New diagnostic and therapeutic possibilities in the treatment of elbow and distal forearm fractures in childhood
Authors: Varga Marcell 
Published: September 2019

Fractures of the elbow and distal forearm are among the most frequent injuries in children. The spectrum of these injuries is very wide from small contusions without clinical consequences to severely displaced fractures with limb threatening conditions. Primary diagnosis and treatment are often performed by emergency physicians, general practitioners or paediatric surgeons. Indications of unnecessary imaging procedures, under- and over-treatment may occur by less-specialised healthcare personnel. Recognizing certain elbow fractures may be a challenge even for an experienced orthopaedic surgeon due to the special characteristics of childhood. Certain distal forearm and elbow fractures may not be detected by conventional X-rays. The evaluation of severely displaced distal radius fractures and setting up a plan for further treatment may be particularly difficult due to the lack of therapeutic consensus. In recent years, there have been a growing evidence that musculoskeletal ultrasound (MSK-US) can increase the effectiveness of diagnostics and may reduce the number of unnecessary X-rays. Elastic intramedullary nailing of displaced distal radius fractures may have many advantages over traditional percutaneous pinning techniques. Intraoperative musculoskeletal sonography (IoP MSK- US) can further increase the safety of these interventions. The aim was to prove the efficacy of a standardised five-point sonographic screening method of paediatric elbow fractures. US examinations were executed by orthopaedic surgeons in an emergency trauma centre. In a prospective diagnostic study, we investigated a standardised two-point method in the differential diagnosis of paediatric pulled elbow. We developed an objective, point of care imaging method for confirming or ruling out pulled elbow.We aimed to prove the diagnostic effectivity of ultrasound in distal paediatric forearm fractures in a prospective, two-centred study with large number of patients. Examinations were executed by orthopaedic and paediatric surgeons. We also aimed to investigate the diagnostic difference of US in radial fractures with different clinical consequences.We have developed a new operative method for severely displaced distal paediatric radial fractures. In our retrospective study we analysed the results of our technique, which is a stable, physis sparing osteosynthesis with a reduced period of necessary cast immobilization. We introduced a new ultrasound-assisted intraoperative aiming method for the ESIN technique of paediatric radius fractures. The aim of the procedure was to reduce the risk of EPL tendon injury during dorsal entry elastic nailing. This was an observational diagnostic study.Conclusions:US is an effective diagnostic modality in the screening of distal paediatric forearm fractures. US shows the same diagnostic efficacy as X-rays in the exact identification of fractures without displacements and angulated greenstick fractures. Occult radius torus fractures in children may be detected more accurately by US. US can detect unstable and severely displaced distal forearm fractures, but X-rays are mandatory for exact fracture identification and therapeutic plan. Paediatric elbow fractures can be screened by point of care ultrasound Using five standardized US planes increases the diagnostic efficacy of paediatric elbow fractures. Occult paediatric elbow fractures can be detected by US In younger children US may give more accurate information about the exact nature of the fracture than X-rays. The differential diagnosis of pulled elbow can be safely confirmed by a standardized twoplanes US method. Short intramedullary elastic nailing may be an alternative to percutaneous pinning in the treatment of severely displaced paediatric distal metaphyseal fractures. Using short intramedullary nailing in distal paediatric forearm fractures there is a need only a short cast for one or two weeks postoperatively. Intraoperative sonography may reduce the risk of extensor pollicis longus tendon injury during dorsal entry elastic intramedullary nailing of the distal radius.