6-year-old Evan fell from monkey bars at the park. He is seen in urgent care with complaints of left elbow pain. He doesn’t want to move his arm. There is some swelling around his left elbow and it is very tender to palpation. His left arm is neurovascularly intact and there are no other obvious injuries.
On the first x-ray obtained, the provider was unable to visualize an anterior fat pad (see photo) due to Evan’s elbow being bent at a sharp angle during the x-ray. Evan was sent back for another lateral elbow x-ray to improve visualization of the anterior fat pad. Why was this important?
The provider knew that a poorly done lateral elbow x-ray could obscure a fracture injury. A large anterior fat pad or any posterior fat pad on an elbow x-ray means that there is swelling in the joint. With this sign, a fracture is present in 70% of anterior fat pad cases and in 90% of posterior fat pad cases.
Evan had a type 1 supracondylar fracture (upper arm bone). His arm was immobilized in a long arm posterior splint. The physician ordered follow-up in 10 days with his PCP or ortho for repeat imaging to confirm the diagnosis and get him the appropriate referral.
Making the effort to obtain high-quality imaging is usually always a good idea when it comes to ruling out fractures!
Source: 2022 EM lecture by Ilene Claudias, MD