gained more attention in the treatment of unstable fractures. However, it remains unclear in which cases a fracture or its reduction should be considered unstable. Study Design:  In order to evaluate which type of fractures profit most from additional pinning after closed reduction, we performed a retrospective analysis of 225 consecutive cases using the recently published AO pediatric classification of long bone fractures. Results:  After closed reduction, position in the cast was lost in 23% of the cases. The proportion of unstable reductions was much higher in completely displaced fractures. The amount of dislocation was more important than the type of fracture according to the AO classification proposal. Conclusions:  Fully displaced fractures should always be reduced in a setting with pins immediately available. If anatomical reduction cannot be achieved, pinning is advocated. The AO proposal for pediatric long bone fracture classification could be a useful tool to render the diverse studies more comparable. However, the important feature of complete versus subtotal displacement is lacking.     

Fractures of the anterior process of the calcaneum; a review and proposed treatment algorithm

BackgroundThere remains a lack of recognition of these fractures, which leads to a delay in diagnosis and appropriate management.MethodsA comprehensive literature search was performed. Following inclusion and exclusion criteria, 23 studies were available for analysis.ResultsDelay in diagnosis is common and has a negative impact on outcome. If an APC fracture is suspected; anteroposterior, lateral and oblique plain radiographs should be requested. Further investigation with computed tomography or magnetic resonance imaging is indicated if plain radiographs are inconclusive and patient remains symptomatic. Non-operative measures are usually adequate for most undisplaced fractures, however surgical intervention maybe required for large, intra-articular fractures in the acute setting and for non-union.ConclusionsA treatment algorithm is suggested that may help with the diagnosis and management of these injuries.Level of evidenceLevel IV.     

Elbow Fractures in Children: Diagnosis and Management

Fractures about the elbow are very common in children, but the anatomy of the child's elbow may make the diagnosis less obvious than in a mature skeleton. An understanding of the ossification and fusion of the secondary growth centers about the elbow is essential to avoid overlooking these injuries and to optimize treatment. If plain radiographs are equivocal, an arthrogram of the elbow may clarify the anatomy and diagnosis. Early neurologic and vascular complications are not uncommon and must be recognized before fracture reduction. Many late complications, such as malunion, osteonecrosis, and physeal bridging, are largely preventable by correct early diagnosis and treatment. Anatomic reduction of articular surfaces, restoration of physeal anatomy, and near-anatomic alignment of fracture fragments in the frontal plane are the corner-stones of successful treatment of pediatric elbow fractures.     

Subcapital hip fractures: the Garden classification should be replaced, not collapsed.

OBJECTIVES: To evaluate rater agreement for a simple 2-category classification of subcapital hip fractures versus the 4-category Garden classification and to determine the effect of clinician experience on the level of agreement. SETTING: Sunnybrook and Women's Health Sciences Centre, Toronto, a level 1 trauma centre. METHOD: Eleven raters, with varying levels of clinical experience (3 fellowship-trained orthopedic surgeons, 4 clinical fellows and 4 residents), classified 34 pairs of anteroposterior and lateral radiographs of patients with subcapital hip fractures according to whether the fracture was stable (the fragments move as a unit) or unstable (the fragments move independently), and according to Garden's original 4-category classification. The exercise was repeated 1 month later. The radiographs were obtained from a fracture database to represent a wide spectrum of injury severity. OUTCOME MEASURES: The level of agreement beyond chance, quantified by use of the SAV statistic of O'Connell and Dobson. RESULTS: The most experienced raters demonstrated almost perfect inter- and intrarater agreement with respect to stable and unstable fractures (SAV > 0.80). The raters demonstrated only fair agreement for the Garden classification (mean SAV 0.64). Even junior clinicians demonstrated substantial agreement regarding fracture stability, with much lower scores for the Garden classification. Collapsing the Garden classification responses into 2 categories (stages I and II v. III and IV) was not synonymous with rater categorization of stable versus unstable. CONCLUSION: The Garden classification for subcapital hip fractures is unreliable and should be abandoned in favour of categorizing fractures as stable versus unstable.