Determining the development stage of the ossification centers around the elbow may aid in deciding whether to use ESIN or not in adolescents' forearm shaft fractures.

Background and purpose - Elastic stable intramedullary nailing (ESIN) is the preferred method of operative stabilization of unstable pediatric forearm shaft fractures. However, the decision whether to use ESIN or open reduction and internal fixation (ORIF) in older children or teenagers is not always straightforward. We hypothesized that the development stage of the elbow would aid in evaluating the eligibility of the patient for ESIN.Patients and methods - All eligible children, aged <16 years who were treated with ESIN in Oulu University Hospital, during 2010-2019 were included (N = 70). The development stages of 4 ossification centers were assessed according to the Sauvegrain and Diméglio scoring. The proportion of impaired union vs. union was analyzed according to bone maturity, by using the optimal cutoff-points determined with receiver operating characteristics (ROC).Results - Development stage ≥ 6 in the olecranon was associated with impaired union in 20% of patients, compared with none in stages 1-5 (95% CI of difference 8% to 24%). Trochlear ossification center ≥ 4 was associated with impaired union in 17% of patients (CI of difference 7% to 36%) and lateral condyle ≥ 6 in 13% of patients (CI of difference 3.4% to 30%). Proximal radial head ≥ 5.5 was associated with impaired union in 18% of patients (CI of difference 7% to 39%).Interpretation - Recognizing the rectangular or fused olecranon ossification center, referring to stage ≥ 6, was in particular associated with impaired fracture healing. This finding may aid clinicians to consider between ESIN and plating, when treating forearm shaft fracture of an older child or teenager.

Growth of the capitellar ossification center and its relationship within the lateral condyle of the distal humerus in skeletally immature elbows: a study using MR images.

To more accurately interpret the anterior humeral and radiocapitellar lines on simple radiographs of pediatric elbow, we investigated age-related changes of the capitellar ossific nucleus (CON) by using MRIs. Elbow MRIs from 79 children aged 1-16 years and free from demonstrable lesions in the distal humerus were retrospectively reviewed. On coronal images, the distal cartilaginous vertex of the capitellum, which articulates with the center of the radial head, was situated about 15%p laterally from the center of CON regardless of age. On sagittal images, the anterior humeral line passed the center of CON in older children (>6 years), but passed anteriorly in children with an age ≤6 years. Also on sagittal images, the anterior cartilaginous vertex of the capitellum was positioned within 10% of the level of the center of CON in all age groups. Recognition of the capitellar ossification pattern within the lateral condyle would aid in more accurate assessment of pediatric elbows on simple radiographs. Based on the results of the present MRI study, the following points were identified for the interpretation of simple radiographs: (1) The radiocapitellar line on anteroposterior views intersects the CON by about 15%p laterally regardless of age; (2) The anterior humeral line on lateral views intersects the center of the CON in older children, but passes anteriorly in younger (≤6 years) children; and (3) The radiocapitellar line on lateral radiographs invariably passes the center of CON regardless of the age.

[Pitfalls in the diagnosis of occult elbow fractures in children]. / Pièges diagnostiques de la traumatologie du coude le l'enfant.

Elbow injuries are frequent but occult fractures are difficult to diagnose on x-rays. However, any delay in the diagnosis may severely impair the prognosis of some fractures. Simple tips may help the clinician read x-rays properly and avoid the classical pitfalls of elbow injuries in children. The chronology of appearance of ossification nuclei around the elbow is important to distinguish normal features from abnormality. Drawing simple geometric constructions on the x-rays may clarify most occult elbow fractures in children.

A comparison of the simplified olecranon and digital methods of assessment of skeletal maturity during the pubertal growth spurt.

Assessment of skeletal age is important in children's orthopaedics. We compared two simplified methods used in the assessment of skeletal age. Both methods have been described previously with one based on the appearance of the epiphysis at the olecranon and the other on the digital epiphyses. We also investigated the influence of assessor experience on applying these two methods. Our investigation was based on the anteroposterior left hand and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1 ) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal growth spurt. A total of nine observers examined the radiographs with the observers assigned to three groups based on their experience (experienced, intermediate and novice). These raters were required to determined skeletal ages twice at six-week intervals. The correlation between the two methods was determined per assessment and per observer groups. Interclass correlation coefficients (ICC) evaluated the reproducibility of the two methods. The overall correlation between the two methods was r = 0.83 for boys and r = 0.84 for girls. The correlation was equal between first and second assessment, and between the observer groups (r ≥ 0.82). There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%) and observer effect (ICC ≤ 3%) for each method. There was no significant (p < 0.05) difference between the levels of experience. The two methods are equally reliable in assessing skeletal maturity. The olecranon method offers detailed information during the pubertal growth spurt, while the digital method is as accurate but less detailed, making it more useful after the pubertal growth spurt once the olecranon has ossified.

MR imaging of capitellar ossification: a study in children of different ages.

BACKGROUND: The capitellar ossification center is used routinely to evaluate elbow alignment on radiography. However, whether capitellar ossification is central and concentric to support this practice is unknown. OBJECTIVE: To define the pattern of capitellar ossification at different ages of childhood. MATERIALS AND METHODS: This HIPAA-compliant study was IRB approved. MR imaging examinations from 81 children (ages 1-13 years, at least 3 boys and 3 girls in each age group) were included. We determined the center points of the ossified capitellum and the cartilaginous capitellum on the sagittal and coronal sequences that best showed differentiation between cartilage and bone. Percentage offset of the center of the ossified capitellum from the center of the cartilaginous capitellum was calculated in anterior-posterior, proximal-distal and medial-lateral dimensions, and compared across age groups and between genders. Linear regressions were used to ascertain the effect of age on percentage offset for all patients and for each gender. RESULTS: Capitellar ossification begins eccentrically with sagittal anterior proximal offset and coronal medial offset. With age, ossification proceeds posteriorly, distally and laterally. Percentage offset gradually diminishes with age. The ossified capitellum centralizes in the sagittal plane by 12-13 years. In the coronal plane, the capitellum ossifies medially beyond the proximal radioulnar joint and remains eccentric at 12-13 years. Centralization in boys lags in the anterior-posterior dimension. CONCLUSION: Capitellar ossification is an eccentric process, with lag in anterior-posterior centralization in boys. Medial offset persists at 12-13 years. Recognition of this eccentric ossification may allow for more accurate assessment of elbow alignment on radiographs, especially in younger children.

Extreme behavioral lateralization and the remodeling of the distal humerus.

OBJECTIVES: The effects of extreme behavioral lateralization (i.e., extreme handedness) on the epicondylar breadth are poorly understood. This study was conducted in order to determine the effects of high levels of right- and left-handedness on epicondyle of the humerus. METHODS: Elbow width of 186 healthy male university students who completed their physical development (extreme left handed = 92, mean age = 18.67, SD = 0.61; extreme right handed = 94, mean age = 18.55, SD = 0.58) were measured with 0.01 mm sensitivity and Edinburgh Handedness Inventory was applied to determine the handedness of the individuals. Participants with scores of +100 were designated as extreme right-handers, and participants with scores of -100 were designed as extreme left-handers. RESULTS: According to the findings, the degree of directional asymmetry was +1.22 (SD = 2.24) in the extreme right handed, whereas in extreme left handed -0.59 (SD = 1.74). The relative deviation percentage in the extreme right handed was 3.1% whereas 2.2% in the extreme left handed. CONCLUSIONS: It could be stated that extreme handedness has an influence on the asymmetry of epicondyle of the humerus; nevertheless, this effect is more significant in the extreme right handed. This is likely to result from the necessity for left-handed people to adapt themselves to the conditions of a dominantly "right-handed" world.

Clinical concepts for treatment of the elbow in the adolescent overhead athlete.

Injuries to the adolescent elbow are common because of the repetitive overuse inherent in many overhead sport activities. The management of these patients is greatly facilitated through a greater understanding of the demands placed on the upper extremity kinetic chain during these overhead activities as well as a detailed examination and rehabilitation for the entire upper extremity kinetic chain. Particular emphasis on improving rotator cuff strength and muscular endurance, along with scapular stabilization, is a critical part of elbow rehabilitation in these patients. In addition, the use of a strategic and progressive interval sport return program is necessary to minimize reinjury and return the adolescent overhead athlete to full function.

Comparação entre a avaliação da amplitude articular estática do cotovelo por meio de três diferentes métodos: goniometria, biofotogrametria e goniometria da imagem radiológica / Comparison of evaluation of static elbow range of motion using three different methods: goniometry, biophotogrammetry and radiological goniometry

Introdução: O objetivo deste estudo foi verificar a confiabilidade e objetividade da goniometria e da biofotogrametria para a avaliação de uma posição do cotovelo através da comparação dos dados obtidos por estes métodos com os obtidos pela goniometria radiológica. Material e Métodos: A pesquisa contou com dezesseis indivíduos, sendo seis examinadores e dez avaliados. Para todas as técnicas de medida utilizadas, cada avaliador colheu três medidas de um mesmo ângulo do cotovelo (143º), que foi considerado como ângulo alvo das análises estatísticas e neste estudo chamado de ângulo chave. Resultados: Após a análise estatística, verificou-se baixa e moderada confiabilidade para a goniometria, e alta e muito alta confiabilidade para a biofotogrametria. Quanto à objetividade, verificou-se valores alto e moderado com o uso do goniômetro, ao passo que com a biofotogrametria somente se observaram valores altos. No entanto, as medidas encontradas com essas técnicas não apresentaram boa correlação com os valores obtidos pela goniometria radiológica. Conclusão: A técnica biofotogramétrica apresentou maior confiabilidade e objetividade em comparação com a goniometria sem, no entanto, apresentar correlação de seus dados com os obtidos pela goniometria radiológica.

Introduction: The aim of this study was to verify the reliability and objectivity of goniometry and biophotogrammetry to evaluate one specific elbow position. Data obtained from these two methods were compared with radiological goniometry data. Material & Methods: The group was composed by sixteen subjects: six examiners and ten volunteers. For all measurements used in this research each examiner took three measures of same angle of the elbow (143º) which was considered as target angle of statistical analyses in this study called key angle. Results: After statistical analysis, it was checked low and moderated reliability to the goniometry and high and very high reliability to biophotogrammetry. In regards to objectivity, it was observed higher and moderate reliability with the goniometer while with the biophotogrammetry only higher values. Though, measurements found with these techniques did not show good correlation with radiological goniometry values. Conclusion: The biophotogrammetry technique showed more reliability and objectivity in comparison to goniometry, however did not show correlation with radiological goniometry data values.

Gender-specific pattern differences of the ossification centers in the pediatric elbow.

BACKGROUND: Only a limited number of studies have investigated the age ranges in which the secondary centers of the elbow appear and ossify. Knowledge of sequence, gender differences and age ranges can aid in accurate assessment of radiographs, especially in cases of injury. OBJECTIVE: To determine the sequence and general age ranges in which each ossification center both appears and fuses, and also to identify differences between genders. MATERIALS AND METHODS: This study included 412 sets of radiographs of children's elbows that were analyzed prospectively by a single experienced pediatric radiologist. The presence as well as state of fusion of each ossification center was noted. The ages of the children ranged from 2 months to 17 years. RESULTS: In girls, the radial head and medial epicondyle appeared at the same age. In boys, there was a trend towards the radial head appearing earlier than the medial epicondyle. There was no statistically significant difference between the age at which the trochlea and olecranon appeared. Our results demonstrate a statistically significant difference between genders in both appearance and fusion. All centers both appeared and fused earlier in girls, with the exception of the appearance of the capitellum. The sequence of appearance and fusion was similar between genders. CONCLUSION: Ossification centers at the elbow both appear and fuse earlier in females but the normal range in age for the times of appearance and fusion of these centers is quite wide for both sexes.

Skeletal age assessment from elbow radiographs. Review of the literature.

Skeletal age is important to evaluate remaining growth. In 50% of normal children and adolescents, skeletal age does not differ from chronological age. During puberty, skeletal age is an important tool when performing a lower limb epiphysiodesis or when treating (conservatively or surgically) patients with spinal deformities. Skeletal age alone is not enough and should be assessed together with other clinical and radiological findings such as standing and sitting heights, Risser sign, Tanner stages and annual growth rate. Puberty starts at 11 years of skeletal age and ends at 13 years of skeletal age in girls; in boys, puberty starts two years later (13 years of skeletal age) and then ends at a skeletal age of 15. Most current clinical and radiographic markers do not help paediatric orthopaedic surgeons to clearly distinguish maturity levels prior to Risser I. Sauvegrain et al. developed a method to assess skeletal age by using elbow radiographs (AP and lateral projections). Between 11 and 13 years of skeletal age in girls and between 13 and 15 years of skeletal age in boys, the olecranon apophysis is characterised by a clear morphological development. This method is a reliable tool to assess skeletal age during puberty because significant morphological changes in the elbow happen every six months.

[Measurement of the carrying angle of the elbow in 2,000 children at ages six and fourteen years]. / Alti ve on dört yas grubundaki 2000 çocukta ölçülen dirsek tasima açisi degerleri.

OBJECTIVES: It is important to know the carrying angles of both elbows in the evaluation of deformities which may be seen after treatment of distal humerus fractures. This study was performed to determine the basal values of the carrying angle in specific age groups. METHODS: The carrying angles of both elbows were measured with the use of a goniometry in 2000 students of randomly selected primary schools in Sivas and its nearby districts. Measurements were performed in those who completed the ages of six (500 girls, 500 boys) and 14 (500 girls, 500 boys) years, with the elbow in full extension and forearm in supination. The mean carrying angles of dominant and non-dominant elbows were analyzed in eight groups. RESULTS: The mean angles measured from dominant arms were significantly greater than those of the contralateral side in both sexes and age groups (p<0.05). The mean angles of both elbows were greater in girls than those of the corresponding elbows in boys at six years of age, while vice versa was the case at 14 years of age; however, these differences did not reach significance (p>0.05). Finally, both boys and girls at 14 years of age had significantly greater angles in dominant and non-dominant elbows compared to corresponding sex and elbow side in six-year groups (p<0.001). CONCLUSION: Our results are consistent with the literature data showing that the carrying angle increases with age and that it is always greater on the dominant side.

Juvenile and adolescent elbow injuries in sports.

Elbow injuries in skeletally immature athletes continue to increase as juvenile and adolescent athletes participate in organized athletics at earlier ages and with greater intensity. Specialization in specific sports at younger ages has led to an increase in injuries related to repetitive microtrauma. As a result, the spectrum of injuries commonly seen in skeletally immature athletes has increased at a time when long-term outcomes and less invasive interventions with biologic principles are gaining greater attention. Optimal treatment of these injuries requires a knowledge of the complex developmental and radiographic anatomy, the pathophysiology and natural history, and the indications and expected outcomes for conservative and operative management.

Aparición de centros de osificación en el codo en niños mexicanos / Late development of ossification centers in the elbow of Mexican children

La información actual sobre la aparición de los centros de osificación proviene de la literatura anglosajona, la cual refiere que la aparición de centros de osificación en el húmero distal es de la siguiente manera: capitelum antes del año de edad, pero puede verse retrasado hasta los 18-24 meses; el epicóndilo medial entre los cinco y seis años de edad; la tróclea alrededor de los nueve a 10 años de edad; el epicóndilo lateral, que es el último en osificarse, entre los 10 a 12 años de edad; radio proximal entre los 3.8 y 4.5 años de edad; olécranon entre los seis y ocho años de edad. Se estudiaron 240 codos, y se ordenaron en seis grupos de acuerdo a su edad de aparición. Se les practicaron radiografías anteroposterior y lateral de codo, encontrando retraso en la aparición del olécranon y la epitróclea. Nuestras observaciones clínicas indican que la aparición de estos centros de osificación se ve retrasada en el niño mexicano.

A new look at the sequential development of elbow-ossification centers in children.

The pattern and sequence of ossification of the six secondary ossification centers around the elbow in the child were mainly derived from studies done >30 years ago. This series reexamined the sequence and pattern based on a cross-sectional study of the elbow radiographs of 1,577 Chinese children with elbow injuries; age range, from newborn to 17 years. The ratio of girls to boys was 1:2. Each child had a radiograph of the normal and the injured elbow giving a total of 3,154 radiographs. A percentile chart of ossification was constructed for each of the ossification centers in both sexes for easy reference. No differences in the timing and ossification pattern were found between the right and left elbow or between the normal and injured elbow in this study. The sequence of ossification in both boys and girls was found to be the same (i.e., the capitulum first, followed by the radial head, medial epicondyle, olecranon, trochlea, and last, the lateral epicondyle). The ages at which 50% of the girls were found to have positive radiologic ossification for each of these centers were ages 1, 5, 5, 9, 9, and 10 years, respectively. In boys, with the exception of the capitulum, an average delay of 2 years was found in each of the ossification centers, although the sequence remained similar.

MR imaging of the normal developmental anatomy of the elbow.

Growth and ossification of the elbow are complex. Interpreting MR images of the elbow in children requires a knowledge of the elbow's developmental changes. This article discusses the basic principles of growth and development of the distal humerus, proximal radius, and ulna. The signal characteristics of cartilage and marrow in the immature skeleton are described. Technical factors related to imaging of growth cartilage are outlined, and specific challenges during imaging of the pediatric elbow are emphasized. The changing MR appearance of the elbow due to ossification and physeal closure is described. The article also explains several pitfalls encountered.

Radiology of the elbow in children.

Elbow injuries are common in children. Correct management depends on a correct diagnosis. Most elbow injuries can be diagnosed by standard radiographs, but the variability of the developing secondary ossification centers which appear at different ages renders the diagnosis difficult. The normal development of the pediatric elbow should be learned by everyone who treats children's elbow injuries.

The shoulder and elbow in Apert's syndrome.

Nine children with Apert's syndrome were studied and found to have progressive bony dysplasia in the shoulder and elbow. The children showed loss of joint motion and radiographic abnormalities including subluxation and flattening of the humeral head with irregularities of the glenoid. The elbow showed flattening and subluxation of the radial head in radiographs and a positive click on physical examination. The limitation of motion and the presence of bony defects were progressive, suggesting that Apert's syndrome is a progressive generalized dysplasia.

[Age-related changes in large joints and long tubular bones of the upper extremity in children (echographic data)]. / Vozrastnye izmeneniia krupnykh sustavov i dlinnykh trubchatykh kostei verkhnikh konechnostei u detei (po dannym ékhografii).

Two hundred and ten children at the age of 17 days up to 15 years have been examined. Echocameras, working in the grey scale regime have been used. At examination of the arm, forearm, brachial, elbow and radiocarpal joints in the children the most informative are longitudinal echographic approaches. At examination of the brachial bone head in the children older than 10 years only the anterior longitudinal approach is informative. To perform the echographic investigation of various elements of the locomotor apparatus of the upper extremities in children older than 9-10 years is difficult. The echographic reveal of additional nuclei of ossification and synostosis stages of the long tubular bones of the upper extremities in children often coincide in time with roentgenological data.