Indications for emergent transfer may include intractable pain, uncertainty of diagnosis, possibility of compartment syndrome, consideration of septic arthritis or necrotizing soft tissue infection (NSTI), potential for dislocation, or a Salter-Harris fracture.If a fracture is not seen, but an abnormal fat pad is seen, treat the patient “as if” a fracture were seen, with immobilization and orthopedic referral.When performing an x-ray of the elbow, look for a dislocation, bony lesion, fracture, or abnormal fat pad.Pearls for Initial Management and Considerations for Transfer Most participants used repeated radiography after 1 week in the further diagnostic work-up. In adults, an occult fracture is usually found to be a radial head fracture, whereas in children it is typically a supracondylar fracture. A supracondylar humerus fracture was considered the most common fracture in case of a positive fat pad sign without visible fracture, followed by radial head and neck fractures (Table 2).If a posterior fat pad is identified without a visible fracture, then an occult fracture should be suspected and will be present up to 75% of the time. A posterior fat pad seen on a lateral x-ray of the elbow is always abnormal.An anterior fat pad is often normal, but if elevated it is abnormal.Elbow fractures may not be evident on an x-ray, but secondary signs, such as a fat pad elevated by bleeding, may indicate that there is a fracture.Normal fat in the olecranon fossa is not visible unless uplifted by joint effusion.The negative and positive predictive values range from 86 - 100, and 95.2 - 100, respectively. Note the intact cortex on the posterior surface of. Across various studies, the sensitivity and specificity of ultrasound in diagnosis ranges from 88 - 100, and 93.5 - 100, respectively. Tenderness on exam, along with a positive fat pad sign on the X-ray, is a strong indicator of a fracture. The lateral view of the elbow shows a focal area of lucency in the posterior aspect of the elbow at the level of the olecranon fossa, closely apposed to the bone. The strongest indicator of an occult elbow fracture is a positive posterior fat pad sign on ultrasound. The x-ray reveals a fat pad sign, or elevated posterior fat pad, with positive elbow joint effusion. Undisplaced supracondylar fracture of distal humerus, Gartland type 1a shows the posterior fat pad sign (AP and Lat view).
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