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Year : 2022  |  Volume : 19  |  Issue : 3  |  Page : 34-37

Elbow TRASH (the radiographic appearance seemed harmless) lesions

Division of Paediatric Orthopaedics, Department of Orthopaedics and Traumatology, Duchess of Kent Children's Hospital, Hong Kong, China

Date of Submission29-Mar-2022
Date of Acceptance04-Apr-2022
Date of Web Publication25-May-2022

Correspondence Address:
Evelyn Kuong
Associate Consultant, Division of Paediatric Orthopaedics, Department of Orthopaedics and Traumatology, Queen Mary Hospital, Duchess of Kent Children's Hospital, Hong Kong
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2667-3665.346022

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Paediatric elbow radiographs pose a particular challenge to orthopaedic surgeons as the non-ossified regions are poorly visualized on plain radiographs of very young children. Therefore, a high index of suspicion must be maintained when a young child presents with a swollen and painful elbow, yet the Xrays do not reveal any obviously displaced fractures. There are eight injuries that have been labelled “TRASH” lesions – “The Radiographic Appearance Seemed Harmless”. Elbow radiographs need to be examined closely for malalignment, displaced flecks of bone which may be attached to larger osteochondral fragments, and asymmetry when compared with the contralateral elbow. MRI provides the best anatomical detail and can help plan appropriate management. If timely diagnosis is not made or the injury is not managed properly, severe complications may arise such as growth disturbance, inadequate reduction of intra-articular fragments, and persistent malalignment of the elbow joint.

Keywords: Elbow fracture, Paediatric trauma, Physeal injury

How to cite this article:
Kuong E. Elbow TRASH (the radiographic appearance seemed harmless) lesions. J Orthop Assoc South Indian States 2022;19, Suppl S1:34-7

How to cite this URL:
Kuong E. Elbow TRASH (the radiographic appearance seemed harmless) lesions. J Orthop Assoc South Indian States [serial online] 2022 [cited 2022 Jul 6];19, Suppl S1:34-7. Available from: https://www.joasis.org/text.asp?2022/19/3/34/346022

  Introduction Top

The accurate interpretation of pediatric elbow radiographs is notoriously difficult due to incomplete ossification around the elbow in young patients. Large cartilaginous “empty spaces” on a plain elbow X-ray may harbor devastating injuries but not readily apparent on cursory inspection of plain radiographs. These injuries may involve the physes, cartilaginous areas of the distal humerus, and osteochondral fragments that become incarcerated in the elbow joint. If missed or improperly treated, these injuries may lead to significant morbidity for a young patient. Waters et al. coined the term “TRASH” lesion in 2010 to emphasize the importance of maintaining a high index of suspicion when a young child sustains a high-energy injury, presents with a significantly swollen elbow, but then comes back with a relatively normal-looking X-ray.[1]

  History, Physical Examination, and Initial Investigations Top

Patients with TRASH (The Radiographic Appearance Seemed Harmless) lesions are often under the age of 10 and suffer from a high-energy trauma such as a fall from height.[2],[3] On physical examination, there is a swollen and painful elbow. Once the usual anteroposterior and lateral projections of elbow X-rays come back looking innocuous, a high index of suspicion must be maintained to continue investigating for more significant injuries that may have been initially missed.

On closer examination of the elbow X-ray, one must look for bony alignment around the elbow joint. Familiarity with the progression of the secondary ossification centers of the elbow in children is necessary to interpret these X-rays with confidence. Malalignment of the elbow may indicate an incarcerated osteochondral fragment that is blocking reduction of the joint or a displaced fracture. Oblique X-rays are often helpful in identifying injuries of the lateral condyle. Small flecks of the bone seen on plain radiographs may reflect a larger displaced osteochondral fragment. Secondary clues such as soft tissue swelling and fat pad signs can help indicate the location of injury. Stress radiographs can provide evidence for ligamentous injuries. Always have an X-ray of the contralateral uninjured limb for comparison.

Ultrasound evaluation is highly operator-dependent. In most centers, ultrasounds are done separately by a radiologist who may not be aware of the diagnostic challenge and concerns of the orthopedic surgeon.

Arthrogram evaluation is useful in defining cartilaginous injuries and intra-articular obstacles. This can also help determine the adequacy of reduction of a subluxated joint or a displaced osteochondral or epiphyseal fragment. The disadvantage, however, is that arthrograms require the patient to be anesthetized in an operating theater. Moreover, the leakage of the dye in the fracture site into the surrounding soft tissues may make interpretation even more difficult.

Computed tomography (CT) scans are useful in delineating suspected osteochondral injuries and intra-articular fragments. However, they may be of limited use if the displaced fragment is mostly cartilaginous.

Magnetic resonance imaging (MRI) can provide the best anatomical detail in these injuries. However, MRI scans may not always be readily available, and the imaging often requires sedation in an injured and restless child.

  List of TRASH (The Radiographic Appearance Seemed Harmless) lesions Top

According to the original description in 2010, the list of lesions includes:

  • Unossified medial condylar humerus fractures [Figure 1]
  • Unossified transphyseal distal humerus fractures
  • Entrapped medial epicondylar fractures [Figure 2]
  • Complex osteochondral elbow fracture-dislocations (<10 years old)
  • Osteochondral fractures (from the olecranon, radial head, or distal humerus) with joint incongruity [Figure 3]
  • Radial head anterior compression fractures (leading to progressive posterior displacement of the radial head and radiocapitellar subluxation)
  • Monteggia fracture-dislocations (beware of plastic deformation of the ulna) [Figure 4]
  • Lateral condylar avulsion shear fractures.
Figure 1: Missed distal humerus fracture through unossified part resulting in malunion. (a) A 2-year-old boy fell from a bunk bed and developed left elbow pain. First X-rays were read as normal by the physician in the emergency department and the boy was sent home without treatment. In retrospect, malalignment can already be seen when reviewing the relationship between the distal humerus and the proximal ulna and radius. The displaced fracture in the unossified part of the distal–medial humerus causes the proximal ulna and radius to displace with it, giving the illusion of joint dislocation. (b) The boy was brought back 6 months after injury by his parents who noted progressive cubital varus deformity. On examination, the cubital varus was 15°, and the elbow range of motion was 0°–100°. (c) Magnetic resonance imaging done at 6 months after injury showed irregularity in the distal humerus physis on the medial aspect, indicating previous fracture. No definite bony bar was seen. (d) On last assessment when the boy was 9 years old, the cubital varus had remained static at 15°. There were no ulnar nerve symptoms. The family decided not to go for corrective osteotomy at the moment

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Figure 2: Displaced medial epicondylar fracture. (a) A 14-year-old boy fell on outstretched hand and presented with a swollen elbow and ulnar nerve dysfunction. X-rays showing the displaced medial epicondyle overlapping with the capitellum and the proximal ulna, giving the illusion of joint dislocation. (b) A computed tomography scan confirms a displaced medial epicondyle fracture fragment inside the elbow joint. (c) Physical examination showing marked bruising over the medial aspect of the elbow with ulnar nerve palsy. (d) Open reduction, ulnar nerve decompression, and internal fixation was performed

Click here to view
Figure 3: Capitellar fracture: (a) A 12-year-old boy fell on outstretched hand during a football game. He presented with a swollen elbow. Anteroposterior X-ray of the affected elbow looks unremarkable. The displaced fragment is only clearly seen on the lateral projection. (b) Open reduction and internal fixation was done via an anterolateral approach to the left elbow joint. The fracture was reduced under direct visualization and fixed with intra-osseous screws. On the last follow-up 4 years after injury, the elbow range of motion was 15°–130° and symmetrical carrying angles

Click here to view
Figure 4: Missed Monteggia fracture-dislocation with plastic deformity of the ulna. (a) A 1-year and 4-month-old girl was noted to have bowing and shortening of the left forearm after a fall injury from her high chair several months ago. On examination, the left forearm was shortened and pronation was limited to 30° only. X-rays revealed posterior subluxation of radial head and plastic deformity of the ulna shaft. The contralateral forearm is shown for comparison of the lengths of the forearms. (b) An ulnar osteotomy and lengthening of 1 cm was performed producing satisfactory reduction of the radial head. (c) On latest examination at 9 years old, the elbow range of motion and forearm rotation is full

Click here to view

Any child under the age of 10 who sustains an elbow dislocation must be evaluated thoroughly for the presence of displaced intra-articular osteochondral fractures and multi-ligamentous instability.

  Management Top

The treatment of these fractures follows the usual management principles of injuries around a joint: Intra-articular fragments must be retrieved from the joint to ensure full joint range of motion in the future and prevent destruction of the articular cartilage. Displaced intra-articular fractures that cause joint incongruity must be reduced anatomically to ensure a congruent joint. Therefore, most of these injuries will require operative reduction of the displaced fracture or fragment. Whether the reduction can be done in a closed manner will depend on the visibility of the fracture after fixation. Arthrogram can often be useful in determining the adequacy of the closed reduction. If the fragment cannot be well visualized by conventional intraoperative radiography, then open reduction must be done to ensure anatomical reduction of intra-articular fragments.

Most of these fractures are highly unstable, and stable fixation must be provided. The manner of fixation will be dictated by the size of the involved fragment, the proximity to physeal plates, and the condition of the surrounding periosteum and ligaments. In very young children, fixation with smooth wires (K-wires) and plaster immobilization is often the fixation method of choice. In older children with larger fragments, fixation options may include screws (intra-osseous screws if they must be placed inside a joint for adequate fixation) or plates. Tiny osteochondral fragments may need to be excised altogether. Disrupted ligaments, periosteum, and osteochondral flaps may need to be prepared with sutures.

The advantage of stable internal fixation of these injuries is that it allows early active motion of the injured joint. However, in multi-ligamentous injuries which can be seen in severe elbow dislocations, the joint may need to undergo an additional period of stabilization with hinged elbow braces. In dire situations where the joint is highly instable or the fixation is precarious, then rigid immobilization may be required until sufficient healing is seen on follow-up. One must bear in mind to err on the side of achieving a stable, albeit slightly stiff elbow joint rather than an unstable joint that markedly hinders the function of the upper limb.

  Complications Top

A unifying complication among these injuries is a missed diagnosis at the time of presentation. Patients often return for medical advice due to poor elbow joint function or malalignment. Care must be taken to maintain a high index of suspicion in a young patient with disproportionate swelling when compared to the X-ray.

Avascular necrosis can result from fractures with tenuous blood supply such as small osteochondral fragments. This may also arise from surgical management of neglected and displaced lateral condyle nonunions where overzealous attempts to pull the displaced fragment back to the anatomical position comprise the remaining blood supply.

Premature physeal closure may only become apparent in later years when the patient presents with malalignment. This particularly is a problem in fractures through unossified portions of the distal humerus [Figure 1].

Persistent joint subluxation may lead to joint instability which is notoriously difficult to treat. This can be the result of nonunion of an osteochondral fracture. As the elbow joint is the vital link between the hand and the patient's trunk, elbow instability can significantly reduce the function of the affected upper limb.

Persistent joint subluxation can also be seen in cases of missed Monteggia fracture-dislocations. The persistent subluxation of the radial head relative to the capitellum can cause limitations in the forearm rotation. This needs to be managed operatively by osteotomizing the ulna and reducing the radial head. Additional soft tissue reconstruction is often needed in chronic cases [Figure 4].

Peri-articular contractures and heterotopic ossification may lead to joint stiffness. This is commonly seen after elbow dislocations and severe disruptions to surrounding ligaments. Heterotopic ossification is often a problem seen in older patients over the age of 10.

Untreated displaced intra-articular fractures will reduce the range of motion of the elbow joint and eventually lead to premature osteoarthritis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Waters PM, Beaty J, Kasser J. Elbow “TRASH” (The Radiographic Appearance Seemed Harmless) lesions. J Pediatr Orthop 2010;30:S77-81.  Back to cited text no. 1
Patwardhan S, Omkaram S. Trash lesions around the elbow: A review of approach to diagnosis and management. Indian J Orthop 2021;55:539-48.  Back to cited text no. 2
Kuberakani K, Rawat J, Bain G. Trash elbow lesions. In: Bain G, Eygendaal D, van Riet R, editors. Surgical Techniques for Trauma and Sports Related Injuries of the Elbow. Berlin, Heidelberg: Springer; 2020.  Back to cited text no. 3


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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