Courtesy; Prof Nabil Ebraheim, University of Toledo, Ohio, USA

1. Common Pediatric Elbow Fractures

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A. Supracondylar fracture of humerus

• Most common pediatric elbow fracture
• Most common cause of elbow effusion in children

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Diagnosis

• Anterior humeral line assessment

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B. Fractures Involving Ossification Centers

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Elbow ossification centers CRITOE

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Key Point

• Essential for interpreting pediatric elbow X-rays

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1. Transepiphyseal Separation – Distal Humerus

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Key Features

• Age below 1 year
• Always consider non-accidental injury
• Often mistaken for elbow dislocation

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Differentiation from Dislocation

• Radiocapitellar alignment maintained
• Olecranon displacement pattern:
  • Dislocation: posterior and lateral
  • Transepiphyseal separation: posterior and medial

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2. Lateral condyle fracture of humerus

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Characteristics

• Usually Salter-Harris Type IV
• Most important intra-articular fracture in children

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Management

• Internal oblique view required even if undisplaced
• Close follow-up due to risk of displacement
• Majority require surgical fixation using lateral approach

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Avoid

• Posterior approach due to risk of avascular necrosis

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Complications

• Non-union leading to cubitus valgus
• Late ulnar nerve palsy

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Management of Complications

• Bone grafting for non-union
• Ulnar nerve transposition if symptomatic

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3. Medial epicondyle fracture

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Key Points

• Last ossification center to fuse
• Commonly associated with elbow dislocation

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Clinical Concern

• Fragment may be incarcerated within the joint

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Management

• Usually conservative

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Indications for Surgery

• Displacement greater than 1 cm
• Fragment trapped within the joint

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4. Radial head fracture / Neck Fracture

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Management Based on Angulation

• Less than 30 degrees: conservative
• Around 30 degrees: closed reduction
• Residual angulation greater than 45 degrees: open reduction

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Techniques

• Percutaneous pin used as joystick

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Complications

• Radioulnar synostosis
• Osteonecrosis
• Loss of motion

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2. Occult Elbow Injury (Fat Pad Sign)

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Concept

• Joint effusion displaces fat pads, making them visible on X-ray

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Fat Pad Findings

Anterior Fat Pad

• Normal: small and parallel to humerus
• Abnormal: elevated triangular appearance (sail sign)

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Posterior Fat Pad

• Normally not visible
• If visible, always pathological

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Key Rule

• Visible posterior fat pad indicates occult fracture until proven otherwise

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Common Causes

Children

• Most commonly supracondylar fracture

Adults

• Most commonly radial head or neck fracture

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Why Fracture May Be Missed

• Undisplaced fracture
• Extra-articular fracture component
• Poor radiographic quality

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Special Imaging View

Radiocapitellar (Greenspan) View

• Elbow flexed to 90 degrees
• X-ray beam angled 45 degrees proximally
• Useful for detecting radial head and neck fractures

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3. Systematic Approach to Pediatric Elbow X-ray

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Four Key Steps

1. Ensure good quality X-ray
2. Correlate with age and CRITOE sequence
3. Look for fractures or missing ossification centers
4. Assess fat pad signs

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4. Important Radiological Lines

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A. Anterior Humeral Line

• Should pass through middle third of capitellum

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Clinical Use

• Diagnosis of supracondylar fractures
• Helps identify mechanism (flexion or extension type)

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B. Radiocapitellar Line

• Line drawn along radial neck
• Should intersect capitellum in all views

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Clinical Use

• Detect radial head dislocation
• Differentiate transepiphyseal separation

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Exam Pearls

• Posterior fat pad indicates occult fracture
• Most common fracture is supracondylar fracture
• Most important intra-articular fracture is lateral condyle fracture
• CRITOE sequence is essential for interpretation
• Medial epicondyle fracture with dislocation may have trapped fragment
• Open reduction of radial neck fractures has high complication rates

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Final Takeaway

• Pediatric elbow evaluation depends on:
  • Age
  • Ossification pattern
  • Radiographic alignment
• Missing subtle signs leads to:
  • Malunion
  • Deformity
  • Long-term functional impairment