The document provides an overview of commonly encountered pediatric elbow injuries seen in the emergency department setting. It reviews the anatomy and imaging evaluation of pediatric elbow fractures including the supracondylar humerus, radial neck, lateral condyle, and medial epicondyle fractures. Specific radiographic findings that help identify subtle fractures are discussed. Challenges in pediatric elbow imaging related to ossification centers are also covered. The goal is to help emergency physicians accurately diagnose pediatric elbow fractures on radiographs.

1. Pediatric Orthopedic Imaging Case Studies
Haley Dusek, MD1, Ainsley Bloomer, MD2,
Danielle Sutton, MD1, Virginia Casey, MD2
Departments of Emergency Medicine1 & Orthopedic Surgery2
Carolinas Medical Center & Levine Children’s Hospital
Presentation #7
CMC Imaging Mastery Project
Michael Gibbs, MD – Lead Editor

2. Disclosures
▪ This ongoing pediatric orthopedic imaging interpretation series is proudly
sponsored by the Emergency Medicine Residency Program at Carolinas
Medical Center.
▪ The goal is to promote widespread imaging interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

4. It’s All About The Anatomy!

5. The Physics of X-Rays
• How far an X-ray projects depends on the density of tissue that the X-ray
beam is attempting to penetrate.
• For reference, X-ray beams travelling through air will be black.
• Versus X-ray beams travelling through bone, which is high density, will
subsequently appear bright white.

6. 1. Confirm patient identity (name, date of birth)
2. Confirm the date of imaging
3. Confirm laterality (right vs. left)
4. Trace the bony cortex and look for irregularities
5. Review images in 2 planes at right angles to each other (AP + lateral) to
characterize fracture patterns, displacement, and angulation
6. Identify which bone and what part of the bone is injured
7. Review X-rays of both the joint above and the joint below the injury
The System: Bony Imaging

7. CMC/LCH Pediatric Elbow Fractures

8. Pediatric Elbows
• 10-15% of all fractures that occur in children
• Most common
• SCH
• Radial neck
• Lateral condyle
• Medial epicondyle
• Average age: 7.4 yr +/- 4.1 yrs
• High percentage of pediatric operatively repaired fractures
• 55% male
• Typically associated with fall onto outstretched arm or direct contact
(playground equipment, bicycles, etc.)

9. Standard Orthopaedic Upper Extremity Exam
• Inspection
• Vascular
• Neurological
• Passive ROM
• Stability

10. Standard Orthopaedic Upper Extremity Exam
• Inspection
• Often for kids, you can observe
and see how much they are willing
to use the extremity on their own
• Overall alignment
• Any skin abrasions?
• Bruising?
• Open fracture?
Vascular
• Check the radial pulse
• should be very palpable in
children
• Cap refill?
• Do you have to get a doppler?
• Use if any concerns or any
question
• Check radial, ulnar, superficial
and deep palmar arches
• Use Allen test

11. Standard Orthopaedic Upper Extremity Exam
Neurological
• Motor
• Thumbs up – radial nerve
• A-ok sign – AIN (median nerve)
• Cross first 2 digits – ulnar nerve
• Abduct all digits – ulnar nerve
• Sensory (intact to light touch?)
• Radial – dorsum of hand
• Ulnar – lateral border of hand
• Median – palmar surface
Passive ROM
• Do all joints move freely?
• If not, in which planes and how
much of a limitation?
• Is there a mechanical block or
limited by pain
Stability
• Is the elbow stable to varus and
valgus stresses?
• Is the distal radioulnar joint stable?

12. Next, Plan Films
• For an elbow, when worried about
fracture, this should include
• Elbow 3 views
• Humerus 2 views
• Forearm 2 views
• If there is concern for elbow and
forearm injury, will need to include
wrist
• This is pertinent given concern for
Galeazzi or Monteggia fractures (a
MUST NOT MISS)

13. Ossification
• This is the tough part about peds
elbow
• this is often where overnight radiologist or
a general radiologist may miss call
• Pediatric elbow injuries should make you
wary
• CRITOL (order of appearance)
• Capitellum 1-2
• Radial head 3-4
• Medial epicondyle 3-5
• I = internal ossification center
• Trochlea 7-8
• Olecranon 9
• Lateral condyle 11
https://www.orthobullets.com/pediatrics/4010/olecranon-fractures--pediatric

14. Subtleties With Each Ossific Nucleus
• Capitellum
• Posterior aspect of its cartilaginous physis is wider than the anterior aspect,
potentially leading to to misdiagnosed fracture at this location
• Radial head
• As it ossifies, the metaphysis of the radial neck may appear angulated with a notch at
the lateral cortex which fills in with time but this may be mistaken for a fracture
• Trochlea
• Exhibits multiple ossification centers and this fragmented appearance may be read as
fracture or avascular necrosis
• Olecranon
• As the physis closes is has sclerotic margins that may be read as some pathology
• Lateral condyle
• Begins as a thin flake which may be mistaken as an avulsion fracture

15. Plain Film Interpretation
• Position of radial head relative to
capitellum
• The radial head should align with the
capitellum in ALL 3 VIEWS to rule out
dislocation
• Draw line down middle of radial neck
and this should intersect the capitellum
at approximately its middle third

16. Plain Film Interpretation
• Position of radial head relative to
capitellum
• The radial head should align with the
capitellum in ALL 3 VIEWS to rule out
dislocation
• Draw line down middle of radial neck and
this should intersect the capitellum at
approximately its middle third
• Anterior humeral line (AHL) relative to
capitellum
• drawn on the lateral, line should intersect
the middle third of the capitellum

17. Plain Film Interpretation
• Position of radial head relative to capitellum
• The radial head should align with the capitellum in
ALL 3 VIEWS to rule out dislocation
• Draw line down middle of radial neck and this should
intersect the capitellum at approximately its middle third
• Anterior humeral line (AHL) relative to
capitellum
• drawn on the lateral, line should intersect the middle
third of the capitellum
• Baumann’s angle (humerocapitellar angle)
• Draw line parallel to longitudinal axis of humeral
shaft and bisecting line parallel to longitudinal axis of
the lateral condyle
• 64 - 81º is considered normal
• a difference of more than 5° between the two sides is
considered abnormal.
https://radiopaedia.org/articles/baumann-angle-1?lang=us

18. Plain Film Interpretation
• Position of radial head relative to capitellum
• The radial head should align with the capitellum in ALL 3 VIEWS to
rule out dislocation
• Draw line down middle of radial neck and this should intersect the
capitellum at approximately its middle third
• Anterior humeral line (AHL) relative to capitellum
• drawn on the lateral, line should intersect the middle third of the
capitellum
• Baumann’s angle (humerocapitellar angle)
• Draw line parallel to longitudinal axis of humeral shaft and
bisecting line parallel to longitudinal axis of the lateral condyle
• Angle should be 70-75 degrees of 5 degreed of contralateral elbow
• Posterior fat pad
• Indicative of possible occult fracture
• Anterior fat pad sign alone has 98.2% negative predictive value https://radiopaedia.org/articles/posterior-fat-pad-sign-
elbow?lang=us#:~:text=The%20posterior%20fat%20pad%20sign,indicating
%20an%20elbow%20joint%20effusion.

19. What They Studied:
Accuracy of Emergency Medicine specialists in diagnosing and
recommending treatment for pediatric elbow fractures at an academic
institution.
How:
Academic institution in Rasht Iran.
Patient’s <14 yo referred to academic institution between 2012-2013
with suspected elbow fracture.
Survey completed by both Emergency Medicine specialist and
Orthopedic specialist after XR obtained with diagnosed fracture and
proposed treatment.
What They Found:
Of 108 patients, 54 had elbow trauma identified.
Identical diagnoses in 36 patients between groups.
EM specialists diagnosed only 1 lateral condylar fracture
compared to 5 in Orthopedic group.
EM specialists diagnosed only 3 growth plate fractures
compared to 5 in Orthopedic group.
Higher rate of proposed inpatient treatment by EM
specialist (42.6%) compared to only 12.9% in Orthopedic
group.
What Can We Take Away?
Specific attention to complex elbow imaging/fractures,
diagnosis and management is recommended.

20. • Causes: birth trauma, falls and (rarely) non-
accidental trauma.
• Typically occurs in kids under 3 years-old, when
the cartilaginous physis is the weak point.
• May be confused with elbow dislocations but
these are not likely in this age group.
• Features:
The radiocapitellar joint remains congruent, i.e.: a
distinguishing feature compared with dislocations
The forearm will not be in line with the humerus
The forearm is most commonly posteromedially
situated
Transphyseal Fracture Of The Distal Humerus
Can’t Miss Diagnosis!

21. Transphyseal Fracture Of The Distal Humerus
Can’t Miss Diagnosis!
Journal of the American Academy of Orthopaedic Surgeons 2016: 24(2):p e39-e44.

22. Journal of the American Academy of Orthopaedic Surgeons 2016: 24(2):p e39-e44.
Transphyseal Fracture Of The Distal Humerus
Can’t Miss Diagnosis!

23. Case #1:
7-year-old fell off
monkey bars onto
outstretched hand.
What do you see?

24. Case #1:
7-year-old fell off
monkey bars onto
outstretched hand.
What do you see?
Lateral condyle
fracture.

25. Displacement Articular Surface Treatment
Type I <2mm Intact Non-op; long arm splint
with elbow flexed 60-90
degrees
1 week follow up
Type II >2mm Intact Operative
Type III >2mm Disrupted Operative
Lateral Condyle Fractures
Usually from fall from height onto outstretched arm.
Consider internal oblique elbow XR to further evaluate.
https://posna.org/physician-education/study-guide/lateral-condyle-fractures

26. Case #2:
9 –year-old with
elbow pain after
collision at football.
What do you see?

27. Case #2:
9 –year-old with
elbow pain after
collision at football.
What do you see?
Mildly displaced
medial epicondyle
fracture.
Keep in mind that
these is no lateral
view… we so cannot
assess for dislocation

28. Displacement Treatment
<5mm • Above elbow posterior slab; flexed at 90 degrees
• Ortho follow up within 2 weeks
5-15mm • Ortho consult; closed v. open repair situation dependent
>15mm • Ortho consultation; operative
Medical Epicondyle Fractures
• Frequently associated with elbow dislocation.
• It is important to differentiate medial epicondyle fractures(common) from medial
condyle fracture (rare):
 Medial condyle fractures are intra-articular and required urgent consultation.
 The medial epicondyle can become incarcerated within the joint.

29. Case #3:
5-year-old reduced
range of motion after
a fall on the
playground.
What do you see?

30. Case #3:
5-year-old reduced
range of motion after
a fall on the
playground.
What do you see?
Displaced proximal
ulnar fracture with
dislocation of the
radial head
(Monteggia fracture)

31. Monteggia Fracture
Letts Classification Treatment
Type A
• Anterior radial head dislocation and apex-anterior plastic ulnar deformation
• Closed reduction
• Long arm casting
in supination
• Focus on
anatomic ulnar
reduction to
guide radio-
capetellar joint
reduction
• Orthopedic follow
up within 2 weeks
Type B
• Anterior radial head dislocation and apex-anterior greenstick ulnar fracture
Type C
• Anterior radial head dislocation and complete ulnar fracture
Type D
• Posterior radial head dislocation and lateral ulnar fracture
Type E
• Lateral radial head dislocation and greenstick fracture of ulna

32. Case #4:
13-year-old with an
elbow deformity
after falling off a
scooter.
What do you see?

33. Case #4:
13-year-old with an
elbow deformity
after falling off a
scooter.
What do you see?

34. Case #4:
13-year-old with an
elbow deformity
after falling off a
scooter.
Post-reduction film:
• Need to insure you
have an AP as well.
• Cannot confirm
reduction from 1
view.

35. Elbow dislocation
• Described based on the direction of the ulna relative to the distal
numerus.
• 90% are posterolateral dislocations
• Treatment: full sedated reduction
• Traction-counter traction with flexion of the elbow
• Posterior slab splint with elbow in most stable position
• Simple: no associated fracture
• Complex: with associated fracture
• Medial epicondyle is most common associated fracture
• Be careful for reduction as fragment can become trapped in the joint
• Extend wrist to keep common flexors on tension
• Medial epicondyle fracture may represent self-reduced elbow
dislocation.
• Ortho referral for:
• ANY elbow dislocation
• Dislocation with associated fracture
• Neurologic compromise
• Irreducible or partially reduced dislocations

36. What they studied:
Functional outcomes of children with brachial-antebrachial palmar
immobilization x3 weeks after elbow dislocation and subsequent
reduction, with or without associated fracture.
How:
From 2018-2020, prospectively included all children treated for elbow
dislocation less than 15 years old in Pediatric ED in France.
Functional assessment based on variety of scoring systems: Mayo
Elbow Performance Score, Oxford Elbow Score, Quick-DASH, etc.
What they found:
Functional outcomes mostly “good” from outset, and
almost all “excellent” at 3 month follow up.
No difference in functional outcome between
dislocations with and without fracture.
Skeletal maturity did affect functional scoring.
What can we take away?
3 weeks of immobilization may be sufficient for
uncomplicated elbow dislocations with or without low
risk fracture and no sign of neurovascular compromise.
**Should be evaluated by pediatric orthopaedics if
possible

37. A Great Open Access Review Article…
to the capitellum, and Baumann’s
.3 More subtle radiographic features,
as the posterior fat pad sign, may be
ative of an underlying fracture even
a fracture is not radiographically
ent.6
The purpose of this review is to
ibe the radiographic characteristics
iated with common pediatric elbow
es and to highlight common pitfalls
iated with pediatric elbow diagnostic
ing.
OrthopedicR
eviews201
7;volum
e9:7030
Correspondence: Steven F. DeFroda,
Department of Orthopaedics, Alpert Medical
School of Brown University, 593 Eddy Street,
Providence, RI 02903, USA.
Tel: +1.4014444030 - Fax: +1.4014446182.
E-mail: Sdefroda@gmail.com
Conflict of interest: the authors declare no
potential conflict of interest.
Key words: Elbow; Pediatrics; Fracture;
Radiographic Evaluation Of Common Pediatric Elbow Injuries
[Or thopedic Reviews 2017; 9:7030] [page 2
Pediatric elbow fractures represent up
10% of all fractures that occur in chil-
n.1,2
The most common fractures are
pracondylar humerus fractures, radial
ck fractures, lateral condyle fractures,
d medial epicondyle fractures.1
erpretation of pediatric elbow radi-
aphs is complicated by the cartilaginous
ure of the immature elbow.3
It is critical
identify subtle fractures and dislocations
cause missed injuries can be associated
h deformity, pain and neurologic compli-
ions.4,5
Because of the challenges pre-
ted when evaluating pediatric elbow
iographs, systematic assessments of
merous radiographic measurements are
eful. These include evaluating the
atomic relationships of the ossification
nters of the elbow, including the position
the radial head relative to the capitellum,
relationship of anterior humeral line rel-
Secondary ossification centers
The capitellum appears between 1 and 2
years of age, however it may appear as early
as 3 months.7
Normally, the capitellum is
anteverted approximately 40 degrees, form-
ing an angle of 130 degrees with the humer-
al shaft. The posterior aspect of its cartilagi-
nous physis is wider than the anterior
aspect, potentially leading to the misdiagno-
sis of a fracture at this location.7
With age,
fusion of the capitellum occurs, frequently
to the trochlea and lateral epicondyle first,
followed by fusion to the distal humerus by
approximately age 14 years.7 The capitel-
lum serves as a critical landmark when
evaluating pediatric elbow x-rays. For
example, the radial head should align with
the capitellum in all views in order to rule
out dislocation. The radial head ossifies at
tal humerus. As the physis closes, it h
sclerotic margins that appear different th
a fracture, with final closure occurring
age 14-15 years.9
Lastly, the lateral e
condyle begins ossifying around age
years. It begins as a thin flake, which m
be mistaken as an avulsion fracture, befo
eventually fusing with the capitellum a
the humerus.7
Radiographic relationships
Knowledge of normal radiograph
relationships within the pediatric elbow
important for diagnostic evaluatio
Assessment of the radiocapitellar joint
performed by drawing a line down the m
dle of the radial neck or shaft on standa
anteroposterior (AP), oblique and late
[Orthopedic Reviews 2017; 9:7030] [page 21]
imaging. We also review common clinical
diagnoses in this population.
Introduction
Pediatric elbow fractures represent up
to 10% of all fractures that occur in chil-
dren.1,2 The most common fractures are
supracondylar humerus fractures, radial
neck fractures, lateral condyle fractures,
and medial epicondyle fractures.1
Interpretation of pediatric elbow radi-
ographs is complicated by the cartilaginous
nature of the immature elbow.3 It is critical
to identify subtle fractures and dislocations
because missed injuries can be associated
with deformity, pain and neurologic compli-
cations.4,5 Because of the challenges pre-
sented when evaluating pediatric elbow
radiographs, systematic assessments of
numerous radiographic measurements are
useful. These include evaluating the
anatomic relationships of the ossification
centers of the elbow, including the position
of the radial head relative to the capitellum,
the relationship of anterior humeral line rel-
ossification center, trochlea, olecranon,
external ossification center. Ossification
begins at 1 year old and each ossification
center sequentially appears at about every 2
years thereafter (Table 1).7
Secondary ossification centers
The capitellum appears between 1 and 2
years of age, however it may appear as early
as 3 months.7 Normally, the capitellum is
anteverted approximately 40 degrees, form-
ing an angle of 130 degrees with the humer-
al shaft. The posterior aspect of its cartilagi-
nous physis is wider than the anterior
aspect, potentially leading to the misdiagno-
sis of a fracture at this location.7 With age,
fusion of the capitellum occurs, frequently
to the trochlea and lateral epicondyle first,
followed by fusion to the distal humerus by
approximately age 14 years.7
The capitel-
lum serves as a critical landmark when
evaluating pediatric elbow x-rays. For
example, the radial head should align with
the capitellum in all views in order to rule
out dislocation. The radial head ossifies at
pathological condition, such as fracture or
avascular necrosis.7 The olecranon begins to
ossify around age 9 years via two or more
ossification centers. Its ossification begins
distally before migrating proximally to
form a concentric articulation with the dis-
tal humerus.7,8 As the physis closes, it has
sclerotic margins that appear different than
a fracture, with final closure occurring by
age 14-15 years.9 Lastly, the lateral epi-
condyle begins ossifying around age 11
years. It begins as a thin flake, which may
be mistaken as an avulsion fracture, before
eventually fusing with the capitellum and
the humerus.7
Radiographic relationships
Knowledge of normal radiographic
relationships within the pediatric elbow is
important for diagnostic evaluation.
Assessment of the radiocapitellar joint is
performed by drawing a line down the mid-
dle of the radial neck or shaft on standard
anteroposterior (AP), oblique and lateral
view
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radiographic evaluation of common pediatric elbow injuries, orth
Found 1result for radiographic evaluation of common pediatric elbow injuries, or… Save Email
Review . 2017 Feb 20;9(1):7030. doi: 10.4081/or.2017.7030.
Radiographic Evaluation of Common Pediatric Elbow
Injuries
Steven F DeFroda , Heather Hansen , Joseph A Gil , Ashraf H Hawari , Aristides I Cruz Jr
Affiliations
PMID: 28286625 PMCID: PMC5337779 DOI: 10.4081/or.2017.7030
Free PMC article
Orthop Rev (Pavia)
1 2 1 3 2

38. Summary of This Month’s Diagnosis
• Lateral condyle
• Medial epicondyle
• Monteggia
• Posterior dislocation
• Transphyseal separation

39. Additional References
Radiographic Evaluation of Common Pediatric Elbow Injuries. Orthop Rev (Pavia). 2017 Feb 20;9(1):7030.
Pediatric elbow fractures: a new angle on an old topic. Pediatr Radiol 2016 Jan;46(1):61-6.
Elbow Dislocations – Emergency Department. The Royal Children’s Hospital Melbourne website. Available
https://www.rch.org.au/clinicalguide/guideline_index/fractures/Elbow_Dislocations_-_Emergency_Department
Medial Epicondyle Fractures in the Children. J American Academy of Orthopaedic Surgeons 2012; 204(4):223-232.
Pediatric Tips & Tricks: Management of Pediatric Capitellar Fractures. U. of Penn. Orth J 2019 Jun; 29 (119-122).
How to approach the Pediatric Elbow. EMRA https://www.emra.org/emresident/article/pediatric-elbow/ (2021, April 8).
Medial Epicondyle Fracture of the Humerus – Emergency Department. The Royal Children’s Hospital Melbourne website.
Available at: https://www.rch.org.au/clinicalguide/guideline_index/fractures/Medial_epicondyle_emerg/#Follow-up
Missed Pediatric Monteggia Fractures JBJS Rev 2018 Jun;6(6):e2.
How to Avoid Missing a Pediatric Elbow Fracture. ACEP Now https://www.acepnow.com/article/how-to-avoid-missing-a-
pediatric-elbow-fracture/
A 10-Year National Analysis of Pediatric Elbow Fractures. Clinical Pediatrics 2022 Nov 7:99228221135525.