Humerus series (pediatric)

The humerus series for pediatrics is a set of anteroposterior and lateral radiographs taken to investigate elbow joint pathology, often in the context of trauma.

As the elbow joint is also imaged in this series, being familiar with the order of elbow ossification is important in assessing the elbow joint in a pediatric patient. This will ensure that a normal ossification center is not mistaken for an epicondylar fracture. Additionally, if an elbow injury is suspected, dedicated elbow radiographs should be acquired.

Indications

Humerus x-rays are indicated for a variety of settings including:

• infection
• trauma 
• bony tenderness at the glenohumeral joint/region 
• restriction of abduction 
• suspected dislocation 
• suspected bone tumors 

Projections

Standard projections

• AP view
  • demonstrates the humerus in its natural anatomical positioning
  • shows the entire shaft of the humerus 
• lateral view
  • orthogonal view of the AP image
  • demonstrates the degree and direction of any suspected dislocations or fractures

Modified trauma projections

• supine AP view
  • an alternative examination to the AP view performed supine
• supine lateral view
  • an alternative examination to the lateral view performed supine 
  • usually done with the use of tube angulation but can be done transthoracic

Patient preparation

Patients should remove any jewelry or clothing over the arm and shoulder to avoid artifact. 

Gonadal shielding

The use of gonadal and fetal shielding has been deemed as non-beneficial to patients' health in current evidence ^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. However, shielding can also reduce the family's anxiety in relation to radiation dose. Therefore, the decision to use shielding will depend on departmental protocols and the radiographer's judgment.

Tips for pediatric humerus radiography

The major difficulty in pediatric radiography relates to:

• motion artifact

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

Immobilization techniques

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 stand on the child' non-affected side, placing one hand on their mid-chest and another holding the proximal forearm.