radER Vol 1.3

Case 1.3

A 35-year-old man presents to your ED complaining of elbow pain after tripping on a patch of ice and landing on his outstretched hand.  You administer pain medication and obtain the following radiograph:

1. Name 2 abnormal findings on this radiograph?

2. What is the diagnosis?

3. What is the ED treatment and follow up for this patient?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

10 Responses

  1. 1. anterior and posterior fat pads

    2. radial head fracture, occult

    3. Sling, +/- long arm splint, pain control, ortho follow up

  2. 1a) Anterior ‘sail sign’ and 1b) posterior fat pad.
    Normally, on a lateral radiograph of the elbow, the anterior fat pad is seen as a small triangular lucency anterior to the distal humeral diaphysis.With fractures, the joint becomes distended with blood. The anterior fat pad becomes displaced superiorly and outward from the humerus giving the so called “sail sign.” The posterior fat pad is ordinarily not visualized on a lateral radiograph because it is tucked away in the olecranon fossa. The posterior fat pad gets displaced out of the olecranon fossa and becomes visible on the lateral radiograph. However, since the fat pad sign can be seen with any joint effusion, you need to use your head… Trauma generally = fracture.

    2) Radial Head Fracture

    3) The treatment of this fracture depends on the amount of angulation. In minimally angulated fractures (which this is), patients can be treated with immobilization in 90 degrees of flexion for approximately one week. With greater angulation, the fracture is treated with closed or percutaneous reduction. Open reduction is reserved for situations where closed or percutaneous reduction fails. Either way I would make sure that this patient follows up with ortho and give them adequate analgesia.

  3. 1. anterior “sail sign” and posterior fat pad
    2. dx: occult radila head fracture
    3. tx: long arm splint and a call/consult to ortho.

  4. 1.
    a) Posterior Fat Pad Sign
    b) Sail Sign

    2. Joint Capsule Effusion
    In the Setting of Trauma – Intra-Articular Elbow Fracture
    Without Trauma – Bursitis, Infection, Gout, etc.

    3. Assuming Fracture – Splint, Sling, Pain Meds. (Anitbiotics for suspected Open Fracture) & Ortho with Early Mobilization Expected

  5. 1.) -there is a sail sign on this radiograph that you can see with an anterior as well as posterior shadowing around the distal humerus.
    – there is loss of the hour glass sign if you look in the marrow cavity of the humerus.
    – the anterior line of the humerus does not meet halfway through the capitellum, it is more anteriorly displaced.
    -there also seems to be a small fracture in the articulation of the olecrenon where the head of the ulnar bone is.
    2.) The above findings could suggest a displacement of the elbow with fluid/or blood build up in the tissues, but the articulation at the olecrenon does look to be intact. I will say that the findings are more representative of a supracondylar fracture. This is consistent with the mechanism of injury. There may be an associated fracture of the ulna, this is hard to tell without another view.
    3.) I would immobilize the elbow in 90 degrees flexion, probably a long arm splint with sling. Give pain meds and follow up in 2 weeks for further evaluation with ortho. I don’t think I would bother ortho with a consult at this point.

  6. 1. Anteior and posterior fat pad/”sail sign”
    2. Non-displaced radial head fracture
    3. Sling with elbow in flexion, follow up with orthopedics

  7. 1. Anterior and posterior fat pads

    2. Non-displaced supracondylar fracture

    3. Immobilize with splint and follow up with ortho

  8. 1. Anterior/posterior fat pad signs
    2. Radial head fracture.
    3. Sling in flexion, analgesia, elevation, rest, Ortho in one week.

  9. 1) posterior and elevated anterior fat pads
    2) radial head fracture, non-displaced
    3) if minimally displaced, you can place in sling and encourage early mobillization with range of motion exercises. otherwise, splint and have patient be seen by ortho

  10. 1. Posterior & Anterior Fat Pad Sign
    2. Supracondylar Fractrure, Extension Type
    3. Posterior Splint, Orthopedic Consultation

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