Elbow radiograph (an approach)

Last revised by Andrew Murphy on 20 Jun 2022

Elbow radiographs are common and oftentimes difficult to interpret without a solid systematic search strategy. 

Choosing a search strategy and utilizing it consistently is a helpful method to overcome common errors seen in diagnostic radiology. The order in which you interpret the radiograph is personal preference. A recommended systematic checklist for reviewing musculoskeletal exams is: soft tissue areas, cortical margins, trabecular patterns, bony alignment, joint congruency, and review areas. Review the entire radiograph, regardless of perceived difficulty. Upon identifying an abnormality, do not cease the review, put it to the side and ensure to complete the checklist.

Assess all soft tissue structure for any associated or incidental soft tissue signs. In the case of the elbow, this will involve assessing for secondary signs of joint effusion.

On the lateral radiograph, inspect for the displacement of the anterior and posterior fat pads embedded in the two layers of the joint capsule. The anterior fat pad is normally seen as a faint line running with the distal humerus, whilst the posterior fat pad is not seen in normal radiographs. 

Elevation of these fat pads, known as the sail sign indicates a joint effusion and should raise suspicion of an occult fracture. 

Common fractures to consider in this setting:

Check each bone in turn:

  • pay particular attention to structures that are superimposed i.e. the coronoid process

There are a few useful lines worth committing to memory (particularly helpful in pediatric presentations):

  • anterior humeral line
    • drawn down the anterior surface of the humerus on the lateral projection it should intersect the middle 1/3 of the capitellum
    • if the line does not intersect this point, distal humeral fracture such as a supracondylar fracture should be considered
    • in some cases (patients under 4 years) the line will pass through the anterior third and these are normal
  • radiocapitellar line
  • carrying angle
    • the axis of a radially deviated forearm and the axis of the humerus which should be, 14° in women and 11° in men,  away from the body 2
    • varus malalignment, consider cubitus varus

One should inspect for smooth, concurrent bony alignment in all views.

  • AP
    • the radial head should have an articulation with the capitellum
    • clear congruity of the trochlea of the distal humerus and the trochlea notch of the proximal ulna
  • lateral
    • the outline of the posterior olecranon fossa and the anterior coronoid fossa should make a 'figure 8' indicating a well-positioned lateral
    • the radial head should have articulation with the capitellum, a useful tool when trying to differentiate from the trochlea
    • smooth joint space between the trochlea notch of the ulna and the distal humerus

Although only applicable to younger patients many larger centers will still get occasional pediatric presentations and therefore it would be amiss to leave this out. Review the ossification centers of the elbow, they should appear in the following order 3

Understanding the order is important, and systematically reviewing the radiograph can ensure one does not miss subtle pathology such as a medial epicondyle fracture.

For a more in-depth approach to pediatric elbows see, pediatric elbow radiograph (an approach)

  • the proximal portion of the humerus 
  • radial head (often superimposed, additional views can be performed)
  • alignment of the ulna and radius (consider larger fracture-dislocation injuries) 
  • coronoid process (quite rare however easily missed)

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