Elbow dislocations

Cite this article as:
Becky Platt. Elbow dislocations, Don't Forget the Bubbles, 2020. Available at:

You are called to assess 14-year old Oliver who has presented to your ED by ambulance with an elbow injury.  He dived to make a save while playing football and landed on his outstretched hand.  He reports feeling a click in his elbow, followed by excruciating pain.  He was given methyoxyflurane in the ambulance which has helped. 

Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.

Oliver’s elbow looks significantly swollen, deformed and bruised.  You feel for a radial pulse – it’s there – and  undertake a neurovascular assessment, which is intact.  You prescribe him some intranasal fentanyl and order AP and lateral x-Rays of his elbow.

The elbow is an incredibly stable joint due to the way the humerus and ulna articulate (giving anterior-posterior and varus-valgus stability), strengthened by the medial and lateral collateral ligaments and the joint capsule.  Muscles and tendons further strengthen this ring.  A significant amount of force is needed to dislocate the elbow. 

Traumatic dislocation of the elbow is rare in the paediatric population comprising only 3-6% of all childhood elbow injuries, but the most common large joint dislocation (Lieber et al., 2012).  It is usually the result of a fall onto an outstretched hand, often with a large amount of force involved.  

Clinically, it is obvious that there is significant injury around the elbow; this is not something you will miss or be tempted not to x-ray.  Displaced supracondylar fractures can sometimes be confused with elbow dislocation as both present with a grossly swollen elbow and significant pain.  A quick and easy way to distinguish the two clinically is to palpate for the equilateral triangle formed by the olecranon and the two epicondyles: this is lost in elbow dislocation as the humerus creates a fullness in the antecubital fossa. There is no need to check movements in a deformed elbow but be sure to undertake a neurovascular assessment as a priority.  

The easiest way to classify simple elbow dislocations is by describing the direction of ulna dislocation in relation to the distal humerus.

Classification of elbow dislocations

90% of paediatric elbow dislocations are postero-lateral with the radiographic appearance as below:

But beware: elbow dislocations rarely present in isolation.  They often coexist with other elbow injuries. Associated fractures are likely to occur prior to closure of the epiphyses; when they are closed, collateral ligaments are likely to be ruptured (Lieber et al., 2012). The most common associated fracture is a medial epicondyle avulsion which can become incarcerated in the joint – scrutinize the elbow x-rays for associated fractures. This illustrates the importance of knowing CRITOE.

Elbow dislocation with medial epicondyl avulsion from Orthobullets.com. The white arrow points to the avulsed medial epicondyl while the red arrow shows where it has been avulsed from.

Oliver returns from x-ray and you review his films. You note the posterior dislocation but cannot see any associated fractures on Oliver’s films. You contact your orthopaedic team for further assistance.


Many elbow dislocations reductions can be carried out in the emergency department with adequate muscular relaxation and appropriate analgesia.  A reasonable amount of force is often required to achieve reduction using traction on the forearm with counter-traction around the elbow.  This should be carried out or supervised by a clinician experienced in the procedure. 

Common pitfalls in elbow reduction

Be very careful to conduct a thorough neurovascular assessment before attempting reduction. The brachial artery and median nerve may become stretched over the displaced proximal ulna and ulnar nerve can become damaged when medial epicondyle avulsions complicate elbow dislocations. If a deficit is found after reduction you need to know whether it was present before you attempted relocation…

And if you can’t reduce the dislocation go back and have another look at the x-ray – it could be due to an avulsed medial epicondyle in the joint. Any elbow dislocation with an incarcerated piece of avulsed bone in the joint must be reduced in theatre and not in the ED.


Possible complications following elbow dislocation include residual limitation of the range of movement, recurrent instability, neurovascular injury, avascular necrosis of the epiphyses and degenerative arthritis. Early diagnosis and stable reduction, with fixation of concomitant fractures if necessary, are generally associated with better outcomes.  For the Emergency department clinician, it is therefore critical that children with this injury are assessed and managed with the minimum possible delay, ensuring that associated fractures are recognised and managed appropriately.

After sedation with ketamine, Oliver’s elbow is reduced in the department with a satisfying clunk signifying reduction.  His elbow is put through a full range of movement to test joint stability and an above elbow backslab applied.  You order repeat x-Rays to evaluate the position and to check for the joint spacing and any fracture fragments within the joint as this would require surgical intervention.  The post-reduction films are good and Oliver’s neurovascular assessment remains normal and he leaves your ED with a follow-up appointment in fracture clinic in a week’s time.


Cadogan, M. (2019) Elbow Dislocation https://lifeinthefastlane.com/elbow-dislocation/

Edgington, J. (2018) Elbow Dislocation – Pediatric.  


Lieber, J., Zundel, S., Luithle, T., Fuchs, J., & Kirschner, H-J. (2012) Acute traumatic posterior elbow dislocation in children.  Journal of Pediatric Orthopaedics B. 21(5) 474-481

Rasool, M. N. (2004). Dislocations of the elbow in children. The Journal of Bone and Joint Surgery, 86, 1050–1058. 

Sibenlist, S. & Biberthaler, P. (2019) Simple Elbow Dislocations in Biberthaler, P., Sibenlist, S. & Waddell, J.P. Acute Elbow Trauma.  Fractures and dislocation injuries (eBook).  Springer

Sofu, H., Gursu, S., Camurcu, Y., Yildirim, T., & Sahin, V. (2016). Pure elbow dislocation in the paediatric age group. International Orthopaedics, 40(3), 541–545

Does Every Child With Fever Have Sepsis? Damian Roland at DFTB19

Cite this article as:
Team DFTB. Does Every Child With Fever Have Sepsis? Damian Roland at DFTB19, Don't Forget the Bubbles, 2020. Available at:

Damian Roland is a Paediatric Emergency Medicine and Honorary Associate Professor, who is also the chair PERUKI (Paediatric Emergency Research United Kingdom and Ireland). Damian delivered this thought-provoking talk on guidelines, gestalt and real-world practice on behalf of Rachel Rowlands, who was unable to attend. You can follow him in Twitter at @Damian_Roland 

#doodlemed on this talk by @char_durand below

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB21 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

Radial head and neck fractures

Cite this article as:
Becky Platt. Radial head and neck fractures, Don't Forget the Bubbles, 2020. Available at:

Aisha is 10 years old. She loves gymnastics but today, during a cartwheel, she injured her right elbow.  Aisha is cradling her right arm in her left hand and is reluctant to move it, despite having had ibuprofen at home.  


Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.


On examination, you note swelling around the elbow, especially on the lateral aspect.  Aisha has tenderness particularly over the radial head and complains of pain on any movement especially supination and pronation.  She has normal sensory and motor function of radial, ulnar and median nerves and normal pulses, colour and capillary refill time to her hand. You prescribe further analgesia, apply a broad arm sling for comfort and order lateral and AP x-rays of her elbow.

Radial head and neck fractures comprise around 5% of all elbow injuries in children, with a peak at 9-10 years of age. They normally result from a FOOSH (‘fall onto an outstretched hand’).  Fractures through the radial head are rare in children: more commonly the physis (the growth plate: the disc of cartilage between the epiphysis and metaphysis), or radial neck will be involved.


Radial Neck fractures

Radial neck fractures can generally be diagnosed on lateral and AP elbow x-ray.  It’s useful to remind yourself of the elbow anatomy prior to looking at the x-ray so that you know what you’re looking for.  It’s really important to appreciate that part of the radial neck sits outside of the capsule. Most radial neck fractures occur at the level of the annular ligament, which forms a collar around the radial neck to anchor it to the ulna.

Elbow ligaments. From RCEM Learning

This means that not all radial neck fractures have a joint effusion. Don’t be fooled by a lateral elbow x-ray without a fat pad sign – this just means there’s no joint effusion; it doesn’t mean there isn’t a radial neck fracture.

The appearance can be quite subtle, so it’s useful to remind yourself what the radial neck looks like on a normal X-ray:

Normal radial neck. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 24158

In particular, notice how the contours of the radial neck form smooth curves, as above. These smooth curves are lost in radial neck fracture:

Radial neck fracture. Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 42688


Mildly angulated radial neck fracture (black arrow) and posterior fat pad (white arrow). Reproduced with permission from Emery et al. Ped Rad. 2016; 46:61-6

How are radial neck fractures classified?

Radial neck fractures were classified by O’Brien (1965)  as follows:

Type I: <30 degrees displacement

Type II: 30-60 degrees displacement

Type III: >60 degrees displacement

O’Brien’s classification of radial neck fractures. From Orthobullets


Other radial neck classifications have been described so, to avoid confusion, it’s probably safest to describe the degree of displacement rather than the classification type, especially as displacement of radial neck fractures in children is uncommon.


How should radial neck fractures be managed?  

Most paediatric radial neck fractures are type I: undisplaced or minimally displaced.  These do really well with conservative management with immobilization in a collar and cuff.  Those with displacement of >30 degrees tend to have a worse outcome and should be referred to orthopaedics as reduction, and possible internal fixation will be required.


Which children need to be discussed with the orthopaedic team before they go home?

  • Any displaced radial neck fractures
  • Any radial neck fractures with a second elbow injury


Radial neck fractures – do not miss…

30-50% of children with a proximal radial fracture have another fracture – examine the child and their x-rays very carefully.  Having a second injury is associated with a poorer outcome. The most common associated injuries are:

  • elbow dislocations
  • medial epicondyle fractures
  • olecranon fractures


Radial neck fractures can also be associated with compartment syndrome of the forearm, although thankfully this is rare.   Compartment syndrome is a limb-threatening condition caused by increased pressure within the closed space of a muscular compartment which causes compression of the nerves, muscles, and vessels within the compartment.  Untreated, this can lead to ischaemic injury within 4-8 hours.


Assessing for compartment syndrome – the 5 Ps

  • Pain – the most important indicator.  Often diffuse and progressive, not resolved by analgesia, worsened by passive flexion of the injury.
  • Pallor – assess distal to the injury.  Dusky or cool skin (compared to the other side) or delayed capillary return.
  • Pulse – weak or absent pulse indicates poor perfusion,
  • Paralysis – assess active movement of the wrist and fingers.  This may cause pain but the purpose is to assess ability to move.
  • Paraesthesia – ask about pins and needles or a feeling of the hand “falling asleep”.  Assess sensation with light touch or using an object such as a pen lid.

Any concerns about potential compartment syndrome must be escalated to an ED or orthopaedic senior without delay as this is a time-critical situation.


Radial Head fractures

Like radial neck fractures, radial head fractures are also most often due to a FOOSH.  Unlike radial neck fractures, radial head fractures typically occur after the proximal radial physis has closed so are more common in older children. They are usually clearly visible on x-ray and the majority are undisplaced and respond well to conservative management in a collar and cuff or sling.  Displaced fractures of the radial head are rare and will need an urgent orthopaedic referral.

Radial head fracture. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 24158



Aisha returns from X-Ray and you spot an undisplaced fracture of the radial neck, visible on the AP and lateral views.  You remember that associated fractures are common and so have a careful look for other injuries and check the epiphyses using the CRITOE rule.  Aisha has an isolated, non-displaced radial neck fracture with no other injuries: you pop her in a collar and cuff and organize virtual fracture clinic follow up.  You make sure to give her and her family advice about analgesia and signs of any neurovascular compromise before they leave.



Barclay, T. (2019) Elbow Joint. Innerbody https://www.innerbody.com/image/skel14.html

Davies, F., Bruce, C. E., & Taylor-Robinson, K. J. (2011). Emergency Care of Minor Trauma in Children. London: Hodder & Stoughton.

De Mattos, C. B., Ramski, D. E., Kushare, I. V., Angsanuntsukh, C., & Flynn, J. M. (2015). Radial Neck Fractures in Children and Adolescents. Journal of Pediatric Orthopaedics, 36(1), 6-12.

Edgington, J. & Andras, L. (2018) Radial head and neck fractures – pediatric https://www.orthobullets.com/pediatrics/4011/radial-head-and-neck-fractures–pediatric

Emery, K. H., Zingula, S. N., Anton, C. G., Salisbury, S. R., & Tamai, J. (2016). Pediatric elbow fractures: a new angle on an old topic. Pediatric Radiology, 46(1), 61–66.

Gaillard, F. https://radiopaedia.org/articles/radial-head-fractures?lang=us Accessed 23/06/2019

Gomes, C. & Lowsby, R. (2018) Elbow Injuries.  RCEM Learning https://www.rcemlearning.co.uk/reference/elbow-injuries/

Hill, C. E., & Cooke, S. (2017). Common Paediatric Elbow Injuries. The Open Orthopaedics Journal, 11, 1380–1393.

Kraus, R. (2014). The pediatric vs. the adolescent elbow. Some insight into age-specific treatment. European Journal of Trauma and Emergency Surgery, 40(1), 15–22.

Lampert, L. (2016). Compartment Syndrome – The 5 Ps. Ausmed. Retrieved from https://www.ausmed.com/cpd/articles/compartment-syndrome

Nicholson, L. T., & Skaggs, D. L. (2019). Proximal Radius Fractures in Children. The Journal of the American Academy of Orthopaedic Surgeons, 00(00), 1–11.

Nickson, C. (2018) Compartment Syndrome. Life in the Fast Lane https://lifeinthefastlane.com/compartment-syndrome/

O’Brien, P.I. (1965) Injuries involving the proximal radial epiphysis.  Clinical Orthopaedic related Research, 41, 51-58.

Shabtai, L., & Arkader, A. (2016). Percutaneous reduction of displaced radial neck fractures achieves better results compared with fractures treated by open reduction. Journal of Pediatric Orthopaedics, 36(4), S63–S66.

Tan, B. H., & Mahadev, A. (2011). Radial neck fractures in children. Journal of Orthopaedic Surgery (Hong Kong), 19(2), 209–212.

Olecranon fractures

Cite this article as:
Becky Platt. Olecranon fractures, Don't Forget the Bubbles, 2020. Available at:

14-year old Noah was rocking on his chair while daydreaming his way through a maths lesson this morning… and fell off.  He reports that he landed directly on his left elbow and that it has been painful throughout the day.  He attends your ED this afternoon with his unamused mother.

Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.

You ensure Noah has been given analgesia before examining him.  His pain score is 5 and he seems comfortable after paracetamol and ibuprofen when his arm is resting.  His elbow is notably bruised and swollen. He is particularly tender over the olecranon and any movement is painful.  His neurovascular status is normal with good radial and ulnar pulses, normal sensation in the radial, ulnar and median nerve distributions and as he’s able to make the rock, paper, scissors and ok hand signs, you’re happy he has full motor function.  You order AP and lateral films of his elbow and pop him in a broad arm sling for comfort before sending him round for his x-rays.

Epidemiology and mechanism of injury

Olecranon fractures in children are rare, comprising around 5% of elbow fractures. Compare this with supracondylar fractures which comprise over half of all elbow fractures in the paediatric population. Olecranon fractures may result from a fall onto an outstretched hand (FOOSH), direct trauma or, occasionally, a stress fracture from repetitive throwing motion in athletes.

They can be classified according to the Mayo classification.

Examination findings

In addition to pain, there will almost certainly be generalised swelling around the elbow, usually with visible evidence of trauma, such as bruising or abrasion, over the olecranon process.  Point tenderness over the olecranon is often a feature, but the degree of swelling can sometimes make this difficult to appreciate.  Inability to fully extend the elbow is common, and pain on extension, supination and pronation is expected.  In those with comminuted or significantly displaced fractures it may be possible to feel crepitus over the olecranon.


Interpreting children’s elbow x-rays can be mind boggling. Epiphyses ossify at different rates and so it can be easy to confuse a normal olecranon epiphysis with a fracture.  The olecranon epiphysis normally appears around 9 years and fuses at 15-17 years.   Be sure to refer to the CRITOE rules and if you’re not sure whether you’re seeing a normal epiphysis or a fracture, seek senior advice.  The olecranon can be best assessed on the lateral film.

This x-ray shows a normal olecranon epiphysis:

Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 26814

Some olecranon fractures are obvious…

…but some can be incredibly subtle as illustrated in this series from Radiology Assistant:

Some olecranon fractures may only be visible on one view.  This may be the AP or the lateral.  The below elbow x-rays show a transverse olecranon fracture visible on the AP view only (arrow).  Note the raised anterior and posterior fat pads on the lateral view.  And an extra bonus point to those who spotted the subtle radial neck fracture.


The majority of olecranon fractures (around 80%) are either undisplaced or minimally displaced (less than 2mm); these can be managed conservatively with an above elbow back-slab with good functional outcome.

Minimally displaced (<2mm) fracture in a 7 year old, requiring conservative management only. Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 23650


In children with a displaced olecranon fracture, there is risk of complications including delayed or non-union, ongoing elbow stiffness and impaired function.  Refer any child who has an olecranon fracture with these features as they’re likely to require surgical intervention:

  • >2-4mm displacement
  • angulation of >30°
  • intra-articular involvement
  • extensor mechanism disruption
  • instability on extension
  • comminution

Olecranon fracture with >30 degrees of displacement, requiring surgical fixation. From Orthobullets.com.

The practitioner seeing injured children in the ED must be aware of the potential for these.  Displaced olecranon fractures can cause growth disturbances resulting in fixed flexion deformity of the elbow joint and associated morbidity into adulthood.

The ulnar nerve is particularly at risk of injury with olecranon fracture. Ensure you carry out a thorough neurovascular assessment, in particular checking sensation over the little finger and that the small muscles of the hand are functioning normally (the “scissors” sign).

A significant proportion of olecranon fractures are associated with concomitant injury, including radial neck fracture and /or supracondylar fracture and any co-existing injury is prognostic for poorer outcome.  When interpreting the x-ray, it is important therefore to have a systematic approach.

Bullets of wisdom 

  • Don’t confuse an unfused olecranon epiphysis with a fracture
  • But don’t forget that olecranon fractures can be subtle – maintain a high index of suspicion in children with direct trauma and inability to extend their elbow
  • Olecranon fractures are sometimes only visible on one view and this can be the lateral or the AP
  • Displaced fractures can have devastating consequences and must be referred to orthopaedics as they may need surgical intervention
  • Document neurovascular status and be sure to check ulnar nerve function
  • And look for a concomitant radial neck or supracondylar fracture

Noah returns from X-Ray and you review his films. He has a posterior fat pad sign and on closer scrutiny you spot an intra-articular fracture of the olecranon. You recognise that this type of fracture can be associated with complications and refer him to the orthopaedic team.  You ensure that his pain score and neurovascular status are being assessed regularly.



Cabanela M.E. & Morrey B.F. (1993) The Elbow and Its Disorders. 2nd ed. Philadelphia, PA, USA: WB Saunders cited in Sullivan, C. W., & Desai, K. (2019). Classifications in Brief: Mayo Classification of Olecranon Fractures. Clinical Orthopaedics and Related Research, 477(4), 908–910.

Caterini, R., Farsetti, P., DʼArrigo, C., & Ippolito, E. (2002). Fractures of the Olecranon in Children. Long-Term Follow-Up of 39 Cases. Journal of Pediatric Orthopaedics B, 11(4), 320–328.

Corradin, M., Marengo, L., Andreacchio, A., Paonessa, M., Giacometti, V., Samba, A., … Canavese, F. (2016). Outcome of isolated olecranon fractures in skeletally immature patients: comparison of open reduction and tension band wiring fixation versus closed reduction and percutaneous screw fixation. European Journal of Orthopaedic Surgery and Traumatology, 26(5), 469–476.

Degnan, A. J., Ho-Fung, V. M., Nguyen, J. C., Barrera, C. A., Lawrence, J. T. R., & Kaplan, S. L. (2019). Proximal radius fractures in children: evaluation of associated elbow fractures. Pediatric Radiology, 1–8.

Edgington, J. & Andras, L. (2019) Olecranon fractures – pediatric https://www.orthobullets.com/pediatrics/4010/olecranon-fractures–pediatric?expandLeftMenu=true

Hill, C. E., & Cooke, S. (2017). Common Paediatric Elbow Injuries. Open Orthopaedics Journal, 11, 1380–1393.

Kraus, R. (2014). The pediatric vs. the adolescent elbow. Some insight into age-specific treatment. European Journal of Trauma and Emergency Surgery, 40(1), 15–22.

Nicholson, L. T., & Skaggs, D. L. (2019). Proximal Radius Fractures in Children. The Journal of the American Academy of Orthopaedic Surgeons, 00(00), 1–11.

Pace, A., Gibson, A., Al-Mousawi, A., & Matthews, S. J. (2005). Distal humerus lateral condyle mass fracture and olecranon fracture in a 4-year-old female – Review of literature. Injury Extra, 36(9), 368–372.

Perkins, C. A., Busch, M. T., Christino, M. A., Axelrod, J., Devito, D. P., Fabregas, J. A., … Willimon, S. . (2018). Olecranon fractures in children and adolescents: outcomes based on fracture fixation. Journal of Children’s Orthopaedics, 12, 497–501.

Rath, N. K., Carpenter, E. C., Ortho, F., & Thomas, D. P. (2011). Traumatic Pediatric Olecranon Injury. A Report of Suture Fixation and Review of the Literature. Pediatric Emergency Care, 27(12), 1167–1169.

Medial epicondylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Medial epicondylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:

In this section, we will mainly discuss medial epicondylar fractures. Medial condylar fractures are a rare pattern of fracture and managed in a similar manner to lateral condylar fractures. It is important to differentiate between medial condylar and epicondylar fractures. Condylar fractures are intra-articular and require urgent open reduction and internal fixation.

Lateral condylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Lateral condylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:

Six-year-old William was playing hopscotch in the playground but fell, landing on his left outstretched hand. Afterwards, he complained of left elbow pain and was taken to the local Emergency Department. He was told that he had a lateral condylar fracture of the humerus…


This is a relatively common fracture in the paediatric population and occurs mainly in children below the age of 7 years old, with a mean age of 6. It accounts for approximately 10-20% of paediatric elbow fractures and is the second most common intra-articular fracture.


The most common aetiology for this fracture is a fall onto an outstretched hand. The patient will complain of pain to the lateral aspect of the elbow. The level of pain may be low in minimally displaced fractures.


Have a look at our post on elbow examination for tips on how to do a full assessment of a child’s elbow.

Inspection of the joint will reveal an elbow with swelling to the lateral aspect. There is usually minimal deformity. Bruising may indicate a brachioradialis tear and therefore likely instability. Tenderness is usually limited to the lateral aspect and crepitus may be palpated on movement. Wrist flexion and extension may reproduce the pain.

It is important to carefully examine the joint below and above the injured area. Don’t forget to examine the rest of the child for other injuries.

Remember to be suspicious of non-accidental injury in cases where there are inconsistencies in the history and injury type.


AP and lateral x-rays of the elbow are required. Oblique views can be valuable if no fracture is seen on lateral or AP views but clinical suspicion remains. This is where your knowledge of the ossification centres comes into play (for detail on this see CRITOE). The ossification centres appear on x-rays in the order: Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon and the External epicondyle, also known as the lateral condyle. The lateral epicondyle appears at the age of 8-12 years old and fuses at age 12-14 years old.

The paediatric elbow is largely cartilaginous. Lateral condylar fractures often only affect the cartilaginous part of the humerus. As cartilage is not radiopaque, the true extent of the fracture is often not fully understood when looking at the x-ray.

The presence of anterior and posterior fat pads may often be the only indication that a fracture is present.

The most commonly associated fracture is the ipsilateral elbow dislocation (usually posterolaterally) and ipsilateral humeral fractures (most commonly the olecranon). Ensure you obtain radiographs for other suspected fractures.

 Lateral condyle fractures can be classified depending on their x-ray appearances.


There are several different classification methods. The most common classifications as below.

Milch Classification
Type 1The fracture line is lateral to the trochlear groove… not into the humero-ulnar joint
Type 2The fracture line is medial to the trochlear groove and is, therefore, a fracture-dislocation and unstable.
Milch Classification
Jakob Classification
Stage 1<2mm displacement, which indicates intact cartilaginous hinge 
Stage 22-4mm of displacement 
Stage 3>4mm displacement with rotation of the fragment 
Jakob Classification

Immediate treatment in the ED

Provide immediate adequate analgesia to the child prior to any examination or investigation.

If the fracture is open, conservatively manage the wound, consider tetanus status and antibiotics.

Keep the child nil by mouth as they may need urgent surgery.

Treatment following imaging

Treatment depends on the degree of displacement of the fracture.

Due to the high complication rate of these fractures, all lateral condylar fractures should be referred for to the on-call orthopaedic team while in the Emergency Department.

Jakob classificationTreatment optionFollow up
Stage 1 (<2mm of displacement)Conservative management with immobilisation with above elbow cast to 90 degrees.Weekly imaging in fracture clinic with the cast in place for 4-6 weeks.
Stage 2 and 3 (> 2mm with or without rotation)These all must go to theatre and have closed reduction with percutaneous pinning or open reduction with screw fixation.3-6 weeks in above-elbow cast and orthopaedic follow up.

Areas of controversy

Serial radiographs are often recommended in the management of conservative management minimally or undisplaced lateral condylar fractures. A systematic review by Tan et al 2018 found that serial X-rays have no clinical significance. However, if the 1 week up x-ray is not satisfactory, this should be followed up appropriately under the patient’s treating orthopaedic team.

Potential complications

This type of fracture is associated with a high rate of complications, which usually develop later, during the healing process.

The reduction must be accurate. If there is malunion, the fragment does not adequately unite or the epiphyseal plate is damaged then complications may occur:

  • Stiffness is the most common complication, usually fully resolving by 48 weeks.
  • Delayed union occurs if the fracture has not healed after 6 weeks. This usually occurs if the fracture visible at 2 weeks.
  • Non-union is more likely when delayed union occurs.
  • Cubitus valgus deformity occurs with lateral physeal growth arrest.
  • Delayed “tardy ulnar palsy” may develop as the child grows and the ulnar nerve is stretched across the elbow with valgus deformity.
  • Avascular necrosis may develop 1-3 years after the fracture.
Image from wikimedia.org

Do not miss bits

Lateral condylar fractures of the humerus can present with minimal pain or deformity and can be missed (16.6% misdiagnosed as presented by Tan et al 20181). Due to the high rate of complication, it is important that we do not miss these fractures.

William was found to have an isolated Jakob stage 3 type lateral condylar fracture and was taken to theatre that evening. Open reduction was required, and internal screw fixation secured the fragment. His cast was removed 4 weeks after and his joint mobility continues to improve.


Bowden G, McNally MA, Thomas RYW, Gibson A. 2013. Oxford Handbook of Orthopaedics and Trauma, Oxford Medical Publications. Page 564-5

Dandy DJ, Edwards DJ, 2003. Essential Orthopaedics and Trauma, Fourth Edition, Churchill Livingstone, page 197.

Raby N, Berman L, Morley S, de Lacey G. 2015. Accident and Emergency Radiology: A survival Guide Third Edition, Sauders Elsevier page 106-110.

Shaath k, Souder C, Skaggs D. 2019. Orthobullets, Lateral Condyle Fracture – Pediatric Accessed 06/04/2019 https://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture–pediatric

Tan SHS, Dartnell J, Lim AKS, Hui JH. Paediatric lateral condyle fractures: a systematic review. Arch Orthop Trauma Surg. 2018 Jun;138(6):809-817. doi: 10.1007/s00402-018-2920-2. Epub 2018 Mar 24. Review. PubMed PMID: 29574555.

Finger injuries: basics and bones

Cite this article as:
Sinead Fox. Finger injuries: basics and bones, Don't Forget the Bubbles, 2020. Available at:


Injuries to the hand are frequent in the paediatric population and are a common reason for presentation to the PED. Despite the frequency of these presentations, assessment and management of hand and finger injuries can be challenging. But never fear! DFTB have come to the rescue with a comprehensive two-part series related to the assessment and management of paediatric hand and finger injuries including some handy tips.

This first post will cover an overview of the basic anatomy of the hand, professional lingo as well as history taking and the clinical examination. Documentation essentials and common phalangeal and metacarpal fractures seen in PED will also be covered.  

First, let’s take a look at the basic anatomy of the bones of the hand.

Professional Lingo: Get to know your pinkie from your pointer!

Although it is helpful to know your pinkie from your pointer when talking to children, it is also important to have knowledge of the professional language used to document and describe hand injuries appropriately. This is not only important from a medico-legal point of view but having the ability to describe the exact location of clinical findings in professional terms makes communication and referral to specialist services much easier.

Clinical History/Documentation Essentials: Take a HAND history

H-          How the injury happened? Ask about mechanism of injury including the environment in which the injury was obtained.

              Hobbies. Ask about the child’s hobbies, sports, activities, career aspirations (in older child) as these may impact on management.

A-          Altered sensations. Ask about any altered sensations such as paraesthesia which could indicate a nerve injury.

N-          Needles/Needs Tetanus? Ask about vaccinations, is the child’s Tetanus vaccination up to date, especially relevant if open wounds or animal/human bites are present.

NAI        Like all paediatric injuries consider the possibility of NAI, especially in the younger child. A comprehensive history is essential to detect the possibility of intentional injury from physical abuse or an unintentional injury as a result of neglect. Consider injuries that are self-inflicted in the older child/adolescent age group.

D-          Dominance. Ask and record the child’s hand dominance as this can impact injury management.

Physical exam – look, feel, move

Clinical assessment of hand injuries involves a systematic exam of both hands including inspection, palpation, and range of motion (ROM).

1. Look

  • Once the child has received appropriate analgesia and you have established a rapport with the child and their parent, begin by looking at the hand without touching, observe the child’s hand at rest and play, involve a play specialist if available- they always bring the right amount of magic to get even the sorest of little hands and fingers moving!
  • Look for bruising, swelling, abrasions or open wounds. Assess for nail bed injuries.
  • Check for any clinical deformities including a rotational deformity which may not become apparent until the child makes a fist. Minimally displaced fractures may be clinically significant if they result in a rotational deformity, so it is vital to routinely assess for same. It is good practice to include the presence or absence of a rotational deformity in your documentation.
Rotational deformity – the normal cascade should point to the thenar eminence

2. Feel

  • Examine the child’s unaffected hand first and keep the child chatting throughout the exam, it helps reduce the child’s anxiety and allows the child to build trust in you.
  • Remember to examine the whole hand. It is important to develop a systematic approach to the examination of the hand including palpation of the wrist, carpal bones (including anatomical snuff box and scaphoid tubercle) metacarpals, metacarpophalangeal joints (MCPJs), phalanges, proximal interphalangeal joints (PIPJs) and distal interphalangeal joints (DIPJs).  Systematic palpation of the entire hand can help localise underlying fractures and concomitant injuries.
  • Evaluate and document neurovascular status.

Examination Pearl: The Wrinkle Test

Neurological assessment in young children or children/adolescents with difficulties communicating can be particularly challenging as they may be unable to report the presence or absence of sensation. The wrinkle test measures autonomic function of peripheral nerves via placement of the child’s hand in warm water for 10 minutes, wrinkles on the fingers indicate intact neurological function.

3. Move

  • Getting a child to move an injured hand can be challenging but certain familiar gestures such as high fives, thumbs up or fist bumps can be used to assess active range of movement in a young or uncooperative child.
  • A game of paper, rock, scissors is a fun and systematic way to test peripheral nerves in children with upper limb injuries. 
  • Be vigilant for tendon injuries. Check out the DFTB finger tendon and ligament injuries post for further details and clinical pearls related to the assessment of specific tendon functions. These functional tests should be included in every clinical examination of an injured hand.

Phalangeal Fractures

Approximately 20% of hand injuries in children are fractures. In particular, the phalanges are the most frequently injured bones of the hand with distal phalangeal and proximal phalangeal base fractures being the most commonly diagnosed fractures.

Proximal phalangeal base fractures

It’s a sunny June afternoon and Patrick a 9-year-old boy is brought to your ED by his Dad. Patrick reports it is the last day of school term before the summer holidays, he tells you he was so excited that when the final bell rang he threw his book bag in the air but, as the bag landed his left little finger got caught in the strap. It sounds like his finger was forcefully abducted by the weight of the bag. He shows you his swollen, bruised, and painful pinkie.  


Typically, proximal phalangeal base fractures result from a finger being abducted beyond acceptable limits of the MCP joints.


A child with a proximal base phalangeal fracture will typically present with swelling, ecchymosis, and focal tenderness on palpation to base of proximal phalanx. A displaced fracture to the base of the proximal phalanx can cause malrotation of the finger. A significantly displaced fracture or a fracture that causes a rotational deformity requires closed reduction to correct the deformity.


Oblique, PA, and lateral X-rays of the injured fingers should be obtained. True lateral X-ray is the most effective way to examine joint congruity. Angulation of proximal phalanx fractures is best seen on the lateral projection.

Salter-Harris Classification

Fractures involving the physis are described by the Salter-Harris Classification system as types I-V.  Salter- Harris type II fractures of the proximal phalanx are a common type of finger fracture in children.

  • Salter-Harris type I fractures involve only the physis and can be difficult to diagnose because X-Rays typically appear normal unless there is displacement.
  • Salter-Harris type II fractures involve extension through the physis and metaphysis.
  • Salter-Harris type III fractures extend through the physis and epiphysis.
  • Salter-Harris type IV fractures extend through the physis, metaphysis and epiphysis.
  • Salter-Harris type V fractures involve crush injuries that shatter the physis. 


Non- Operative: Un-displaced or minimally displaced Salter-Harris type I or II fractures of the proximal phalanx without clinical deformity are usually managed with buddy taping to an adjacent finger for support and encouragement of early range of motion, typically for 3-4 weeks.

For displaced Salter Harris type II fractures of the proximal phalanx closed reduction can be carried out in ED. Depending on the age and preference of the child, closed reduction can be performed using a ring block +/- procedural sedation. The proximity of the physis assures a high degree of remodelling. The ED practitioner’s thumb or a cylindrical object such as a pen or pencil can be used to achieve adequate reduction. Post reduction stability is maintained by buddy tapping +/- splinting.

Operative: Severely displaced, unstable or open fractures require evaluation by a hand surgeon.

X-ray shows a displaced Salter-Harris type II fracture to the base of Patrick’s proximal phalanx. There is a rotational deformity on clinical exam. You reduce the fracture in ED using a ring block and Nitrous Oxide. On reassessment post reduction the clinical deformity is corrected and check X-rays are satisfactory. You discharge Patrick home with his finger buddy taped and arrange follow up in an outpatient clinic.  

Phalangeal shaft, neck and condylar fractures

Phalangeal shaft fractures

Treatment for fractures along the shaft of the phalanges is dictated by the orientation of the fracture as well as the degree of angulation on initial presentation. Clinical exam is also extremely important as even innocuous appearing fractures along the phalangeal shaft can be clinically significant if they cause a rotational deformity of the injured digit. A rotational deformity must be corrected as failure to do so can lead to long term functional impairments for the child.

Non operative: For length stable fractures with minimal displacement, buddy taping to an adjacent finger for support and to allow early range of motion can be an effective treatment for approximately 3-4 weeks.

Operative: Oblique or spiral fractures requiring closed reduction need more rigid immobilisation such as an ulnar or radial guttar splint or cast. Alignment of these fractures can be difficult to maintain and fixation is often required; surgical opinion is advised.

Surgery is also indicated in cases of open or severely displaced fractures or where there is instability post-reduction.

X-ray of long oblique proximal phalanx shaft fracture Courtesy of Orthobullets: https://www.orthobullets.com/hand/6114/phalanx-fractures

Phalangeal neck fractures

Neck fractures of the proximal and middle phalanges are classic paediatric injuries, rarely seen in adults. They typically result from a crush injury to the finger such as a child getting the finger caught in a closing door.

Non operative: Non-displaced fractures to the neck of the proximal or middle phalanges can usually be managed safely by immobilizing the digit for 3-4 weeks.

Operative: Surgical consultation is recommended for any displaced neck fractures as these are inherently unstable and require close follow up.

Condylar fractures

The condyles are a pair of tuberosities that form the distal articular surfaces of the proximal and middle phalanges. Condylar fractures are intra-articular fractures and can be unstable, therefore surgical consultation is recommended as these fractures require meticulous reduction to ensure proper joint congruity.

Volar plate avulsion injuries

Tori is a 14-year-old girl and a talented soccer goalie. She reports that while trying to save a penalty, her right middle finger was forcefully hyperextended and is now very painful. She shows you her right middle finger which is swollen and bruised at the PIPJ.

An overview of volar plate injuries

The volar plate lies between the flexor tendons and the palmar PIPJ capsule. It originates from the proximal phalanx and inserts into the middle phalanx. The volar plate contributes to the stability of the PIPJ by preventing hyperextension of the PIPJ.  Volar plate injuries encompass a spectrum of soft tissue injuries and can occur with an avulsion fracture at the volar base of the middle phalanx.  Subluxation or dislocation of the PIPJ may also occur.


Volar plate injuries are commonly caused by forced, sudden hyperextension injuries of the PIPJ, seen typically in older children/adolescents involved in hand/contact sports. Occasionally volar plate injuries can be caused by a crush injury to the digit.


Diagnosis of a volar plate injury is based on history and clinical examination. Typically, there is swelling of the PIPJ. Bruising to the volar surface of the PIPJ is sometimes observed. Maximal tenderness on palpation is over the volar PIPJ and the patients may report pain on passive hyperextension of the PIPJ. The collateral ligaments should be tested as with collateral ligament injuries to check stability of the PIPJ.

 X-rays may reveal an avulsion fracture at the base of the volar surface of the middle phalanx and can help identify PIPJ subluxation or dislocation.

Case courtesy of Dr Mohammad A. ElBeialy, Radiopaedia.org. From the case rID: 46050


Non- operative: A stable joint without a large avulsion fracture (<40% of articular segment) and/or a reducible fracture with 30 degrees of flexion is usually managed conservatively with splinting. In less severe injuries the injured finger can be buddy taped.

Operative: Surgical opinion should be sought if there is instability of the PIPJ or there is a large avulsion fracture.

When you examine Tori’s hand there is an isolated injury to Tori’s right middle finger as evidenced by swelling, bruising and tenderness to the PIPJ. Although active ROM is painful, Tori is able to fully extend and flex the finger. X-ray demonstrates a small avulsion fracture to the volar base of the middle phalanx on her right middle finger and you correctly diagnose her with a volar plate injury. Tori’s injury is stable and suitable for buddy taping to allow for early range of motion and prevent stiffness.

Distal Phalangeal Fractures

Distal tuft fracture

Khalid is a 2-year-old boy. He is brought to ED by his Mum as he caught his right index finger in the hinge side of a closing door. You examine his hands and note swelling and erythema to the distal phalanx of his right index finger. There is no nail bed injury or open wounds and he is moving the finger freely as you observe him playing with a toy tractor which was kindly supplied by the PED play specialist. His Mum appears more upset than he is, so you calmly reassure her that a serious finger injury is unlikely but an X-ray is required to rule out a fracture.


Distal tuft fractures are common in the toddler or pre-school age groups and typically occur as a result of direct crush injuries such as getting little fingers caught in a closing door.


A concomitant nail bed laceration or pulp laceration may be present in children who have a distal tuft fracture. In this case the fracture is classed as an open fracture and opinion should be sought from Plastic Surgery Team. Check out the DFTB post on fingertip injuries for more information related to the assessment and management of nail bed injuries. Be alert for injury to flexor/extensor tendons.


Non-Operative: Most children who have a closed distal tuft fracture are treated conservatively with splinting or buddy taping.

Operative: Surgical treatment is reserved for patients with distal tuft fractures who have nail bed injuries, subtotal/total amputations, or an unstable transverse fracture pattern.

X-ray demonstrates an un-displaced tuft fracture. You buddy tape Khalid’s fingers and reassure Mum that the fracture is small and unlikely to cause Khalid any functional problems.

Seymour fractures

Jordan is a 12-year-old boy who is brought to the PED with an injury to his left thumb. During a rugby match he was tackled to the ground and an opposition player stood on his thumb. He shows you a swollen, bruised partially flexed thumb. There is blood at the proximal nail fold and the nail plate is partially avulsed. The finger is visibly contaminated with dirt and soil from the rugby pitch, so you irrigate it with saline prior to X-ray and check that Jordan’s vaccination status is up to date.


A Seymour fracture is an injury unique to children. This fracture pattern is usually caused by a crush injury and results in an angulated Salter-Harris type I or Salter-Harris type II fracture with an associated nail bed injury. It is important to recognise this fracture pattern as early referral to a hand surgeon is important to avoid complications.


The typical presentation is a swollen, bruised, and painful finger flexed at the DIPJ. There may be blood under the nail or the nail plate can be completely avulsed proximally causing it to sit superficial to the eponynchial fold (aka proximal nail fold). Soft tissue (often the germinal matrix of the nail) can become interposed in the fracture which prevents fracture reduction and healing.


PA X-ray views of the injured finger often appear normal. Lateral view X-ray are used to confirm the diagnosis.

Pro tip! Because of the flexed appearance at the DIPJ, a Seymour fracture can be misinterpreted as bony mallet injury; however a mallet finger fracture line enters DIPJ, while Seymour fracture line traverses physis (does not enter DIPJ).


Non-Operative: Closed injuries are managed with closed reduction and splinting. The child may be followed up with a weekly X-ray to ensure maintenance of fracture reduction.

Operative: Substantive injuries require open reduction and nail bed repair.

Bottom Line

It is important to seek surgical opinion regarding the management of Seymour fractures as if left untreated possible complications include osteomyelitis, malunion, and pre-closure of the physis.

Jordan’s x-ray shows an angulated Salter-Harris type II fracture to the distal phalanx and you correctly diagnose a Seymour fracture. You refer Jordan to the plastic surgery team who decide to take Jordan to theatre to ensure a thorough washout and repair of the nail bed injury.

Metacarpal Fractures

Katie is a 15-year-old girl who presents to your ED with her father. Her father reports that she had an argument with her Mum and punched a wall at home, he also reports that this is not the first time an incident like this has occurred. Katie shows you her right hand which is grossly swollen and bruised over the dorsal surface. There are no open wounds and she reports focal tenderness on palpation to her 5th metacarpal bone. There is an obvious loss of knuckle height and rotational deformity to her little finger. During the exam she is visibly withdrawn and quiet and you are suspicious that there is more than a hand injury bothering Katie.  


Metacarpal fractures are common in adolescent athletes. The most common type of metacarpal fracture is the so-called ‘‘boxer’s fracture’’, which involves the neck of the ring or small finger metacarpal. This injury usually occurs as a result of direct bony trauma when the child/adolescent strikes a fixed object such as a wall with a closed fist or is struck on a fisted hand with an object such as a bat/hurl/hockey stick for example.


The child/adolescent will usually present with bruising, swelling and diffuse pain over the dorsum of the hand. There may be loss of knuckle prominence. Be vigilant for rotational deformity; no degree of malrotation is acceptable.

Ensure to evaluate skin integrity over the injured area, check for and document the presence of open wounds; consider the possibility that these could be so-called ‘’fight bites’’ and will require antibiotics. Substantial injuries or infected open wounds require a surgical opinion as these may require admission for IV antibiotic cover and washout in theatre. Check integrity of flexor/extensor tendons in the presence of open wounds. Remember to check Tetanus vaccination status.

A child/adolescent who presents to the PED with a hand injury because of a fight or an injury mechanism such as puching a wall requires special attention- screening for mental health and/or social problems is paramount. Involvement of medical social worker teams or mental health teams may be necessary. The HEEADSSS screening tool may be useful to guide this line of inquiry.  


Treatment is generally based on the level of injury (e.g. head, neck, shaft and base) and clinical findings (rotational deformities, open wounds, fracture stability).  

Un-displaced stable fractures of the neck or shaft (2nd-5th metacarpals)

Non-operative: Can be treated in rest volar splint/back -slab and followed up in clinic

Angulated neck of metacarpal fractures

Most common is fracture of 5th metacarpal or  ‘‘Boxer’s fracture’’

Treatment guided by degree of angulation. Seek surgical opinion

Non-operative: Closed reduction in PED using nerve block +/- procedural sedation and immobilisation in cast

Operative: Surgery may be required in the presence of open wounds, suspected tendon injuries or if angular deformity is substantial and/ or there is a rotational deformity on clinical exam.

Case courtesy of Dr Benoudina Samir, Radiopaedia.org. From the case rID: 23848

Displaced intra articular, unstable, comminuted or unstable fractures

Operative: These fractures all require surgical referral

Metacarpal head fracture (intra-articular) Courtesy of Orthobullets: https://www.orthobullets.com/hand/6037/metacarpal-fractures

Thumb metacarpal fractures

Thumb metacarpal base fractures require surgical opinion. Disruption of carpometacarpal (CMC) joint congruity can result in significant functional impairments for a child/adolescent particularly loss or limitation of pincer or power grip.

Specific names are given to fractures of the base of the 1st metacarpal

  • Bennett fracture: defined as an intra-articular 2-part fracture of the base of 1st metacarpal bone *(see also Reverse Bennett fracture below)
  • Rolando fracture: similar to Bennett fracture but prognosis is worse. Defined as a comminuted intra-articular fracture of the 1st metacarpal, producing at least 3 parts.

X-ray demonstrates a severely angulated fracture to the neck of Katie’s 5th metacarpal bone. Taking this into consideration and the presence of rotational deformity, you refer her to the hand surgery team for management. They decide to admit her for manipulation under anaesthetic (MUA). While awaiting admission you get the opportunity to establish a rapport and talk to Katie about her mental health. You use the HEEADSSS screening tool to guide your inquiry. She reveals information about difficulties at home related to her mother’s substance abuse and reports that she has been missing a lot of school due to bullying. Katie agrees that she needs help dealing with these issues and you refer her to the inpatient mental health team with her permission. Her dad is also informed.

*Reverse Bennett fracture dislocation

An intra-articular fracture dislocation of the base of 5th metacarpal bone is called a reverse Bennett fracture. This fracture pattern is inherently unstable and referral to hand specialist is essential.

Reverse Bennett fracture dislocation Case courtesy of Dr Alborz Jahangiri, https://radiopaedia.org/cases/reverse-bennett-fracture-dislocation-1


Andy Neill. AFEM 033 | Hand: Lingo and soft tissues. Retrieved from https://litfl.com/bscc/clinical-anatomy/hand-anatomy/

Abzug, J. M., Dua, K., Bauer, A. S., Cornwall, R., & Wyrick, T. O. (2016). Pediatric phalanx fractures. Journal of the American Academy of Orthopaedic Surgeons24(11), e174-e183.

Sullivan, M. A., Cogan, C. J., & Adkinson, J. M. (2016). Pediatric hand injuries. Plastic Surgical Nursing36(3), 114-120.

Wahba, G., & Cheung, K. (2018). Pediatric hand injuries: Practical approach for primary care physicians. Canadian Family Physician64(11), 803-810.

Weber, D. M., Seiler, M., Subotic, U., Kalisch, M., & Weil, R. (2019). Buddy taping versus splint immobilization for paediatric finger fractures: a randomized controlled trial. Journal of Hand Surgery (European Volume)44(6), 640-647.

To CT or not to CT?

Cite this article as:
Dani Hall. To CT or not to CT?, Don't Forget the Bubbles, 2020. Available at:

Does introduction of a national guideline improve c-spine injury detection?

A wise paediatrician once told me that practicing medicine is part art, part science. Pathology and decision making are not always black and white. Sometimes we have to interpret the grey areas, balancing risk.

Cervical spine injuries in children are rare but missing a c-spine injury has devastating consequences. On the flip side, we are taught to apply the ALARA principle whenever deciding whether a child needs a CT.

ALARA stands for As Low As Reasonably Achievable and is a constant consideration for children whose tissues are very radiosensitive to minimize the lifetime risk of cancer. Obtaining good c-spine x-rays can be tricky and interpreting them requires skill. When managing children with potential for cervical spine injury we ask ourselves does this child need imaging of their c-spine and should it be a CT? In 2014 the National Institute of Health and Care Excellence, NICE, introduced a decision rule to help us select which children need c-spine imaging, and whether it should be by x-ray or CT. This was replicated in the Royal College of Radiology Paediatric Trauma Protocols, published that same year. The guidance describes seven indications for CT, six for CT without an x-ray and the seventh for when there is uncertainty following x-ray:

  1. Children with a GCS <13 on initial assessment
  2. Intubation
  3. A definitive diagnosis of c-spine injury is required
  4. Other body areas are being scanned for head injury or multi-region trauma
  5. Focal peripheral neurology
  6. Paraesthesia in the upper or lower limbs
  7. 3-view c-spine x-ray demonstrates a significant bony injury, was technically difficult to perform or inadequate, or was normal but with a strong clinical suspicion of injury

NICE describe a caveat to this list: don’t automatically CT a stable child’s c-spine if you’re organising a CT head. NICE recommends the decision for CT versus x-ray should be made on a case-by-case basis after a discussion between a senior ED clinician and senior radiologist. We’ll come back to this later.

Six years on, Catherine Nunn and colleagues have published a paper assessing the impact of the introduction of the NICE c-spine guideline on both the number of c-spine CT scans requested and the number of c-spine injuries diagnosed.

Nunn et al. Have changes in computerised tomography guidance positively impacted detection of cervical spine injury in children? A review of the Trauma Audit and Research Network data. Trauma. 2020 DOI: 10.1177/1460408620939381

What question did the study team ask?

Nunn and her team looked back at data of children under the age of 16 in the Trauma Audit and Research Network (TARN) in two time periods, 2012 – 2013 and 2015 – 2016, to capture a before and after assessment of the NICE guideline. They gathered the following information from the TARN database:

  • How many children young people under the age of 16 years had c-spine CT imaging?
  • How many had a c-spine injury (CSI)?
  • What was the mechanism of injury?
  • Was there a different between major trauma centres and trauma units?

A bit about TARN

TARN is a national organisation in the UK, and the biggest trauma registry in Europe, collecting data on moderately and severely injured patients from both major trauma centres (MTCs) and trauma units (TUs). Since its introduction in the 1990s, its data has been integral to quality and research initiatives in trauma care. Patients are included in the registry if they require critical care, are transferred between hospitals for ongoing acute critical care, have a hospital length of stay of more than 3 days or if they die as a result of their traumatic injury. Patients who don’t meet these criteria are not included in the database.

What did the study team find?

Did the NICE guideline increase the specificity of detecting a c-spine injury?

Following the introduction of the NICE guideline, there was a decrease in the proportion of children who had a cervical spine CT, from 13.7% to 12.1%, but this wasn’t a statistically significant drop.

What the team did find was an increase in the rate of injury in the children who were initially imaged with CT, from 10% to 16.4%, meaning the specificity of the selection of children for CT c-spin improved after the introduction of the guideline.

Over 80% of children received high risk radiation to the neck and had no injury. Balancing the risk of radiation against missing an injury continues to be a challenge.

Unsurprisingly, road traffic accident was the most common cause of c-spine injury, followed falls.

What about major trauma centres versus trauma units?

Trauma networks were introduced in the UK a decade ago, dividing regions up into a hub major trauma centre (MTC) with spoke trauma units (TUs). Although MTCs are designated to deliver high-quality specialist trauma care, with efficient pathways getting children to scan as part of more specialized care, severely injured children often present to a TU. Nunn’s team found that the introduction of the NICE guideline was associated with a reduction in the percentage of c-spine scans in both MTCs and TUs: both MTCs and TUs were more selective about which children had a c-spine CT.

Trauma Units were more selective in their choice of children undergoing cervical spine CT with a lower proportion having a CT, but a higher proportion of those scanned having a c-spine injury, meaning there was a higher sensitivity of scan in TUs.

This might reflect the caveat suggested by NICE that we shouldn’t automatically CT a stable child’s c-spine when organising a CT head and the decision in these circumstances should be made on a case-by-case basis. Nunn’s team suggest that the efficiency of MTCs getting patients to scan means that more children are being scanned rapidly (as the pathways intend), but more are scanned who are less likely to be injured (meaning more children are exposed to radiation who don’t have an injury).

Is CT the best imaging modality?

Nunn’s team found that 20% of the CT scans in both time groups were falsely negative. Put another way CT only detected 80% of the c-spine injuries, with the other 20% being picked up on subsequent MRI. SCIWORA, or Spinal Cord Injury Without Radiological Abnormality, is a phenomenon particular to children, who may have spinal cord or ligamentous injury that cannot be seen on x-ray or CT.

Is there a role for MRI instead of CT? MRI is much more sensitive in detecting cord and ligamentous injuries but is logistically challenging because these scans aren’t quick – younger children need sedation or general anaesthetic – and putting severely injured children in an MRI for up to 40 minutes is risky. Nunn’s team suggested there will be times skipping CT altogether and performing a delayed MRI, maintaining c-spine precuations until a child is more stable, might be more practical.

The bottom line

Introduction of a paediatric c-spine CT decision tool had a positive impact. The sensitivity of detecting a c-spine injury increased, and fewer children proportionately had CT scans without injury. Twenty percent of children with c-spine injury had negative CT scans so the question remains, should early MRI be advocated instead of CT in a group of children with suspected injury?

Infographic by Emma Hudson

VP shunts

Cite this article as:
Angharad Griffiths. VP shunts, Don't Forget the Bubbles, 2020. Available at:

Rhiannon is a 2 year old with spina bifida who had a VP shunt inserted during the first month.  It was revised because of a “blockage” at 18 months.  She has not been herself for the last 24hours; more lethargic than usual- especially this morning when she woke up where she also felt hot.  She vomited in the car on the way to the Emergency Department.  She has had previous urinary tract infections.

Rhiannon was afebrile on presentation in ED.  In triage, she was observed as being awake and drinking from a bottle but wasn’t perturbed by having her observations taken or finger-prick glucose.  Overall she was a little quiet in the ED and her mum was concerned that this was absolutely different from her baseline.  Her urine microscopy was not concerning.  She had a mild neutrophilia and a normal CRP.  Subcutaneous examination of her shunt, from her skull to the right clavicle was normal.  She vomited once in the ED.


This is a common presentation and one that can be challenging to manage. Missing a shunt problem can have catastrophic consequences. This post will take you through some pearls and pitfalls of managing children with VP shunts presenting to the ED.


What is a VP shunt?

A ventriculoperitoneal (VP) shunt is a medical device used to drain fluid via a pressure gradient, away from the brain for conditions of excessive cerebrospinal fluid (CSF).  The intention is to shunt fluid away and avoid excessive pressure on the brain.  It is one of the commonest performed neurosurgical procedures and is the treatment of choice for the vast majority of patients with hydrocephalus.


Shunts drain according to the differential pressure gradient between the ventricle and the tip of the distal catheter.  The ventricular end of the catheter is inserted through a burr hole in the right parietooccipital region and the valve often sits behind the right ear.  The distal portion is subcutaneously tunneled down into the abdomen where it’s positioned inside the peritoneal cavity.

The diagnosis of raised intracranial pressure in children with VP shunts is challenging.  The symptoms are non-specific and the commonest causes often benign.  Rhiannon could easily have a simple viral illness or her symptoms could be associated with rising intracranial pressure. Missing a shunt malfunction in these patients can be catastrophic.


Physiology of CSF circulation and drainage

  • CSF  is produced at a rate of approximately 20ml/h in children and adults. In normal circumstances, in a normal adult, CSF is recycled three times a day. The normal adult volumes of CSF (approximately 150mls) are reached by age 5.  The volume in a neonate can be estimated at  2ml/kg.
  • Around 50% of CSF is created by the choroid plexus of the lateral, third and fourth ventricles.  The rest of the CSF arises from the extracellular fluid of the brain.  CSF travels out of the foramen of Lushka and foramen of Magendie (at the level of the fourth ventricle), and heads through to the subarachnoid spaces, along the spinal cord to the cerebral hemispheres.  Over the cerebral hemispheres, the CSF is reabsorbed by arachnoid villi and then into the venous sinuses which drain into the jugular (internal) veins.
  • Intracranial pressure (ICP) rises when CSF production exceeds absorption.
  • Hydrocephalus is the consequence of the excessive accumulation of CSF. This could be from disruptions in formation, flow or absorption.
  • As hydrocephalus worsens and intracranial pressure increases, the temporal and frontal horns dilate, sometimes asymmetrically; and there’s elevation of the corpus callosum and stretching of white matter tracts.


Lateral = Lushka — Median = Magendie


Shunting CSF is an effective way to avoid the neurological damage that ensues if the build-up of CSF is left untreated.

Three shunts types are mainly used to shunt CSF: Ventriculoperitoneal (VP), ventriculopleural (VPL), and ventriculoatrial (VA). By far, the commonest are VP shunts.


Reasons for shunt placement

There is a myriad of reasons as to why a VP shunt should be placed.  They can be categorized into congenital or acquired causes.


Having a VP shunt in itself is a cause for concern for patients and caregivers.  Common areas for concern in paediatric patients include:

  • Flying and travel: there is no evidence that flying is dangerous but patients have concern over access to neurosurgical help should they need it. Shunt alert cards displaying the type of shunt are available.  The need for augmented travel insurance is also an area of concern.
  • Sports: Contact sports such as boxing are contra-indicated, and the US paediatric neurosurgeons named wrestling and football (soccer) as the commonest sports with adverse events.  Neurosurgeons in the UK are advising that football and rugby wearing a skullcap are acceptable.  You can still go scuba diving.
  • Future employment: in the UK, the Royal Air Force, Royal Navy and Police Force are the only services that preclude entry.
  • Programmable shunts and magnets: Background magnetic fields of household objects such as microwaves etc are safe as are walk-through metal detectors.  Post MRI check is advised with some programmable shunts but all are MRI safe.  The iPad2 has a strong magnetic field and can re-program some shunt valves, thus important to keep them at safe distances.
  • Shunt length: reassurance that placing sufficient length inside the abdomen will suffice and allow for growth.
  • Weight: Obesity is a risk factor for failure of VP shunts and dislodgement.


Shunt related complications

Failure rates are quoted as 30-40% at 1 year and 50% at 2 years in the paediatric cohort. A patient can expect to have 2-3 shunt revisions over the course of 20 years and the median time to shunt failure is just 1 and a half years. Paediatric revisions are more commonplace than adult revisions.


Risk factors for shunt failure include:

  • Younger patients (<6months), particularly neonates
  • Complex comorbidities, for example, cardiac, myelomeningocele, IVH’s, tumour and post-meningitic hydrocephalus, spinal dysraphism, and congenital hydrocephalus
  • Prior shunt failure and short time intervals between revisions
  • Male sex
  • Low socioeconomic status


Causes of shunt failure

Obstruction, blockage or occlusion

The commonest cause of shunt malfunction is proximal occlusion. There’s no clear data on whether programmable or non-programmable shunts are less likely to occlude.

It’s hypothesized that on insertion, the lumen can be obstructed with brain parenchyma from the cerebral cortex before reaching the ventricle, or choroid plexus when inserted near to the foramen of Monroe. It can also be occluded with blood following choroid plexus haemorrhage along with other cellular matter such as macrophages, giant cells, connective tissue, fibrin networks, debris, neoplastic cells.

Distal catheter blockage tends to occur later and when it occurs, it should raise the suspicion for an intra-abdominal pseudocyst or adhesions which may affect future peritoneal catheter placements.

Shunt infection

Shunt infection is the second most common reason for malfunction. The data is mixed, particularly as some older papers use data from before the time of antibiotic-impregnated catheters, skewing the data. Risk factors include young age (including neonates), post-op CSF leak, previous shunt infections, and the presence of a gastrostomy tube.

The vast majority of shunt infections are acute.  Far fewer late-onset infections have been reported. They can be attributed, mostly, to peritonitis, abdominal pseudocyst, bowel perforation, and haematogenous inoculation.

Shunt infection is associated with an increased risk of seizure disorder, decreased intellectual performance, and a two-fold increase in long term mortality. Re-infection occurs in one-quarter of children.

The proportion of shunt infections falls off rapidly after the first several months following implantation. The vast majority occur during the first 6 months. Children will present with signs of shunt failure, as well as systemic infection.  Fever is common and if we were to sample CSF (which is not often done in the ED), the presence of >10% neutrophils in the ventricular fluid is highly specific and sensitive of infection.

The commonest organisms are skin flora, including Staphylococcus epidermidis, Staph. aureus and gram-negative rods.  Infections with Staph. aureus and epidermidis are associated with an earlier onset as they are skin commensals. Infections with Staph. aureus are associated with a significantly increased likelihood of subsequent shunt infection.

Shunt fracture

This is often a late complication and almost always occurs along the distal portion between the valve and peritoneum.  With age, fibrous tissue becomes calcified and does not slide freely within the subcutaneous tissue then the tubing can crack.  This is more likely to happen in the neck where most movement occurs.

Tension can also form along areas of calcification causing tethering and stretching as the child grows.  It is important to note that early shunt fracture can occur and this could be a consequence of trauma to the tubing during surgery.

CSF can still drain resulting in an insidious duration of symptoms, clouding and confusing the diagnostic process.

Shunt series radiographs should always be sought in this cohort, though frequently fractures and disconnections are incidental findings during surveillance exams.

VP shunt fracture. Reused with permission from Education and Practice, Archives of Disease of Childhood


Shunt disconnections

Catheters are generally multi-component and hubbed together so disconnections can occur soon after surgery. The disconnection impedes the flow of CSF and it may still leak.  The onset of these symptoms may be slow.  Disconnections can happen at either the proximal or distal aspect of the valve.

Case courtesy of Dr Adam Eid Ramsey, Radiopaedia.org. From the case rID: 71794


Abdominal pseudocyst

This is a rare complication of VP shunts and is usually a late complication occurring years after initial placement. A pseudocysts is a fluid-filled sac that collects at the distal tip of the catheter.  It is thought that they form because of inflammation or due to abdominal adhesions.  It can present with abdominal pain or distention with, or without, a palpable abdominal mass.  Neurological symptoms occur when there is elevated ICP.

Shunt migration

The proximal or distal catheter tip may migrate.  With growth, the proximal catheter can withdraw from the ventricle (extremely rare), or the distal catheter can shift away from the peritoneum.  The distal tubing can become tethered and cause traction on some of the components causing a disconnection.  Distal migration occurs as the child grows.



It is possible that a VP shunt can over-drain as well and ‘under-drain’.  With rapid over-drainage, the dura can be stressed and subdural haematomas and/or extra-axial fluid collections can form.

A slit ventricular syndrome occurs when gravitational forces exert a siphoning effect on the ventricles.  This effect is generally amplified by pressure.


Clinical presentation of shunt malfunction

Children with a blocked shunt can present with a myriad of symptoms including:

  • headache
  • nausea
  • vomiting
  • fever
  • irritability
  • abnormal level of consciousness

Infants and older children may present differently.


  • difficulty feeding
  • bulging fontanelle

Older children may present more specifically with

  • Nausea, somnolence, lethargy, cognitive difficulties, or eye pain.


Predictably, fever is commoner in children with shunt infections. Those with shunts because of myelomeningoceles may present with symptoms such as:-

  • weakness,
  • difficulty walking
  • bowel/bladder dysfunction
  • lower cranial nerve palsies.

Children present with these symptoms all the time to the ED. They are clearly not specific to a shunt problem.  As a consequence, diagnosing shunt malfunction on clinical grounds alone is incredibly difficult. Patients with shunt fracture or disconnection can present with a slow onset of symptoms.  They may have pain/tenderness localized to the area of fracture/disconnection or an area of calcification of an area of fluctuant swelling.


Diagnosis, evaluation, and imaging

The diagnosis of a shunt malfunction requires a combination of CT, shunt series radiographs, and occasionally (though seldom in the ED), CSF sampling.

A CT is likely to show an increase in ventricular size and occasionally, periventricular lucency representing oedema.  There may be increasing ventricular size on cross-sectional imaging but up to 15% will have “such profound alterations on brain compliance that their ventricles will not enlarge in the face of shunt failure and increased ICP”.  Ventricular size doesn’t appear to reach a plateau until approximately 14months after placement of the shunt (regardless of type implanted).

A lumbar puncture (LP) may demonstrate increased opening pressures, but not always.  It is also used for evidence of infection.  This not performed commonly in the ED in the context of possible shunt malfunction.

Shunt series (SS) radiographs are used to check the overall course of the catheter, looking for disconnection or disruption.  The series will not show obstructions, only damage to the catheter. It can rarely demonstrate complications such as a CSF pseudocyst (abnormal separation of bowel loops near the catheter tip) but shouldn’t be relied upon for this.

The number of radiographs needed varies according to the size of the child.  It is usually 3-4 radiographs, including two views of the skull and the continuous trajectory of the shunt tubing down the neck, chest, and then looping into the abdomen.

If a series is performed after the scan, theoretically a 2 view skull radiographs can be eliminated, provided that the chest x-ray includes the base of the neck. Unnecessary radiation may then be avoided.

The use of ultrasound is an area of ongoing research and has been largely unvalidated in children with VP shunts.


No clear cause for Rhiannon’s symptoms was found following a thorough examination.  A CT was performed because of concern over shunt failure. Her ventricles were noted to be slightly larger than a CT performed previously.  Shunt series radiographs showed continuous, non-kinked tubing.  She was admitted under the care of the Neurosurgeons and her shunt was revised.  No physical reason for shunt obstruction was found.


Selected references

Mansson PK, Johansson S, Ziebell M, Juhler M. Forty years of shunt surgery at Rigshospitalet, Denmark: A retrospective study comparing past and present rates and causes of revision and infection. BMJ Open. 2017;7(1).

Berry JG, Hall MA, Ph D. A multi-institutional 5 year analysis of Initial and multiple ventricular shunt revisions in children. Neurosurgery. 2008;62(2):445–54.

Pople IK. Hydrocephalus and shunts: What the neurologist should know. Neurol Pract. 2002;73(1).

Paff M, Alexandru-Abrams D, Muhonen M, Loudon W. Ventriculoperitoneal shunt complications: A review. Interdiscip Neurosurg Adv Tech Case Manag. 2018;13(June 2017):66–70.

Gonzalez DO, Mahida JB, Asti L, Ambeba EJ, Kenney B, Governale L, et al. Predictors of Ventriculoperitoneal Shunt Failure in Children Undergoing Initial Placement or Revision. Pediatr Neurosurg. 2016;52(1):6–12.

Wu Y. V Entriculoperitoneal S Hunt C Omplications in C Alifornia : 1990 To 2000. 2007;61(3):557–63.

Brinker T, Stopa E, Morrison J, Klinge P. A new look at cerebrospinal fluid circulation. Fluids Barriers CNS. 2014;11(1):1–16.

Rochette A, Malenfant Rancourt MP, Sola C, Prodhomme O, Saguintaah M, Schaub R, et al. Cerebrospinal fluid volume in neonates undergoing spinal anaesthesia: A descriptive magnetic resonance imaging study. Br J Anaesth [Internet]. 2016;117(2):214–9. Available from: https://dx.doi.org/10.1093/bja/aew185

Desai KR, Babb JS, Amodio JB. The utility of the plain radiograph “shunt series” in the evaluation of suspected ventriculoperitoneal shunt failure in pediatric patients. Pediatr Radiol. 2007;37(5):452–6.

Stone JJ, Walker CT, Jacobson M, Phillips V, Silberstein HJ. Revision rate of pediatric ventriculoperitoneal shunts after 15 years: Clinical article. J Neurosurg Pediatr. 2013;11(1):15–9.

Brian W. Hanak et al. Cerebrospinal fluid shunting compliations in children. Pediatr Neur. 2017;52(6):381–400.

Hanak BW, Ross EF, Harris CA, Browd SR, Shain W. Toward a better understanding of the cellular basis for cerebrospinal fluid shunt obstruction: Report on the construction of a bank of explanted hydrocephalus devices. J Neurosurg Pediatr. 2016;18(2):213–23.

Khan F, Shamim MS, Rehman A, Bari ME. Analysis of factors affecting ventriculoperitoneal shunt survival in pediatric patients. Child’s Nerv Syst. 2013;29(5):791–802.

Shastin D, Zaben M, Leach P. Life with a cerebrospinal fluid (CSF) shunt. BMJ [Internet]. 2016;355(October):1–5. Available from: https://dx.doi.org/doi:10.1136/bmj.i5209

Simon TD, Butler J, Whitlock KB, Browd SR, Holubkov R, Kestle JRW, et al. Risk factors for first cerebrospinal fluid shunt infection: Findings from a multi-center prospective cohort study. J Pediatr [Internet]. 2014;164(6):1462-1468.e2. Available from: https://dx.doi.org/10.1016/j.jpeds.2014.02.013

Buster BE, Bonney PA, Cheema AA, Glenn CA, Conner AK, Safavi-Abbasi S, et al. Proximal ventricular shunt malfunctions in children: Factors associated with failure. J Clin Neurosci [Internet]. 2016;24:94–8. Available from: https://dx.doi.org/10.1016/j.jocn.2015.08.024

Mcgirt MJ, Zaas A, Fuchs HE, George TM, Kaye K, Sexton DJ. Factors Infecton for Pediatrc and Venticulopertoneal of Shunlt Predictors Infectous Patiogens. 2014;36(7):858–62.

Mcclinton D, Carraccio C, Englander R. Predictors of ventriculoperitoneal shunt pathology. Pediatr Infect Dis J. 2001;20(6):593–7.

Erol FS, Ozturk S, Akgun B, Kaplan M. Ventriculoperitoneal shunt malfunction caused by fractures and disconnections over 10 years of follow-up. Child’s Nerv Syst. 2017;33(3):475–81.

Dabdoub CB, Dabdoub CF, Chavez M, Villarroel J, Ferrufino JL, Coimbra A, et al. Abdominal cerebrospinal fluid pseudocyst: A comparative analysis between children and adults. Child’s Nerv Syst. 2014;30(4):579–89.

Boyle TP, Kimia AA, Nigrovic LE. Validating a clinical prediction rule for ventricular shunt malfunction. Pediatr Emerg Care. 2018;34(11):751–6.

Tuli S, O’Hayon B, Drake J, Clarke M, Kestle J. Change in ventricular size and effect of ventricular catheter placement in pediatric patients with shunted hydrocephalus. Neurosurgery. 1999;45(6):1329–35.

DeFlorio RM, Shah CC. Techniques that decrease or eliminate ionizing radiation for evaluation of ventricular shunts in children with hydrocephalus. Semin Ultrasound, CT MRI [Internet]. 2014;35(4):365–73. Available from: https://dx.doi.org/10.1053/j.sult.2014.05.002

Smyth MD, Narayan P, Tubbs RS, Leonard JR, Park TS, Loukas M, et al. Cumulative diagnostic radiation exposure in children with ventriculoperitoneal shunts: A review. Child’s Nerv Syst. 2008;24(4):493–7.

Nasal foreign body removal using a magnetic device

Cite this article as:
Ana Waddington Tessa Davis. Nasal foreign body removal using a magnetic device, Don't Forget the Bubbles, 2020. Available at:

Button battery removal from a nasal cavity using a magnetic telescopic pickup tool

A 4-year-old boy presented to the Emergency Department (a major trauma centre in the UK, with a dedicated paediatric ED and 48000 annual paediatric emergency presentations) with a possible foreign body in his right nostril. Earlier that day, one of the parents had noticed that something might be in the nostril after wiping the child’s nose after a minor nosebleed. The parents were unsure what the foreign body was, or how long it had been there.

The nurse at triage noticed something that looked metallic in the right nostril. Our department had recently purchased a magnetic telescopic pick-up tool online for less than £2 (see image) for this eventuality.

The pickup tool was covered with a latex glove, and while the parent cuddled the child to keep them still, the tool was gently inserted into their right nostril. Within one second a click was felt, and the tool was withdrawn from the nostril. On the end of the magnetic tool was a button battery.

Re-examination showed no further foreign objects and some mild inflammation at the entrance of the right nostril. 

The patient was reviewed by the ENT team who prescribed an anti-bacterial nasal cream and followed up in outpatient clinic two weeks later. At that point the examination was normal.

The idea to purchase a magnetic pickup tool for the department came from Tim Horeczko’s PEM Playbook article and podcast ‘Foreign bodies in the head and neck‘. In it he writes:

Magnetic pick-up tools – used by mechanics, engineers, and do-it-yourselfers – are inexpensive and readily available in various sizes, shapes, and styles such as a telescoping extender.  Look for a small tip diameter (to fit in the ear canal as well as the nose) and a strong “hold” (at least a 3lb hold).

Our tool was 2lbs/0.9kg hold. This was adequate for removal of the button battery.

There is one previous case report of a button battery being removed from the nasal cavity of a three-year-old using a magnet (Alletage et al, 2014). In this case, the team created their own device (the Jacobson extractor) with an earth magnet attached to a 14F nasal trumpet (with a flexible arm) attached to a curette. This method was used after a number of failed attempts with other techniques, including suction removal and a balloon catheter. 

There are two other nasal foreign body case reports where a magnet was used (not a button battery). Douglas et al (2002) reported a one-year-old with a ball bearing in the nostril which was referred to ENT due to unsuccessful ED removal and was then successfully removed using a similar tool to the one used in this case report. And Yeh at al (2012) report a 26-year-old with two magnetic disc earrings (one up each nostril) which required two cardiac pacemaker magnets attached to two forceps. One device was used simultaneously in each nostril to separate the earrings.

There are three case reports where magnets were used to remove metallic objects from the ear. Landry et al (1986) used a magnetized screwdriver to remove a button battery from a nine-year-old’s ear; Nivatvongs et al (2015) used a telescopic magnetic rod to remove a button battery from a nine-year-old’s ear under general anaesthetic after multiple failed alternative techniques were attempted in the Emergency Department, and Din et al (2019) reported the use of a specially-designed angled magnetic probe to remove a metal bolt from a ten-year-old’s ear canal.

Our case report is the first where a simple magnetic telescopic pickup tool was used to remove a button battery from the nose as the first attempt resulting in successful and swift removal. 

Note: full consent has been obtained from the child’s family for publication

To learn more about foreign body removal check out Becky Platt’s talk and accompanying post from DFTB Essentials.


Cite this article as:
Stephen Gilmartin. Apophysitis, Don't Forget the Bubbles, 2020. Available at:

David is a 12-year-old boy who attends the emergency department complaining of bilateral heel pain. His pain has been getting gradually worse over the past month. He is a keen footballer, but his symptoms have gotten to the stage where he is now unable to play through his pain.


Apophysitis is a term used to describe a group of overuse traction injuries which commonly cause pain in adolescents. We have all heard of Osgood Schlatter disease. It is the most common form of apophysitis. Other anatomical areas that are commonly affected include the inferior pole of patella (Sinding-Larsen-Johansson), calcaneal tuberosity (Sever’s), medial epicondyle of the elbow (within spectrum of Little League elbow) and various sites on the pelvis. They’re subtly different from osteochondrosis, which is instead due to changes in the epiphyseal ossification centre.

An apophysis is an area of bony growth separate to the ossification centres. It acts as a site of tendon or ligament attachment and will eventually fuse with the bone as the body matures. Rapid growth and relative bone weakness combined with repetitive movements cause increased traction forces at the point of attachment. The apophysis is the weakest point in the muscle-tendon-bone junction; repeated strain at this point leads to bone fragmentation and micro-separation. This abnormal growth leads to swelling and pain at the site. Similar overuse injuries result in tendon and muscle injuries in adults.

Apophysitis is most common during ages of peak growth i.e. between 10-14 years in girls and 12-16 years in boys. Apophysitis is traditionally more common in boys, but the incidence is growing in girls. This is likely linked to increasing sports participation rates among girls of this age. The mean age of onset is younger in girls due to the earlier appearance of the ossification centres. Earlier fusion leads to the cessation of symptoms at a younger age in girls when compared to boys. In lower limb apophysitis, up to 50% of patients will experience bilateral symptoms.


Let’s take a look at some x-rays

This 11-year-old male basketball player has been complaining of heel pain. His ankle x-ray shows increased density of the calcaneal apophysis, typically seen in children between 7 and 14 years with Sever’s Disease. There is loss of fat/soft tissue planes in the region of the retrocalcaneal bursa in keeping with acute inflammation.

Case courtesy of Dr Dinesh Brand, Radiopaedia.org. From the case rID: 60324


This 12-year-old female long-distance runner complains of anterior knee pain, localised to the inferior aspect of her patella. Her lateral knee x-ray shows dystrophic ossification of the inferior patella with subtle thickening of proximal patellar tendon. These changes are consistent with a diagnosis of Sinding-Larsen-Johansson.

Sinding-Larsen-Johansson. Case courtesy of Dr Michael Sargent, Radiopaedia.org. From the case rID: 6323


This 13-year-old female volleyball player presents with progressive pain over her tibial tuberosity. Her pain is exacerbated by jumping. Her lateral knee x-ray shows fragmentation of apophysis with overlying soft tissue swelling, classic for Osgood Schlatter Disease. Some isolated fragmentation can be normal at the tibial tuberosity.

Osgood Schlatter’s Disease. Case courtesy of Dr Hani Salam, Radiopaedia.org. From the case rID: 9740


This 11-year-old boy presents to the ED with worsening elbow pain. He is an avid cricket player and is trying to make his county underage team but finds his pain much worse while bowling. His AP elbow x-ray shows widening of the physis at the medial epicondyle. This is consistent with a diagnosis of Little League Elbow. You may also see fragmentation.

Little League Elbow from Orthobullets


This is an MRI of a 14-year-old male long-distance runner complaining of anterior hip pain. His pain is becoming increasingly worse on running and is now affecting his times. MRI shows bone marrow and surrounding soft tissue oedema at the anterior superior iliac spine involving the sartorius muscle origin without separation as may occur in an acute avulsion injury. This is consistent with ASIS (anterior superior iliac spine) apophysitis. Plain radiographs are usually normal or may only show subtle changes of pelvic apophysitis.

ASIS apophysitis. Case courtesy of Dr Chris O’Donnell, Radiopaedia.org. From the case rID: 31877


History and exam

Apophysitis has a typical history and the diagnosis is largely based on an accurate history and exam. An adolescent will present with gradual onset focal pain over the involved site. They are typically highly active and may be going through an acute increase in there training levels. They may be currently progressing to higher levels of sport or competing in multiple sports at multiple grades. The initial symptom will be pain present at the start of physical activity. In the early stages the pain will often subside once the child has fully warmed up, only to return once they have cooled down. As the process progresses the child will have persisting symptoms throughout physical activity and the pain will eventually result in total cessation of activity.

Clinical examination will reveal point tenderness over the affected site. There may be mild swelling over the area. Pain will be reproduced by resisted contraction of the affected muscle, e.g. resisted plantar flexion of the ankle in Sever’s disease and resisted knee extension in Osgood-Schlatter’s. A good way to assess this is to ask the patient to demonstrate actions which exacerbate their pain.


Differential diagnosis

Alternative diagnoses and investigations should be considered if there are any concerning features on history or exam. Atypical features on presentation are:

  • Sudden onset pain
  • Pyrexia
  • Non-weightbearing
  • History of trauma
  • Point of tenderness or age of patient not typical for apophysitis.

The most common differential diagnoses are osteomyelitis, avulsion fractures, osteochondritis, stress fractures and malignancy. Investigations should be performed in accordance with suspected differential diagnosis.

The below cases and accompanying images highlight the need for you have possible alternative diagnoses in the back of your mind. The patient should be presenting with gradual onset pain, over an apophysis site, at the appropriate age (10-16) for apophysitis. A history which includes high levels or sudden increase in activity can be helpful. Any atypical features should be actively sought out.


This elbow x-ray is from a 13-year-old male baseball pitcher attending with sudden onset medial elbow pain. The medial epicondyle is displaced with a sliver adjacent bone, representing a medial epicondyle avulsion fracture. There is marked adjacent soft tissue swelling and joint effusion. Compare this to the Little League elbow x-ray.

Medial epicondyl avulsion fracture. Case courtesy of Dr Henry Knipe, Radiopaedia.org. From the case rID: 41533


A 10-year-old female basketball player attended with sudden onset knee pain following a fall. The x-ray shows a bone fragment avulsed from inferior patella at point of tendon insertion with moderate overlying soft tissue swelling: a patella sleeve fracture. This contrasts with the findings of dystrophic ossification of Sinding-Larsen-Johansson.

Patella sleeve fracture. Case courtesy of Dr Yuan Ling, Radiopaedia.org. From the case rID: 69680


A 13-year-old female long jumper attends with anterior knee pain following a fall resulting in forced flexion of their flexed knee. She has significant pain and is unable to straight leg raise. Her x-ray shows displacement of tibial tuberosity with significant overlying soft tissue swelling: an avulsion fracture of the tibial tuberosity. Compare this to the typical radiographic features of fragmentation and mild swelling observed in Osgood-Schlatter disease.

Tibial tuberosity avulsion fracture. Case courtesy of Radiopaedia.org. From the case rID: 12022


A 13-year-old girl presents with worsening ankle/heel pain over the last week. Her pain is exacerbated on while running and playing football. She has been pyrexic over the past 24 hours and is now unable to weight bear. The x-ray of her ankle shows diffuse soft tissue swelling abutting the distal end of her fibula. There is suspicious erosion of distal fibular cortex. These findings are suspicious for osteomyelitis of the distal fibula.

Osteomyelitis of the distal fibula. Case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 10046


An 8-year-old boy attends with gradual onset knee pain while running. He begins to notice some associated swelling. His mother feels he is becoming increasingly lethargic. Lateral x-ray shows sclerotic lesion involving the dia-metaphyseal region of the tibia with a wide zone of transition and characteristic “Sunburst ” type of periosteal reaction seen in osteosarcomas.

Osteosarcoma of the tibia. Case courtesy of Dr Iqbal Naseem, Radiopaedia.org. From the case rID: 22814



Despite the diagnosis being clinical, a baseline x-ray is often useful. An x-ray can help ensure there is no avulsion fracture and a study by Rachel et al found x-rays changed management in up to 5% of patients with Sever’s disease.

Findings of apophysitis can vary on imaging and some patients may not show any radiological changes on plain films. The typical x-ray findings include increased density and fragmentation at secondary ossification centres. Overlying soft tissue swelling can often be seen. MRI will reveal increased fluid signal, apophyseal oedema and fragmentation.

This lateral plain film view shows the calcaneal apophysis with high density and fragmentation consistent with Sever’s disease.

Sever’s on x-ray. Case courtesy of Dr Fateme Hosseinabadi , Radiopaedia.org. From the case rID: 69971

Compare the x-ray to this MRI image showing oedema and fragmentation at the calcaneal apophysis and extending into the adjacent calcaneal tuberosity. These findings are commonly seen in patients with Sever’s disease.

Sever’s on MRI. Case courtesy of Dr Paulo A Noronha, Radiopaedia.org. From the case rID: 63302



Apophysitis is a self-limiting process. Most patients will return to full activity following 4-6 weeks of rest or reduced activity. Despite successful return to activity, patients may continue to experience some symptoms. The symptoms will cease definitively once growth centres fuse.

The focus of treatment should be to reduce symptoms sufficiently to allow continued sports participation.

Strategies shown to improve recovery are

  • analgesia
  • activity modification
  • muscle stretching and strengthening programmes

Other therapies which have little evidence but may be helpful in some cases include

  • ice application
  • foot orthotics or heel raises in Sever’s disease
  • taping or bracing

There is no place for surgery in the standard treatment of apophysitis. Any short-term benefit observed from surgery cannot be justified when weighed against the potential damage to an immature skeleton. Surgery may be considered an option if there is a displaced avulsion fracture or a loose body in an affected joint.



Apophysitis is a largely preventable process and as a result recent focus has been placed on both primary and secondary prevention programmes. It can be difficult at an individual level to make changes as these patients tend to be highly active and competitive people. This has seen some youth sport bodies enforcing limits on game participation and mandatory rest to avoid repetitive strain.

Simple advice to give parents and children include:

  1. Encourage 1-2 days off from competitive sport per week
  2. Encourage 2-3 months off from each sport per year
  3. Participate on only one team per sport
  4. Avoid early sport specialisation
  5. Avoid increasing levels of training by more than 10% from one week to the next
  6. Maintain good sleep, hydration and dietary habits.


Take home tips

  • Apophysitis has a typical history of gradual onset pain over an apophysis in highly active adolescents.
  • It is a self-limiting process but can cause debilitating pain.
  • Treatment should focus on analgesia, activity modification and muscle stretching programmes.
  • Symptoms will resolve definitively once ossification centres fuse.


Not to miss bits

  • Any atypical features should be investigated appropriately. The area around the apophysis is a common site for avulsion fractures, osteomyelitis and malignancy.
  • These patients are high risk for other overuse injuries. All patients should be given secondary prevention advice.


And our favourites, the controversies

  • Despite the diagnosis being clinical, baseline x-rays can be useful to out-rule other differential diagnoses.
  • There is little evidence displaying additional benefit for treatment with taping or splints.
  • Custom orthotics can be useful for patients suffering from Sever’s Disease.


David undertook a month long physio led programme of activity modification and muscle stretching. He was given secondary prevention advice to avoid overtraining. He is now back to symptom free football participation.  



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Elengard, T., Karlsson, J., & Silbernagel, K. G. (2010). Aspects of treatment for posterior heel pain in young athletes. Open Access Journal of Sports Medicine, 1, 223–232.

Fleisig, G. S., Andrews, J. R., Cutter, G. R., Weber, A., Loftice, J., McMichael, C., Hassell, N., & Lyman, S. (2011). Risk of serious injury for young baseball pitchers: a 10-year prospective study. The American Journal of Sports Medicine, 39(2), 253–257.

Frush, T. J., & Lindenfeld, T. N. (2009). Peri-epiphyseal and Overuse Injuries in Adolescent Athletes. Sports Health, 1(3), 201–211.

Gregory, B., & Nyland, J. (2013). Medial elbow injury in young throwing athletes. Muscles, Ligaments and Tendons Journal, 3(2), 91–100.

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Cite this article as:
Stephen Gilmartin. Osteochondrosis, Don't Forget the Bubbles, 2020. Available at:

The Limp family arrive at the emergency department with two of their children. Katie is a 10-year-old complaining of right foot pain.  The pain has been getting worse over the past month and she is now beginning to develop some stiffness.  She is a keen athlete and trains five times per week.  Her younger brother Michael is a six-year-old attending with progressive left hip pain.  Both children’s injuries were atraumatic, and they are systemically well.



Osteochondrosis is a disorder of bone growth primarily involving the ossification centres at the epiphysis.  It commonly begins in childhood and results in osteonecrosis of the growth plate.  This can lead to altered bone and cartilage formation beyond the growth plate.

Although often confused with apophysitis, which is more clearly due to traction overuse injuries, osteochondrosis is often described as idiopathic osteonecrosis as there has been no definite cause found.  There have been some links showing genetic factors and high activity levels can increase a person’s risk of developing osteochondrosis.




History and examination

Osteochondrosis presents in a similar fashion independent of location.  The symptoms will have a subacute onset with one or more of; joint pain, swelling or dysfunction.  The patient may comment on symptoms worsening while stressing the site during activity.  This is typical in throwing or gymnastics for Panner disease and weight-bearing activities such as running and jumping in lower limb osteochondrosis.

The joint involved may have mild swelling and tenderness.  Other common findings are stiffness and a reduced range of motion. Active children will often seek medical attention once their pain and stiffness begin to affect sporting performance.

Important points to establish on history and exam are no sudden pain, absence of temperature and no systemic complaints. This will help you to consider important differentials including osteomyelitis, malignancy and stress fractures.



X-ray is the diagnostic tool of choice. Findings depend on anatomical location and the stage of disease.  Each location has its own radiological criteria which can be quickly referenced online.  MRI may be required in certain cases if the diagnosis remains unclear following initial imaging. Early typical x-ray findings are potentially normal. Radiological findings tend to show:

Initial findings

  • Irregular epiphyseal growth
  • Flattening of the epiphysis
  • Soft tissue swelling

As disease progresses

  • Sclerosis
  • Fragmentation
  • Joint destruction

Blood tests have no role in the diagnosis of osteochondrosis but will aid the work-up of possible differentials including infection and malignancy.


Perthes Disease

A 10-year-old boy presents to the ED with progressive left leg pain.  It has been progressing over the past few months with normal knee x-ray.  The pain is now becoming localised to the hip. He has a hip x-ray performed which shows flattening of the femoral head with widening of the femoral neck.  There is increased joint space and sclerosis at the physis.  His x-ray shows advanced Perthes disease.

Case courtesy of Dr Michael Sargent, Radiopaedia.org. From the case rID: 5978


Panner Disease

A 13-year-old cricket player attends with elbow pain.  The pain started gradually while bowling.  He is now complaining of stiffness and pain which is affecting his performance. His x-ray shows irregularity of the capitellum with associated sclerosis. These findings are consistent with a diagnosis of Panner disease.

Image source Orthobullets.com


Freiberg’s Disease

A 15-year-old female runner presents complaining of progressive forefoot pain while training.

Her x-ray shows widening of the metatarsophalangeal joint.  There is flattening of the metatarsal head with cystic lesions.  These findings are seen in Freiberg disease. Progressive disease will show sclerosis and increased cortical thickening.

Case courtesy of Dr Hani Salam, Radiopaedia.org. From the case rID: 9296


Kohler Disease

A 9-year-old presents with worsening left foot pain.  X-ray reveals thinning and sclerosis of the navicular bone.  This is typical for Kohler disease.  You may see fragmentation in advanced cases.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org. From the case rID: 18657



Osteochondrosis is self-limiting and the bone will eventually revascularize to a certain extent.  The goal of therapy is to facilitate maximal revascularisation while minimising long term symptoms.

An appropriate treatment plan should be decided on a case by case basis and in conjunction with orthopaedics, physiotherapists and the patient themselves.  Although there is limited evidence to guide the type and length of treatment, there are some factors which can help guide clinicians.

  • Radiological stage: There are radiological staging criteria unique to each form of osteochondrosis. These categorise disease progression on x-ray.
  • Joint function: Patients range of motion and stiffness should be assessed. If there is a significant loss of joint function the patient should be treated more aggressively to prevent progression
  • Patient symptoms: If the patient’s pain is significant, they may need some immobilisation to aid with pain prior to progression of their rehabilitation.
  • Age at presentation: as a rough rule of the thumb, the younger the patient’s bone age the more likely they are to respond to conservative management.

Three broad treatment strategies exist.

Conservative: This will involve modified activity to ensure no further stress is placed on the area involved. A physiotherapy programme can help to strengthen the area and improve joint function.  This approach is suitable for patients with minimal symptoms and early changes of disease progression on x-ray.

Immobilisation:  Immobilisation can be beneficial for patients with significant pain or more advanced changes on x-ray.  This may be in the form of a cast, walking boot or splint depending on the area involved.  This needs to be weighed up against the risk of worsening joint stiffness.

Surgery:  It is very rare if ever that patients will require surgery.  When used it is only in advanced stages of disease and when appropriate conservative management has proved ineffective. Surgical options include osteotomy, arthroplasty and physeal drilling.



Osteochondrosis is a self-limiting pathological process. Patients will usually show full clinical and radiological recovery if diagnosed and treated early. Despite this, some patients will continue to have long term pain and stiffness; this can occur despite appropriate treatment plans.

This is especially true for Perthes Disease patients have a high risk of arthritis and subsequently requiring a total hip replacement. One case series found that >50% of all Perthes Disease patients will require total hip replacement with the mean age of initial total hip replacement of 37.8 years.

Bone age of <6 years and <50% femoral head involvement have been shown to be good prognosticating factors for Perthes.


The Limps are delighted with your assessment.  Katie has been diagnosed with Kohler Disease.  You place her in a boot for 4 weeks for symptoms management.  Following this she undergoes a specific return to activity regime to manage her training load and recovery.  She is totally symptom-free at 6 months.

Michael is lucky that his diagnosis of Perthes was made early.  His x-ray shows he is in the early stages with minimal femoral head involvement and good femoral head coverage.  He is started on a physio programme with closely monitored clinical and radiographic assessment until full recovery.


Take homes

  • Osteochondrosis is an idiopathic osteonecrosis affecting children
  • It is diagnosed with a combination of accurate history and typical radiograph findings
  • Early diagnosis and treatment can aid a complete recovery
  • Bone age <6 years, <50% of femoral head involved and good femoral head coverage are good prognosticating factors for Perthes disease

Not to miss bits

  • Differential diagnoses including malignancy and infection may present similarly
  • Common systemic causes of osteonecrosis should not be missed i.e. haematological (sickle cell, malignancy), Rheumatological (SLE).
  • Although the pathophysiology of osteochondrosis is self-limited. If not treated promptly it can result in long term morbidity.


  • Potential causative factors include genetic links and repetitive activity.
  • There are no firm directives regarding the length of treatments including immobilisation.
  • Benefits of surgery are variable and need to be considered on a case by case basis.


Selected references

Achar, S., & Yamanaka, J. (2019). Apophysitis and Osteochondrosis: Common Causes of Pain in Growing Bones. American Family Physician, 99(10), 610–618.

Claessen, F. M. A. P., Louwerens, J. K. G., Doornberg, J. N., van Dijk, C. N., Eygendaal, D., & van den Bekerom, M. P. J. (2015). Panner’s disease: literature review and treatment recommendations. Journal of Children’s Orthopaedics, 9(1), 9–17.

Terjesen, T., Wiig, O., & Svenningsen, S. (2010). The natural history of Perthes’ disease. Acta Orthopaedica, 81(6), 708–714.

Talusan, P. G., Diaz-Collado, P. J., & Reach, J. S. (2013). Freiberg’s Infraction: Diagnosis and Treatment. Foot & Ankle Specialist, 7(1), 52–56.

Olstad, K., Ekman, S., & Carlson, C. S. (2015). An Update on the Pathogenesis of Osteochondrosis. Veterinary Pathology, 52(5), 785–802.

Joseph, B. (2015). Management of Perthes’ disease. Indian Journal of Orthopaedics, 49(1), 10–16.

Masrouha, K. Z., Callaghan, J. J., & Morcuende, J. A. (2018). Primary Total Hip Arthroplasty for Legg-Calvé-Perthes Syndrome: 20 Year Follow-Up Study. The Iowa Orthopaedic Journal, 38, 197–202.

Chan, J. Y., & Young, J. L. (2019). K&#xf6;hler Disease: Avascular Necrosis in the Child. Foot and Ankle Clinics, 24(1), 83–88.