EM in 5: Elbow Xrays

Author: Anna Pickens, MD (@AnnaEMin5, Creator of EMin5) // Reviewed by: Alex Koyfman, MD (@EMHighAK), Brit Long, MD (@long_brit), and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s edition of EMin5 by Dr. Anna Pickens.  Today we’ll review elbow xrays in kids!  


Elbow xrays can be tricky to read, especially in kids, so here are some tips!

 

Here are the 5 things to check each time:


Let’s go through each of them…

 

1. FIGURE – 8  (lateral view)

First we have to make sure that the xray was a “good picture.”  In other words, was everything lined up appropriately so that we can accurately read it.  The way we check this is to look for the “figure 8” on the lateral view.

2. FAT PADS:

The anterior fat pad is normal.  What is NOT normal is if you see it bulging out in what we call the “sail sign.”  This is an abnormal effusion of the joint that indicates a fracture is present (even if you can’t see it!)

You should NEVER be able to see a POSTERIOR FAT pad.   If you can see one, this is automatically abnormal and indicates a fracture. 

3. ALIGNMENT:

You should then check 2 anatomical lines: the anterior humeral line and the radiocapitellar line.  If these are not present (or mal-aligned), that indicates a fracture.

4. BONES:

There are 3 bones that we should then check to look for common fractures: the olecranon, the radial head, and the distal humerus.

5. CRITOE

Lastly, we need to check the ossification centers.  These are areas that eventually fuse together over time as the child grows, and you can ensure that you are not missing a fracture by checking the following chart and comparing it to the expected ossification centers for that child’s age.

So in review, here are the 5 areas to check on a pediatric elbow xray:

(And other than CRITOE/ossification centers, these all work for adult xrays too!)

Suggested/Further Reading:

Don’t Forget the Bubbles

Radiology Masterclass

Radiology Assistant

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