Pediatric elbow radiograph (an approach)

Last revised by Jeremy Jones on 18 May 2021

Pediatric elbow radiographs are commonly encountered in the emergency department and, when approached in a systematic fashion, are not as difficult to interpret as most people think!

Check that the ossification centers are present and in the correct position. They appear in a predictable order and can be remembered by the mnemonic CRITOE (age of appearance are approximate):

  • capitellum (age 1)
  • radial head (age 3)
  • internal epicondyle (age 5)
  • trochlea (age 7)
  • olecranon (age 9)
  • external epicondyle (age 11)

Check the anterior humeral line:

  • drawn down the anterior surface of the humerus
  • should intersect the middle 1/3 of the capitellum
  • if it does not, think supracondylar fracture

(under the age of 4, the line will intersect the anterior 1/3)

Check the radiocapitellar line:

Check for raised fat pads:

Check around every bone on the film:

  • 10-20% of all pediatric elbow injuries
  • peak age: 6-10 years
  • mechanism: usually varus force applied to an extended elbow
  • unstable intra-articular fracture
  • prone to displacement due to the pull of forearm extensors
  • more: lateral condyle fracture
  • 5% of all pediatric elbow fractures
  • peak age: 8-11 years
  • mechanism: FOOSH with extended elbow and supinated forearm
  • most fractures involve the physis
  • more: radial neck fracture

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Cases and figures

  • Figure 1: ossification centers
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  • Figure 2: anterior humeral line
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  • Figure 3: radiocapitellar line
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  • Case 1: elbow effusion
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  • Case 2: supracondylar fracture
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  • Case 4: medial epicondyle avulsion
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  • Case 3: lateral condyle fracture
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  • Case 5: radial head dislocation
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  • Case 6: olecranon fracture
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