Elbow series (pediatric)
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The elbow series for pediatrics is a set of radiographs taken to investigate elbow joint pathology, often in the context of trauma. It usually comprises an anteroposterior and lateral projection in order to minimize radiation dose to the patient. Depending on the department and clinical indication, other non-standard, modified projections may also be done.
Being familiar with the order of elbow ossification is important in assessing the elbow joint in a pediatric patient to ensure that a normal ossification center is not mistaken for an epicondylar fracture.
Elbow x-rays are indicated for a variety of settings including:
suspected fracture of the proximal radius and ulna
suspected fracture of the distal humerus
radial head dislocations
detecting joint effusions (fat pad sail sign)
demonstrates distal humerus, proximal radius and ulna
shows both the medial and lateral epicondyles in profile
Modified trauma projections
Where patients are in considerable amount of pain, these projections may be useful in obtaining diagnostic images whilst requiring little to no patient movement.
Patients should remove any jewelry or clothing over the arm to avoid artifact.
The use of gonadal and fetal shielding has been deemed as non-beneficial to patients' health in current evidences 1-3 and may or may not be useful for pediatric extremity imaging. Placing gonadal shielding can increase the examination time and may cause the child more stress.
Tips for pediatric elbow radiography
The major difficulty in pediatric radiography relates to:
To overcome this, a variety of techniques can be used 4:
distract the patient with toys, games and/or conversation
using the swaddling technique; wrap the child in a blanket to promote comfort and sleep
have the child sit on the carer's lap to ensure they are comfortable
Children will find it difficult to keep their arm still; particularly if the limb is injured. One option is to have a carer or radiographer hold the child's arm at the distal forearm and proximal arm. For patients who are unable to fully extend their elbow for the anteroposterior view, using an immobilization sponge to elevate the distal forearm can be useful without causing too much distortion in the image.
- 1. Rebecca M. Marsh, Michael Silosky. Patient Shielding in Diagnostic Imaging: Discontinuing a Legacy Practice. (2019) American Journal of Roentgenology. 212 (4): 755-757. doi:10.2214/AJR.18.20508 - Pubmed
- 2. BIR. Guidance on using shielding on patients for diagnostic radiology applications. (2020) The British Institute of Radiology. https://www.bir.org.uk/media/414334/final_patient_shielding_guidance.pdf - PDF
- 3. AAPM. AAPM position statement on the use of patient gonadal and fetal shielding. (2019) American Association of Physicists in Medicine. https://www.aapm.org/org/policies/details.asp?id=468&type=PP - Policy text
- 4. Ng JHS, Doyle E. Keeping Children Still in Medical Imaging Examinations- Immobilisation or Restraint: A Literature Review. (2019) Journal of medical imaging and radiation sciences. 50 (1): 179-187. doi:10.1016/j.jmir.2018.09.008 - Pubmed