Fracture Fridays: Olecranon fracture in a pitcher (Re-post)

The Case

A 16 year old pitcher presents to the ED complaining of right elbow pain. There is no history of direct trauma, and it has been “hurting more and more over the past few weeks.” He is here because he was told by his coach at practice earlier in the day that he wouldn’t be allowed to pitch in the playoffs tomorrow unless he was seen by a doctor first. On exam his right arm is neurovascularly intact. He has pain along the dorsum of the elbow at the very proximal end of the ulna. The pain is worse when he rests his elbow on the bedside table. You get an X-Ray, because without it this teaching case would be boring.

The elbow X-Ray, with something that looks weird right where your patient hurts

The elbow X-Ray, with something that looks weird right where your patient hurts

The Diagnosis

This X-Ray shows a fracture of the olecranon. It is not unsurprising that there was no history of trauma, because this can present as a stress fracture. Interestingly there is a high prevalence in children with osteogenesis imperfecta – and this injury has been known to lead to the diagnosis in milder phenotypes. In many cases this injury is the result of traction of the triceps on the olecranon when the arm decelerates at the end of the throwing motion as well as impaction of the olecranon itself into the adjacent fossa. It should be considered along with little leaguer’s elbow as common overuse injuries in young baseball players.

Interpreting X-Rays in the elbow is a topic in and of itself, but suffice it to say knowing the normal anatomic landmarks of the elbow is helpful. I took a picture of a drawing from Netter.

Scanned from god 'ole Netter

Scanned from god ‘ole Netter

There’s one other thing to mention about X-Rays before we move on. I’m not a big fan of acronyms (especially ones that aren’t really words), but if you are this one may help. It reviews the ossification centers of the elbow. An olecranon that is ossifying could be mistaken for a fracture.

  • C- Capitulum, (3 months)
  • R- Radial head, (5 years)
  • I- Internal (medial) epicondyle, (7 years)
  • T- Trochlea, (9 years)
  • O- Olecranon, (11 years)
  • E- External or Lateral epicondyle, (13 years)

Ossification centers of the elbow in cartoon form

Management

Non-displaced fractures (like the one above) can be managed with rest. So for the young man above, the season is over, as he needs a few weeks of no throwing, followed by gradual return to play. This injury would be appropriate for sports medicine referral as well as ortho. Minimally displaced injuries should be splinted with a long arm posterior splint, and seen by ortho. Fractures with more significant displacement (though exact distance is hard to come by) may benefit form ORIF. See the below image for an example.

The patient from the beginning of the post is happy that this wasn't his X-Ray

The patient from the beginning of the post is happy that this wasn’t his X-Ray

Steroids in pharyngitis: Do they make a difference?

If you have a few moments to spare today I’d recommend you do one or both of the following:

Read the following post from the excellent FOAM blog R.E.B.E.L. EM.

It is an excellent review of a recent systematic review of corticosteroids for pharyngitis. The study includes children, and at both 24 and 48 hours patients had improved pain relief when compared with placebo.

Check out the actual article and decide for yourself whether or not a single dose of steroids in pharyngitis makes a difference that is important for your patients.

Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials BMJ 2017; 358 :j3887. PMID: 28931508

What are the normal CSF values for infants?

The question of what we should define as “normal” CSF indices is one that has vexed me for awhile. How many white blood cells are too many? Should we even look at glucose and protein if we’re likely to give antibiotics anyway? A recent paper from Thompson et al. published in PEDIATRICS attempted to answer similar questions. There are reference values reported in numerous texts and manuals but this study is much larger. and multi multicenter so it’s worth a read

What they did?

This was a multicenter, cross-sectional study that 7,766 included infants ≤60 days old with CSF cultures and complete CSF profiles. Infants with meningitis or those who were hospitalized >3 days were excluded. infants ≤28 days and those 29 to 60 days. They also did separate analyses for negative Enterovirus PCR.

What they found

Noteworthy conclusions were that babies ≤28 days had higher CSF WBC counts & protein concentrations and lower CSF glucose concentrations versus those 29 to 60 days old. Here, in tabular form are the means, standard deviations and more for CSF values in Enterovirus PCR negative and all.

from Thompson et al., PEDIATRICS 2018

What you should do

The next time you perform an LP on a febrile infant take a look at these values. Know that normal is a range, and that in general the WBC is higher in ≤28 day olds. In this study know that the upper bound for WBC was:

  • ≤28 days: 15 cells/mm3
  • 29–60 days: 9 cells/mm3

You can read the entire article here

References

Joanna Thomson, Heidi Sucharew, Andrea T. Cruz, Lise E. Nigrovic, Stephen B. Freedman, Aris C. Garro, Fran Balamuth, Rakesh D. Mistry, Joseph L. Arms, Paul T. Ishimine, Dina M. Kulik, Mark I. Neuman, Samir S. Shah, for the Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) HSV Study Group, Cerebrospinal Fluid Reference Values for Young Infants Undergoing Lumbar Puncture. PEDIATRICS, 2018.