Radiology Corner – The Case of Elbow Pain

By: Terry R. Yochum, DC, DACBR, Fellow, ACCR and Michael S. Barry, DC, DACBR

History

This adult female patient fell on a hyperextended elbow and wrist while jogging. There is considerable restriction in range of motion of the elbow with localized elbow pain. What do you see?

Figure 1. What do you see?

Figure 1. What do you see?

Diagnosis

There is a vertical fracture line extending through the articular surface of the radial head with minimal offset of the articular contour. Observe the slight lateral displacement and offset of the cortex of the lateral edge of the metaphysis of the radius.

Discussion

General Considerations

Fractures of the radial neck and head are the most common fractures of the adult elbow, accounting for approximately 50% of all injuries to this region. In children and adolescents, the incidence is significantly lower, with a frequency of approximately 15%. The majority of proximal radius fractures are due to a fall on an outstretched hand, transmitting a longitudinal axis of force to create impaction of the radial head into the capitellum. An incomplete fracture of the radial head which extends from the center of the articular surface for approximately 10 mm, is called a “chisel” fracture. In the presence of a positive fat-pad sign if a fracture is not identified, specific radial head views may demonstrate a fracture of the radial head.

Radial head fracture. The fracture line may be subtle and easily overlooked, so the observer must search for the various signs that indicate an occult fracture:

  • Fracture line. A radiolucent line is seen usually oriented vertically and penetrating the articular cortex toward the lateral side of the head.
  • Cortical disruption. At the fracture site, the cortex will be broken.
  • Cortical deformity. At the fracture site, a sharp step-off or angulation is common, due to fragmental displacement. Depression of the fracture fragment may produce a “double cortical” sign, which is seen as a linear opacity paralleling the normal articular cortex of the radial head.
  • Altered supinator fat line. On a normal lateral film, a linear radiolucent line representing the outer fascial plane of the supinator muscle, 1 cm above the anterior radial surface, will be observed. In fractures of the radial head or neck the fat line may be obliterated, blurred, or ventrally displaced by more than 1-2 cm.
  • Fat-pad sign. A useful sign of an intra-articular fracture of the elbow is the clear depiction of displaced humeral capsular fat-pads. In the normal elbow a layer of fat (“fat-pad”) lies between the synovial and fibrous layers of both the anterior and posterior joint capsule. In the lateral projection of the normal elbow the anterior fat-pad is seen as an obliquely oriented radiolucency. When acute intracapsular swelling is present from any origin (hemorrhagic, inflammatory, or traumatic), the anterior fat-pad is elevated to be oriented horizontally, while the posterior fat-pad will now be visible (“fat-pad” sign). In joint distentions the elevated fat-pads, especially anteriorly, may be obliterated due to hemorrhage or edema; therefore, the posterior fat-pad, when visible, is the most reliable sign of intraarticular effusion. In children and adolescents, 90% of posterior fat-pad signs will have an associated fracture. In adults the sign is less frequently seen, and its absence does not exclude the presence of a fracture.

Radial neck fracture. The most common fracture is an impaction at the junction of the head and neck. The only sign may be a sharpened angle on the anterior surface, best described on the lateral projection. Complete fractures will be readily seen as a transverse lucent line with varying degrees of displacement. A comminuted fracture of the radial head in combination with dislocation of the distal radioulnar joint is called an Essex-Lopresti fracture.

References

  1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, 2nd ed. Baltimore, MD: Williams & Wilkins, 1996.

 

About the Authors

Dr. Terry R. Yochum is a second generation Chiropractor and a cum laude graduate of the National College of Chiropractic, where he subsequently completed his radiology specialty. He is a Diplomate of the American Chiropractic Board of Radiology and served as its vice-president and president for seven years (1983-1990).

Dr. Michael S. Barry is a 1988 cum laude graduate of Palmer College of Chiropractic. He completed a three-year radiology residency at Logan College of Chiropractic following two years of clinical practice in Las Vegas, Nevada. He received his diplomate in radiology from the American Chiropractic Board of Radiology in 1992.