Updates in pediatric upper extremity imaging

Abstract

Minimizing radiation exposure is crucial for both patient and provider safety. The harmful effects of ionizing radiation are well-documented. Further research is necessary to effectively decrease these risks. The present study compiles the most recent data available from orthopaedic surgery and radiology literature, with a focus on pediatric upper extremity imaging. The purpose of this study is to give a comprehensive update in order to improve patient and provider safety and guide future research.Radiographs are the most commonly employed imaging modality in the upper extremity, and there is a wealth of articles focusing on optimizing its use in pediatric patients. Recommendations include utilizing in-room fluoroscopy for final imaging after closed forearm fracture reduction in the emergency department and foregoing formal post-reduction radiographs. Additionally, literature supports that early postoperative radiographs and radiographs after pin removal in patients who have undergone closed reduction and percutaneous pinning of supracondylar humerus fractures do not change management. Similarly, pediatric patients who have been treated for musculoskeletal infection do not require follow-up radiographs, in the absence of clinical concern. Other imaging modalities, such as ultrasound, computerized tomography (CT), and magnetic resonance imaging (MRI) have expanded their indications in pediatric upper extremity injuries in recent years. This includes ultrasound for diagnosing fractures and tendon pathologies, new CT technology that decreases radiation exposure, and MRI scans with potentially safer contrast agents.In summary, research has been expanding our understanding of radiation exposure and exploring ways to minimize this during pediatric upper extremity imaging. Further research is necessary to facilitate safer diagnostic tests in pediatric patients.

Key concepts: (1)Fluoroscopy should be utilized as definitive post-reduction imaging after closed reduction of pediatric forearm fractures.(2)Radiographs do not need to be obtained in the early-postoperative setting or after pin removal in patients who have undergone closed reduction and percutaneous pinning of supracondylar humerus fractures.(3)Only obtain follow-up radiographs if there is a clinical concern in pediatric patients who have been treated for a musculoskeletal infection.(4)The application of ultrasound, CT scan, and MRI are continuing to expand and improve in pediatric upper extremity pathologies.

Keywords: Fluoroscopy; Forearm; Imaging; Radiographs; Ultrasound; Upper extremity.

Figure 1

Posteroanterior (PA) and lateral wrist radiographs in an 11-year-old male after sustaining a distal radius fracture.

Figure 2

PA and lateral fluoroscopic views obtained after closed reduction and casting of the patient in Fig. 1.

Figure 3

Anteroposterior (AP) and lateral elbow radiographs of a 6-year-old male who sustained a right type III supracondylar humerus fracture.

Figure 4

Closed reduction and percutaneous pinning of the supracondylar humerus fracture seen in Fig. 3.

Figure 5

AP and lateral elbow radiographs obtained after pins were removed from patient seen in Figure 3, Figure 4.

Figure 6

Transverse ultrasound cross-section of the extensor carpi ulnaris (ECU) tendon as it sits within the ulnar groove during neutral forearm rotation.

Figure 7

Ultrasound showing subluxation of the ECU tendon out of the ulnar groove during forearm supination.

Figure 8

Twenty-three-year-old male with healing scaphoid fracture. PCD-CT (A) and energy-integrating detector (EID)-CT (B) of the right wrist both scanned on the same day. Cortical and trabecular features are more distinct on the PCD-CT image. PCD-CT, photon-counting detector-computerized tomography.