Pédiatrie Elbow Trauma: An Orthopaedic

Perspective on the Importance of Radiographie

Interpretation
Sidney M. Jacoby, M.D.,^ Martin J. Herman, M.D.,^ William B. Morrison, M.D.,^
and A. Lee Osterman, M.D.^

ABSTRACT

Radiographie interpretation oí pédiatrie elbow trauma presents a daunting task for

both the radiologist and treating orthopaedic surgeon. Proper radiographie diagnosis and
appropriate intervention requires a thorough understanding and appreciation of devel-
opmental anatomy. As the pédiatrie elbow matures, it transitions from multiple cartilagi-
nous anlagen through a predictable pattern of ossification and fusion. When children
sustain trauma to the elbow, they may have a limited capacity to communicate specific
complaints and are sometimes difficult to examine reliably. Furthermore, the presence of
multiple growth centers, and their variability, makes radiographie evaluation of pédiatrie
elbow injuries partieularly challenging. These variables, coupled with the known adverse
long-term sequelae of pédiatrie elbow trauma (painful nonunion, malunion, elbow stiff-
ness, growth disturbance, etc.) highlight the importance of accurate radiographie inter-
pretation, which facilitates appropriate treatment. By using an orderly, systematic approach
based on well-defined anatomical relationships and accepted radiographie markers, the
radiologist may effectively interpret and communicate pertinent findings to the treating
orthopaedic surgeon. Furthermore, using common elassifieation systems may facilitate
interdisciplinary communication. Finally, it is crucial that caregivers of children consider
the possibility of ehild abuse in suspect cases.

KEYWORDS: Pédiatrie elbow, trauma, radiography, growth plate

i rauma to the child's elbow may result in bony,
cartilaginous, or soft tissue injury. Just as adults instinc-
tively protect their central core from a fall with their
arms outstretched, children tend to break their fall in
similar form. Epidemiológica] studies have shown that
pédiatrie elbow fractures have both a higher incidence
and greater variability in fracture patterns as compared
with adults.' Overall, 65 to 75% of all fractures in
children occur in the upper extremity, with supracondy-
lar humérus fractures accounting for the majority of
elbow trauma, followed by lateral condyle and medial
epicondyle fractures.'^ As the principal imaging tool,
radiographs reveal soft tissue swelling, fractures, and
joint effusions, which allow for the recognition of
injuries that may require orthopaedic intervention.
The bony anatomy of the child's elbow develops in
a predictable pattern with growth. Understanding the
radiographie appearanee and timing of this developmental

'Department of Orthopaedic Surgery, ^Department of Radiology,
Thomas JeiFerson University, Philadelphia, Pennsylvania; ' Depart-
ment of Orthopaedic Surgery, Drexel University College of Medicine,
St. Christopher's Hospital for Children, Philadelphia, Pennsylvania;
Philadelphia Hand Center, Philadelphia, Pennsylvania.
Address for correspondence aiid reprint requests: Sidney M. Jacoby,
M.D., Department of Orthopaedic Surgery, Thomas Jefferson
48
University, 1015 Walnut Street, Suite 801, Philadelphia, PA 19107.
What the Orthopaedic Doctor Needs to Know; Guest Editor,
Catherine C. Roberts, M.D.
Semin Musculoskelet Radiol 2007;l 1:48-56. Copyright 0 2007 by
Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY
10001 USA. Tel: + 1(212) 584-4662.
DOI 10.1055/S-2007-984412. ISSN 1089-7860.
 PEDIATRIC ELBOW TRAUMA: AN ORTHOPAEDIC PERSPECTIVE/JACOBY ET AL
Table 1 Pédiatrie Elbow Ossification Centers by Age
Sequence and Timing of Elbow Ossification
Structure Approximate Years of Age
Capitellum 1 radius and ulna.'* The distal humérus is comprised of
Radial head 4-5
Medial epicondvls 4-5
Troch lea 8-9
Olecranon 8-9
Lateral epicondyle 10
Note: Females tend to have an earlier appearance of ossification
centers by 1 to 2 years,
sequence allows the radiologist to separate more easily
subtle fractures from normal anatomy (Table 1; Fig. 1). In
addition to understanding the radiographie images, all
physicians involved in the care of children must be aware
of the common mechanisms of injury and relevant phys-
ical findings. Communication of pertinent history and
physical findings by the referring physician to the radiol-
ogist improves the radiologist's ability to diagnose specific
conditions. This information, coupled with the knowl-
edge of the sequence of grovrth center ossification and
statistical frequency of injury at various sites about the
elbow, helps avoid errors in diagnosis. The interpretation
of pédiatrie elbow trauma therefore requires a systematic
approach that incorporates a patient's age, pertinent
history and physical findings, and a strong thorough
understanding of common injury patterns and normal
radiographie anatomy.
ANATOMY
Tbe elbow is a complex joint consisting of tbree osseous
articulations, multiple capsuloligamentous reinforce-
ments, and musculoskeletal attachments. Because of its
bony and soft tissue constraints, the elbow predomi-
Medial
(inlernal)
epiconOyle
Rad fa Trochlea
Heaa
Figure 1 Anteroposterior and lateral schematic of pédiatrie elbow (growth centers labeled).
49
nantly functions as a ginglymus, or hinge joint. As a
child matures, the simple circular diaphysis of the
humérus undergoes dramatic geometric change to ac-
complish both hinge and pivot articulations with the
medial and lateral columns tbat flare outward in tbe
coronal plane and terminate at the transversely oriented
articular segment of the trocblea. Tbe capitellum is
the anterior articular extension of tbe lateral column.
The medial column deviates at approximately twice tbe
angle of the lateral column and thus maintains a more
distinct bony prominence. The triangle bounded by
tbe medial column, lateral column, and articular surface
defines the olecranon fossa posteriorly and the coronoid
and radial fossa anteriorly. The proximal radius and ulna
also form an articulation with each other to complete tbe
third limb of osseous stability.
The concave articulating surface of tbe ulna is
termed tbe trochlear notch. This structure consists of an
anterior triangular projection termed the coronoid process,
which serves as tbe insertion of the bracblalis musde. Tbe
posterior margin of tbe trocblea is termed the olecranon,
which serves as tbe insertion site for the triceps muscle.
The lateral distal humeral column consists of the
capiteUum, which articulates with the radial head. Just
distal to the radial bead, tbe radius constricts to form tbe
neck and tben expands distally again to form tbe radial
tuberosity, which serves as tbe attachment site for the
biceps tendon. Tbe annular ligament encircles the radial
head and helps secure the radius and ulna.
RADIOGRAPHIC ASSESSMENT
Radiographs are the principal modality utilized in diag-
nosing elbow injuries. Basic radiographie examination
consists of anteroposterior (AP) and lateral projections
of tbe elbow. If tbere is any question concerning the
Olecranon Radial Head
50 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 11, NUMBER 1 2007

presence or position of apophyseal and epiphyseal

growth centers, oblique views and comparison views of
the opposite limb can he extremely useful/ The AP view
should he obtained with the forearm supinated and the
elbow positioned in as full extension as possible. The
lateral view should be obtained in a 90-degree flexion of
the elbow. Skiho et al reported on the importance of a
true lateral view by noting that even slight external
rotation of the elbow in this view obscures the reliability
of specific markers such as the anterior humeral line in
determining the presence or ahsence of joint pathology."
Obtaining high-quality orthogonal views in children is
sometimes difficult because of poor cooperation, hut it is
crucial for identifying subtle abnormalities.
In many cases the presence of elbow trauma is Figure 2 Schematic of posterior fat pad swelling.
immediately apparent to the radiologist and treating
physician- For instance, high-energy trauma resulting in
displaced elbow fractures and dislocations does not re- terior fat. This displacement becomes visible on a lateral
qLiire critical analysis. However, many pédiatrie fractures radiograph in the form of a posterior fat pad {Fig. 2).
are subtle and therefore require a closer and more dis- Numerous studies have examined the presence of a
ciplined approach. Critical analysis of elbow radiography posterior fat pad and its correlation with occult frac-
includes the following adjunctive criteria: a search for fat ture. Although some authors report that a hemarth-
pad elevations, close inspection of the anterior humeral rosis without a visualized fracture on initial radiographs
and radiocapitellar hnes, identification of the presence and does not correlate with the presence of occult fracture,
proper position of ossification centers, and finally, a others believe the posterior fat pad sign in patients with a
focused search for fractures of high frequency based on history of trauma is predictive of an occult fracture of the
the history and clinical examination of the patient. elbow. Skaggs et al support the practice of managing
As first described by Norell in 1954, the fat pad children with a history of elbow trauma, an elevated
represents a thin layer of fat that overlies both the posterior fat pad, and no other radiographie evidence of
anterior and posterior aspects of the elbow joint capsule. fracture as if they have a nondisplaced fracture about the
The posterior fat pad lies in the shallow intercondylar elbow, diagnosing with follow-up radiographs, occult
depression on the posterior surface of the humérus and is elbow fractures are found in 80% of children with an
therefore invisible on the normal lateral radiograph. In isolated posterior fat pad on initial radiographs. '
an adequate film, the anterior fat pad is a normal finding The anterior humeral and radiocapitellar hnes
seen on the lateral view. As a consequence of joint (Figs. 3A,B) are also usefiil radiographie markers for
trauma, both blood and marrow may collect and expand detecting subtle fractures. ' On a lateral radiograph, a
the joint capsule, resulting in the displacement of pos- line drawn along the anterior humeral cortex normally

ANTËfUOR HUMERAL
UNE SHOULD FALL
WfTH/N THB C£Nr£R
JHÍRD OF THE SHAFT OF RADfUS
CAPiTELLAR SHOULD LfNEUP
OSSiFtCA TÍON CENTER WITH CAPITELLAR
OSSIFICATION
CENTER

Figure 3 ¡Al (B) Schematic representations of anterior humeral and radiocapitellar lines.
 PEDIATRIC ELBOW TRAUMA: AN ORTHOPAEDIC PERSPECTIVE/JACOBY ET AL
Figure 4 Schematic representation of radiocapiteiiar associa-
tion through elbow range of motion.
passes through the middle of the capitellum in children
older than 2.5 years. In children younger than 2.5 years,
the anterior humeral line may pass through the anterior
third of the capitellum secondary' to the small size of the
ossification center. In the normal elbow radiograph in
children of all ages, a line that hisects the radial shaft
passes longitudinally through the center of the capitel-
lum in all views of the elbow (Fig. 4). If the integrity of
these lines is compromised, elbow pathology including
fracture or dislocation likely exists. For example, if the
anterior humeral line passes through the posterior third
of the capitellum, an extension-type supracondylar hu-
merus fracture has likely occurred.
SPECIFIC FRACTURE TYPES
Supracondylar Fractures
Supracondylar humcrus fractures are the most common
injuries about the elbow in children, accounting for up to
60% of all fractures in this region. In a large study of
3350 children, Otsuka et al ft)und the supracondylar
fracture to be the most common fracture in all children
younger than 8 eight years. The most common mech-
anism of injury is a fall on an outstretched arm. Most
supracondylar fractures (95%) are extension-type inju-
ries; that is, the distal fragment displaces posteriorly and
is relatively extended compared with the shaft; this
extension may be accompanied by medial or lateral
displacement in the coronal plane. The remainder of
supracondylar fractures are the result of a flexion-type
injury (5%). The Gartland classification (Fig. 5) is most
commonly utilized to describe extension-type injuries.
51
Figure 5 Gartland classification of supracondylar fractures.
Dense black line represents the periosteal sleeve (note complete
displacement in type 3 supracondylar fracture). (A) Type 1 non-
displaced extension-type fracture. (B) Type 2 displaced exten-
sion-type fracture with intact posterior hinge. (C) Type 3
completely displaced extension-type fracture.
This classification system places these fractures into
three categories: Type 1 (nondisplaced fractures), type
2 (displaced with posterior cortex intact), and type 3
(displaced with no posterior cortical apposition).
Most supracondylar fractures are radiographically
apparent. Type 1 (nondisplaced) fractures, however, are
often subtle and difficult to detect on plain radiographs,
particularly on the AP image. The posterior fat pad sign
is almost always seen in association with nondisplaced
supracondylar fractures, and it is a usefijl tool in diag-
nosis (Fig. 6). Any deviation of the anterior humeral line
from normal should raise suspicion of a supracondylar
fracture with posterior displacement (Figs. 7 and 8).
Figure 6 Lateral elbow radiograph demonstrating a posterior
fat pad, indicated by arrow, suggestive of s nondisplaced supra-
condylar fracture (Gartland type 1), The patient was initially
treated in a long arm cast for a presumptive nondisplaced
supracondylar fracture and was found to be pain free during
subsequent follow-up visits.
52 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 11, NUMBER 1 2007
Figure 7 Lateral elbow radiograph demonstrating a supracon-
dylar fracture with extension-type injury, anterior humeral line
shown in red (Gartland type 2).
Lateral Condyle Fractures
Fractures of the lateral condyle, the second most com-
mon fracture about the elbow in children, represent
hetween 10 and 20% of all fractures in this region.
This injury occurs when a varus force is applied to the
extended elbow with the forearm in supination.'"* Milch
described lateral condyle fractures with particular em-
phasis on the location of the fracture line relative to the
capitellum and trochlea (Fig. 9). In most lateral condyle
fractures, the fracture Hne extends through the meta-
physis of the lateral distal humérus just above the
ossification center ofthe capitellum and traverses distally
to the joint surface, passing through the capitellar
ossification center (Milch 1) or medial to the ossification
center (Milch 2) through the trochlea.
An alternative classification system described by
Jakob classifies lateral condyle fractures on the basis of
the integrity of the cartilage joint line and fragment
displacement. A type 1 injury shows minimal displace-
Figure 8 Lateral and anteroposterior radiographs demonstrat-
ing a supracondylar fracture with complete displacement and no
cortical apposition ¡Gartland type 3)-
Figura 9 Milch classification of lateral condyle fractures. Frac-
ture line extends through the metaphysis of the lateral distal
humérus above the ossification center of the capitellum and
traverses distally to the joint surface, passing through the capi-
tellar ossification center (Milch 1 ) (A) or medial to the ossification
center (Milch 2) through the trochlea (B).
ment without violation ofthe joint surface. This incom-
plete fracture is often only discernible on an oblique
radiograph of the distal humérus {Fig. 10). A type 2
fracture has 2 to 4 mm of displacement of the lateral
condyle fracture fragment at the metaphysis ofthe distal
lateral humérus with an intact and stable articular
cartilage hinge at the joint surface. The type .3 injury is
a complete fracture of the metaphysis and articular
cartilage at the joint surface, frequently with complete
displacement ofthe fragment.
One of the shortcomings of radiographie anal-
ysis of lateral condyle fractures is the difficulty in
judging the degree of articular surface continuity.
Based on initial radiographs, it is often difficult to
determine if the minimally displaced fracture traverses
Fjgure 10 Oblique radiograph demonstrating a type 1 lateral
condyle fracture.
 PEDIATRIC ELBOW TRAUMA: AN ORTHOPAEDIC PERSPECTIVE/JACOBY ET AL
Figure 11 Magnetic resonance imaging scan üf a mmimaily
displaced lateral condyle fracture with articular congruity disrup-
tion, as indicated by arrow.
the cartilage hinge. Those fractures that do not cross
the cartilage hinge at the joint line are usually stable
and at low risk for fracture displacement or nonunion
when treated in a cast, whereas those that are mini-
mally displaced hut through the cartilage of the distal
humérus may he unstable and require surgical stahili-
zation. Magnetic resonance imaging (MRI) (Fig. 11)
or arthrogram of the elbow may he necessary to further
Figure 12 (A) Anteroposterior radiograph demonstrating a right elbow with a minimally displaced medial epicondyle fracture; (B)
depicts a displaced medial epicondyle fracture of the right elbow.
53
evaluate minimally displaced fractures of the lateral
condyle to determine the stabilit)' of the fracture and
the need for fixation to prevent the detrimental con-
sequences of late displacement such as nonunion or
malunion.
Medial Epicondyle Fractures
Fractures of the medial epicondyle (Fig. 12) account for
•--'12% of pédiatrie elbow fractures, and they most
commonly occur in older children between 10 and
14 years, with a peak at 11 years of age. The primary
mechanism of injury is a valgus torce on the elbow or by
tension within the flexor-pronator mass. Displacement
of medial epicondyle fractures may he medial, medial
with fragment rotation, or distal with injury severity
based on the degree of displacement. No classification
system is routinely used, and treatment varies widely for
isolated injuries from cast immohilization to open re-
duction with fixation.
Approximately 50% of these injuries are associ-
ated with elbow dislocations."" The majority of elbow
dislocations occur in older children with posterior dis-
placement of the ulna and radius. Careful scrutiny of
radiographs for concomitant bony injuries and judicious
use of other imaging modalities to diagnose osteochon-
dral and ligamentous injuries are crucial for comprehen-
sive evaluation of elbow dislocations. Entrapment of an
avulsed medial epicondyle fragment in the elbow joint
54 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 11. NUMBER 1 2007
Figure 13 Anteroposterior radiograph of a right elbow demon-
strating a medial epicondyle fracture entrapped in the eibow joint.
after reduction of an elbow dislocation may be a partic-
ularly subtle radiographie finding. Higb-quality postre-
diiction radiographs tbat clearly show elbow joint
congruity and tbe presence of a medial epicondyle out-
side the joint are mandatory for those children who
sustain tbis injury. In younger children (especially those
younger than 10 years), the medial epicondyle may be
incompletely ossified and absent or quite small appearing
on radiographs, making the diagnosis of an isolated
fracture or joint entrapment difficult. Additionally, the
trochlear ossification center may be mistaken for an
aviilsed and entrapped medial epicondyle (Fig. 13) in
younger children. If the diagnosis of a medial epicondyle
fracture or its entrapment after a dislocation are sus-
pected but not obvious, comparison elbow views or
further imaging with MRI or computed tomography
(CT) is indicated.
Transphyseal Fractures of the Distal Humérus
Transphyseal fractures of the distal humérus (Fig. 14)
are relatively uncommon fractures. They occur in very
young children, usually younger than 3 years. Common
mechanisms of injury include traumatic birth, child
abuse, or a fall onto an outstretched arm. In the case of
child abuse or birth injury, shear forces on the distal
humeral pbysis are tbe etiology of tbis fracture pattern.
Figure 14 Anteroposterior radiograph revealmy a
fracture of the distal humérus.
Before complete capitellar ossification, the radiographie
•appearance maybe difficult to distinguish from an elbow
dislocation, an injury that is almost never seen before tbe
age of 6 to 8 years. In those children with physeal
separations of the humérus, tbe anterior humeral line
appears completely anterior to the capitellar anlagen and
tbe radiocapiteUar line is intact, a finding not seen in
children with dislocation of the elbow joint. If tbe
diagnosis is suspected based on tbe cbild's history and
clinical findings, comparison elbow views, elbow ultra-
sound, MRI, and elbow arthrography are useful tools to
confirm this serious injury. Because this injury is un-
common and the result of forcible injury, child abuse
must be considered for most cbildren who sustain this
injury. The radiologist must carefully evaluate the child's
radiographs for other fractures and request a skeletal
survey it the clinical scenario dictates this action.
Olecranon Fractures
Olecranon fractures are relatively uncommon in children.
Compromising ~ 5 % of all elbow fractures, most of these
injuries are nondisplaced and tbe result of a direct blow to
tbe elbow, a twisting injury, or a fall onto an outstretcbed
band. Displaced fractures are typically transverse or
oblique through the metaphysis of the proximal ulna
distal to the apopbysis and are intra-articular. Up to 32%
of tbese fractures bave associated elbow injuries, includ-
ing radial neck fractures, coronoid fractures, medial
epicondyle fractures, and osteocbondral defects.^ ''^
Interpretation of olecranon trauma bas innate
difficulties tbat may result in inaccurate diagnoses
(Fig. 15). The normal radiographie appearance of the
olecranon apophysis may be misinterpreted as a non-
displaced fracture at any age. In older cbildren approach-
ing skeletal maturity, the apophysis develops a sclerotic
border as it fuses witb the ulnar metapbysis; bony
 PEDIATRIC ELBOW TRAUMA: AN ORTHOPAEDIC PERSPECTt VE/JACO BY ET AL 55

Figure 15 Comparison lateral elbow radiographs in a child who sustained a 5-cm laceration over the left olecranon. Free air is seen on
the lateral left radiograph ¡A), consistent with a soft tissue injury. Comparison view of the right elbow (B) shows similar olecranon
morphology, minimizing the possibility of an olecranon fracture. Because the child was tender with palpation, the possibility of a
nondisplaced olecranon fracture could not be ruled out. and he was therefore placed in a splint after suturing of the laceration.

bridging becomes evident first adjacent to the joint line
and then progresses toward the ulnar posterior cortex
and may mimic an incomplete fracture. Comparison
radiographs are most useful when the diagnosis is in
question. It is important for the radiologist to be aware
that a normal radiograph of the olecranon apophysis, or
any growth plate, docs not rule out a nondisplaced
fracture. When coupled with a history of trauma and
point tenderness, soft tissue swelling, and elevation of
the posterior fat pad, the possibility of a nondisplaced
physeal or bony injury is likely.
Proximal Radius Fractures
Radial head and neck fractures comprise between 4 and
5% of pédiatrie elbow fractures. In children, radial
metaphyseal neck fractures and Salter-Harris proximal
radial physeal fractures arc more common than radial
head fractures seen in adults. The mechanism of injury is
a fall onto an outstretched hand that causes impaction of
the radial head against the capitellum, often coupled with
valgus stress of the joint. Nondisplaced fractures may not
be evident on initial radiographs and are the second most
common fracture diagnosed on foUow-up radiographs
when an isolated posterior fat pad elevation is seen on the
initiiil radiograph. Oblique views of the elbow and a
radial head view may be necessary' to disclose suhde
proximal radius fractures. The majority of these fractures
are metaphyseal fractures of the neck and Salter-Harris 2
injuries of the physis. In children younger than 4 years,
these fractures may be difficult to appreciate radiograph-
ically because of incomplete or absent radial head ossifi-
cation. A clinical history of trauma with painftil forearm
rotation raises the suspicion for these injuries. The
O'Brien classification is frequently used to describe radial
head and neck fractures. A type 1 O'Brien fracture has
less than 30 degrees angulations; a type 2 fracture is
angulated between 30 and 60 degrees. Type 3 describes a
fracture with greater than 60 degrees of angulation.
Proximal radial fractures may be seen in association
with avulsion fractures of the medial epicondyle, poste-
rior elbow dislocations, and proximal ulna fractures.
Radial Head Dislocations
Radial head dislocation (Fig. 16) is an infrequent trau-
matic injury in the pédiatrie elbow. Isolated radial head
dislocation may occur secondary to traumatic nipture of
the annular ligament, but more commonly this injury
occurs in association with a fracture of the ulna. The
combination of radial head dislocation and ulna fracture
is termed a "Monteggia fracmre." The Bado classifica-
tion describes the direction of radial head displacement
and is the most common scheme used to describe the
types of Monteggia fractures. The radial head most
commonly dislocates anteriorly, whereas the apex of
the ulnar deformity generally points in the direction of
the radial head dislocation. Children, however, may
sustain "Monteggia-equivalent" injuries with plastic de-
formation of the ulna, greenstick or incomplete fractures
of the ulnar shaft, ulnar and radial shaft, or proximal
metaphyseal ulnar fractures. All children diagnosed with
fractures or plastic deformation of the ulna must have
quality orthogonal views of the elbow to ensure that the
radial head is not subluxated or dislocated. Any variation
of the normal radiocapitellar relationship should raise
suspicion for fracture. Forceful hype rex tension of the
elbow in children younger than 4 years may result in pain
and decreased use of the extremity by the child, a
diagnosis known as "nursemaid's elbow." Forearm supi-
nation with elhow flexion is the treatment for this injury,
with return of normal elbow function seen within
56 SEMINARS IN MUSCULOSKELETAL RADIOLOGY/VOLUME 11, NUMBER 1 2007
Figure 16 Lateral radiograph showing an anterior radial head
dislocation. Radiocapiteiiar line is clearly disrupted, indicating
anterior dislocation of the radial head.
minutes after reduction. Despite the suspicion that this
injury represents occult radial head subluxation, radio-
graphs are normal. Radiographic evaluation is necessary
only for children who have prolonged arm dysfiinction or
pain after the reduction maneuver.
CONCLUSION
Pédiatrie elbow trauma is a common injury that can
present diagnostic challenges to treating physicians.
Imaging evaluation should always begin with conven-
tional elbow radiography that includes AP and lateral
views. Oblique views as well as imaging of the eontrala-
teral elbow are often usefiil in detecting subtle fractures
and normal variants. Plain radiography is sufficient to
diagnose most elbow injury patterns; however, addi-
tional modalities, including ultrasound, MRI, CT, and
arthrogram are indicated if the diagnosis is in doubt.
An appreciation for developmental elbow anat-
omy as well as understanding the mechanism of injury is
critical for accurate diagnosis. Furthermore, attention to
soft tissue findings (posterior fat pad) and normal oss-
eous relationships (anterior humeral and radiocapitellar
congmity) help identify pathology. Finally, communica-
tion between the radiologist and orthopaedist may be
enhanced with the use of a "common language," pre-
dicated on mutual understanding of radiographie prin-
ciples as well as commonly used classification systems
that can help direct treatment plans.
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