This document discusses radiographic evaluation of common pediatric elbow injuries. It begins by noting that elbow fractures represent up to 10% of fractures in children, with the most common being supracondylar humerus fractures, radial neck fractures, lateral condyle fractures, and medial epicondyle fractures. Interpretation is complicated by the cartilaginous nature of the immature elbow. The document outlines normal anatomy and development of the elbow, secondary ossification centers, common radiographic views and parameters, and radiographic relationships that are important for evaluation. It concludes that understanding these radiographic findings is essential to properly diagnose common pediatric elbow injuries.

1. Radiographic evaluation
of common pediatric
elbow injures.
Dr. Saikat Ghosh
Resident, Phase B
MS (Orthopaedics)
Chittagong Medical College.

2. Normal Variations in anatomy in the skeletally
immature patient may be mistaken for fracture
or injury due to the presence of secondary
centers of ossification. Variations in imaging
exist from patient to patient based on sex, age,
and may even vary from one extremity to the
other on the same patient. Despite differences in
the appearance of bony anatomy there are
certain landmarks to distinguish normal from
abnormal.
Abstract

3. Pediatric elbow fractures represent up to
10% of all fractures that occur in Children.
The most common fractures are
supracondylar humerus fractures,
radialneck fractures, lateral condyle
fractures, and medial epicondyle fractures.
Interpretations of pediatric elbow
radiographs is complicated by the
cartilaginous nature of the immature
elbow.
Introduction

4. It is critical to identify subtle fractures and
dislocations because missed injuries can be
associated with deformity, pain and
neurologic complication. Because of the
challenges presented when evaluation
pediatric elbow radiographs, systematic
assessments of numerous radiographic
measurements are useful.
Introduction

5. • Elbow fractures represent 9% to 10% of all
upper extremity fractures in children.
• Of all elbow fractures, 85% occur at the distal
humerus 55% to 75% of these are supracondylar.
• Most occur in patients 5 to 10 years of age, more
commonly in boys
• There is seasonal distribution for elbow fractures
in children, with the most occurring during the
summer and the fewest during the winter.
Epidemiology

6. Radiographic evaluation of the skeletally
immature elbow requires knowledge of the
normal sequence and appearance of the
secondary ossification centers of the elbow
in order to correctly distinguish pathology
from normal anatomy. At birth the elbow
joint is completely cartilaginous and cannot
be reliably evaluated via plain radiography.
Normal anatomy and development

7. The appearance of secondary ossification
centers of the elbow are predictable,
however may vary from patient to patient
based on sex, maturity, and may even vary
from one extremity to the other, making
imaging of the contra lateral elbow useful
in identifying subtle abnormalities. The
mnemonic device CRITOL can be used to
remember the chonologic order of
ossification
Normal anatomy and development

8. (capitellum, radial head, medial epicondly,
trochlea, olecranon,, lateral epicondyle. This
can also be remembered as CRITOE
(capitellum, radial head, internal ossification
center, trochela, olecrannon, external
ossification center. Ossification begins at 1
year old and each ossification center
sequentially appears at about every years
thereafter.

9. Secondary Ossification Center of the elbow.

10. Normally, the capitellum is anteverted
approximately 40 degree, froming an angle
of 130 degree with the humeral shaft.
With age fusion of the capitellum occurs,
frequently to the trochela and lateral
epicondyle first, followed by fusion ton the
distal humerus by approximately age 14
years.
Secondary ossification Centers

12. The capitellum serves as a critical landmark
when evaluating pediatric elbow x-ray. For
example, the radial head should align with
the capitellum in all views in order to rule
out dislocation. The radial head ossifies at
around age 3-4 years. As it ossifies, the
metaphysis of the radial neck may appear
angulated with a notch at the lateral cortex,
which fills in with time, however, this may
be mistaken for a fracture.
Secondary ossification Centers

13. The medical epocondyle ossifies between 3-
6 years of age, It is varible in its ossification
pattern and is often the last center to fuse at
approximately 17 years of age. The trochlea
exhibits multiple ossification centers
beginning around age 7-8 years. Its
tragmented appearance should not be
confused with pathological condition, such
as fracture or avascular nerosis.
Secondary ossification Centers

14. 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 distal hurnerus. As the
physis colses, it has sclcrolic margins that
appear different than a fracture, with final
closure occurring by age 14-15 years. Lastly
the lateral epicondyle begins ossifying
around age 11 years.
Secondary ossification Centers

17. 1. Antero posterior view
2. Lateral view
3. Internal and External oblique view
4. Stress view
5. Greenspan (radio capitellar)
6. Coyle’s view
7. Inferiosuperior view
8. Elbow acute flexion ap view
9. Supracondylar ap view
10. Jones view.
Different X-ray Views

18. 1. Lines:
• Anterior Humeral line (AHL)
• Middle Humeral Line (MHL)
• Radio Capitellar Line
• Coronoid line
2. Angles:
• Baumann’s angle
• Carrying angle
• Capiteller angle
•Metaphyseo diaphyseal angle
Radiographic Parameters

19. 3. Signs:
• Fat pad sign
• Tear drop sign
• Crescent sign
• Fish tail sign
Radiographic Parameters

20. Knowledge of normal radiographic
relationships within the pediatric elbow is
important for diagnostic evaluation.
Assessment of the radiocapitellar joint is
erformed by drawing a line down the middle
of the radial neck or shaft on standard
anteroposterior (AP), ogblique and
lateralradiographs. This line should interest
the capitellum at approximately its middle
third on all radiographic views.
Radiographic relationships

22. The anterior humeral line (AHL) is an
important radiopraphic landmark used to
assess the alignment of the distal humerus
and is often used to evluate the anterior
posterior displacement of supracondylar
humerus fractures. This line is drawn on the
lateral projection of the elbow along the
anterior cortex of the humerus and should
intersect the middle third of the capitellum in
most normal elbows.
Radiographic relationships

23. Midhumeral Line

24. Anterior Coronoid line (ACL)

28. Baumann’s angle (or the humerocapitellar
angle) is another radiographic measurement
that may be used to assess the normal
relationships of the distal humerus and is
measured on the AP projection of the elbow.
It is used to evaluate for the presence of a
supracondylar or other types of distal
humerus fracture.
Radiographic relationships

31. THE METAPHYSEAL-DIAPHYSEAL ANGLE FORMED BETWEEN THE LONG AXIS
OF THE HUMERUS AND A LINE CONNECTING THE LATERAL AND MEDIAL
EPICONDYLES.

38. Teardrop or figure eight sign

41. Supracondylar humerus (SCH) fractures are
the most common type of elbow fracture in
children. Anterior humeral line which should
intersect the middle third of the capitellu. In
an extension type supracondylar fracture the
capitellum lies posterior to the anterior
humeral line.
Supracondylar Humerus

44. •Peak age: 6 years
•Hall mark of Radiology: Posteriorly
based metaphyseal fragment.
•In case of minimally displaced fractures
internal oblique view & contralateral
films & CT, MRI, arthrogram may be
helpful.
Lateral condyle fractures

45. •Peak age: 9-14 yns.
•More Common in male.
•These fractures occurs up to 50% with
elbow dislocation.
•Widening in irregularity of the physis may
be the only radiographic sign is minimally
displaced fractures.
Medial epicondyle fractures

46. •Peak age: <2 yns
•Often associated with child abuse.
•X-ray: Relation between Primary ossification
center of the distal Humerus & the proximal
radius & Ulna.
•It is distinguished from elbow dislocation by
measuring the Radio- copiteller line.
•It is distinguished from supracondylar
fracture as metaphysis maintain a smooth
border where in supracondylar fracture this is
irregular.
Distal humeral physeal injury

47. Monteggia fractures are complex injuries
involving a fracture of the ulna asociated wit
proximal radioulnar joint dissociation and
radiocapitaller. This fractures should be
evaluated with standard AP and lateral
radiographs of the forearm and elbow. Any
ulnar shaft fracture warrants a radiograph of
the elbow Disruption of the ulna, even minor
bowing, should alert the observer to assess
the proximal radioulnar joint for disruption.
Monteggia fracture

48. Capitellar ostcochondritis dissecans (OCD)
is a pathologic entity with an unknown
etiology ad can be confused with panner’s
disease (osteochondrosis of the capitellum).
Capitellar OCD typically affects children
older than 10 years of age, Is associated with
overuse syndromes. Panner’s disease affects
those younger than 10 years old is not
necessarily associated with overuse, and has
a self-limited benign clinical course.
Capitellar osteochondritis dissecans

49. •Peak age: 7-12 yns
•Isolated injury only 50% . Sometimes
associated with proximal ulnar injury.
•X-ray: Oblique view of Elbow.
•Radial neck fractures with unossified radial
head is difficult to detect. In that occasion
the only sign may be irregularity of proximal
metaphysis.
Radial neck fractures

50. Pediatric elbow fractures are commonly
encountered by pediatricans, orthopedists
and emergency physicians representing up
to 10% of all fractures that occur in
children. Diagnostic radiology is an
essential component of proper evaluation.
Understanding these radiographic findings
and relationships in the pediatric elbow is
important to avoid pitfalls in diagnosing
these relatively common injuries.
Conclusions

51. THANK
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