Imaging Studies
Anteroposterior (AP), lateral, and oblique radiographs of the elbow adequately visualize most elbow fractures.
To detect subtle elbow fractures, it is key to systematically view elbow films looking at certain aspects of the elbow.
Anterior humeral line
This is a line that is drawn along the anterior aspect of the humeral shaft on the lateral radiograph.
The line passes through the middle one third of the capitellum in bones that are not injured.
Only true lateral views should be used to assess this line.
For example, a supracondylar fracture changes the anterior humeral line as it passes through the capitellum.
Radiocapitellar line
his is a line that bisects the proximal radial shaft and should pass through the capitellum on every view.
Fat pads
On lateral films, the anterior fat pad normally lies against the anterior surface of the distal humerus. See the image below.
Anterior and posterior fat pads with radial head fracture. A joint effusion displaces this fat pad anteriorly and produces the sail sign.
The posterior fat pad is not visible in films of the normal elbow; in patients with suspected elbow fracture, a posterior fat pad should be treated as a fracture.
Fat pads may be elevated if fluid is present from other conditions such as joint infection or inflammation.
Ossification centers
Often, the pediatric elbow is difficult to evaluate due to the ossification centers of the elbow.
One common mnemonic for the order of appearance for the ossification centers of the elbow is CRITOE.
Table. CRITOE. (Open Table in a new window)
| Ossification Centers | Age of Appearance, y |
| Capitellum | 1-2 |
| Radial head | 4-5 |
| Internal (medial) epicondyle | 4-5 |
| Trochlea | 8-10 |
| Olecranon | 8-9 |
| External (lateral) epicondyle | 10-11 |
Procedures
In general, an orthopedic consultant best handles decisions regarding reduction of significantly angulated and displaced fractures.
If neurovascular structures are compromised, the emergency physician may need to apply forearm traction to reestablish distal pulses.
If pulse is not restored with traction, emergent operative intervention for brachial artery exploration or fasciotomy is indicated.
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| Ossification Centers | Age of Appearance, y |
| Capitellum | 1-2 |
| Radial head | 4-5 |
| Internal (medial) epicondyle | 4-5 |
| Trochlea | 8-10 |
| Olecranon | 8-9 |
| External (lateral) epicondyle | 10-11 |
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