Radial head fractures may occur in conjunction with ulnar shaft fracture (Monteggia equivalent) Associated fractures are common, including capitellum, olecranon, and lateral humeral condyle, as well as dislocation of the distal radioulnar joint When the diagnosis is uncertain, oblique, radiocapitellar, and comparison views may be useful in addition to standard AP and lateral radiographs Patients with radial head and neck fractures may complain of wrist pain but have focal tenderness to palpation over the anatomic location of the injury Injury may be associated with trauma to the posterior interosseous nerve FIGURE 111.22 Nondisplaced fracture of the olecranon in an 8-year-old boy (bottom arrow ) Note the elevated fat pads (top arrows ) Radial neck fractures are far more common in children than fractures of the radial head, which tend to occur primarily in skeletally mature individuals The cause of injury is typically a fall onto an outstretched, supinated arm On examination, tenderness overlying the proximal radius strongly suggests the diagnosis, although it is worth noting that patients occasionally present with pain referred to the wrist ( Fig 111.23 ) The most common fracture pattern extends through the physis with a metaphyseal fragment (Salter–Harris type II) or through the neck proper (3 to mm distal to the epiphyseal plate) Elbow imaging may also reveal a posterior fat pad on the lateral view if a hemarthrosis is present; however, when the metaphysis alone is injured, a hemarthrosis may be absent and the fat pads normal In addition, attention should be paid on radiographs to the radiocapitellar line to pick up subtle displacement of the radius Radial neck fractures with less than 30 degrees of angulation should be immobilized in an above-the-elbow cast at 90 degrees of flexion Greater degrees of angulation require closed reduction FIGURE 111.23 Buckle fracture of the radial neck in a 9-year-old girl (arrow ) Wrist pain was the chief complaint The treating physician failed to identify the proximal radial fracture, which was, however, noticed by the radiologist Radial head fractures, by contrast, are less common before skeletal maturity When they occur, there is risk of progressive subluxation, requiring orthopedic follow-up Operative treatment is considered for displacement over mm, articular fragmentation, and comminution The incidence of complications, especially loss of motion and overgrowth of the radial head, is significant, making orthopedic referral advisable for all radial head and neck fractures Injured children with minimally displaced or nondisplaced fractures should have the elbow immobilized in the ED and referred for outpatient orthopedic follow-up Elbow Dislocations CLINICAL PEARLS AND PITFALLS Fractures most commonly associated with elbow dislocation include fractures of the medial epicondyle, coronoid process, olecranon, and proximal radius Posterior dislocations of the elbow must be carefully examined for neurovascular injury, with particular attention to possible median nerve entrapment, and injuries to the ulnar nerve or brachial artery Nerve injury is more common than vascular injury True arterial rupture is seen almost exclusively with open dislocations but has been described on occasion with closed injuries True elbow dislocation in the pediatric patient is uncommon, despite being the second most frequently dislocated joint in adolescents and adults Dislocations of the elbow are usually accompanied by significant soft tissue and bony damage The force and torque of the fall causing the dislocation typically results in posterior and lateral displacement of the radius and ulna, tearing of the anterior capsule, and often rupture of the medial collateral ligament as well ( Fig 111.24 ) In addition to obvious pain, deformity, and significant swelling, in the setting of dislocation the affected forearm may appear shortened and the humeral head can be detected as fullness in the antecubital fossa A thorough neurovascular examination is imperative due to the risk of ulnar and median nerve injury and the potential for trauma to the brachial artery Ulnar nerve lesions typically occur when the dislocation is complicated by intra-articular entrapment of an avulsed medial epicondyle After initial evaluation, patients should be temporarily splinted—avoiding hyperextension—prior to imaging to ensure no further neurovascular injury occurs The AP and lateral radiographs should be assessed for the direction of the dislocation and for the presence of associated fractures FIGURE 111.24 Elbow dislocation in an 8-year-old girl A displaced fracture of the medial epicondyle was evident on the postreduction radiographs ... dislocations but has been described on occasion with closed injuries True elbow dislocation in the pediatric patient is uncommon, despite being the second most frequently dislocated joint in adolescents