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Bone Sense™ – Case Snap: Paediatric Elbow Injuries

Case Presentation

A 2-year-old girl presented to the Emergency Department after a fall at home. She was calm, walking normally, but held her left arm close to her side. There was no swelling or crying, but she refused to move the limb.

Initial Imaging and Clinical Suspicion

An AP view of the elbow appeared normal.

Always obtain at least two orthogonal views. If in doubt, consider three views—AP, lateral, and oblique.

The lateral view was suboptimal—possibly an oblique—and looked abnormal. Given clinical suspicion, orthopaedic consultation was sought.

Imaging Pearls

  • If you can’t see a fracture clearly, Ortho likely won’t either.
  • Repeat imaging with a true lateral view is warranted in uncertain cases.
  • Good quality imaging is crucial for paediatric elbows.

Definitive Diagnosis

The repeat true lateral X-ray revealed a lateral condyle fracture of the distal humerus.

This fracture is:

  • Intra-articular
  • Involving the growth plate (physis)
  • A Salter-Harris Type IV fracture, passing through the metaphysis, physis, and epiphysis

These fractures are prone to:

  • Displacement
  • Growth disturbance
  • Joint deformity (e.g., cubitus valgus)
  • Non-union

Clinical Red Flag

A child refusing to move a limb, even in the absence of pain or swelling, Xray should always be evaluated thoroughly for occult injury.

Understanding the Immature Elbow X-ray

  • Ossification Centres – CRITOE Mnemonic:
    – Capitellum (~1 year)
    – Radial head (~3 years)
    – Internal (medial) epicondyle (~5 years)
    – Trochlea (~7 years)
    – Olecranon (~9 years)
    – External (lateral) epicondyle (~11 years)

How to apply to this case?

  • Fusion Timeline:
    These ossification centres fuse at different ages and in a predictable pattern. Any abnormal positioning, fragmentation, or premature fusion may indicate trauma.
  • Radiographic Pitfalls:
    – Ossification centres may appear as separate fragments—do not confuse them with fracture fragments. 
  • Important Radiographic Lines:
    – Anterior Humeral Line: Should intersect the middle third of the capitellum on a true lateral view.
  • – Radiocapitellar Line: Should pass through the centre of the capitellum on all views.
  • Soft Tissue Clues:
    – Look for the fat pad sign: a visible posterior fat pad is almost always abnormal and strongly indicates an occult fracture. The anterior fat pad is usually visible, but elevation (the sail sign) indicates a joint effusion.

Salter-Harris Fracture Classification

Type I

Physis only – difficult to detect. Good prognosis.

Type II

Physis + metaphysis – most common. Excellent prognosis.

Type III

Physis + epiphysis – intra-articular. Guarded prognosis.

Type IV

Metaphysis + physis + epiphysis – high risk. Variable prognosis.

Type V

Crush injury to physis – often missed. Poor prognosis.

Lesson Learned

1. A proper elbow X-ray series in children should include three views: AP, true lateral, and oblique.

2. Ultrasound can help but is operator-dependent and may not be available after hours.

3. Escalate concerns early—better safe than sorry when dealing with growth plates & intra-articular fractures.

Elbow injuries in children are frequently subtle, yet they carry significant clinical consequences if missed. In primary care or emergency settings, the challenge lies in interpreting an immature elbow X-ray. 

This case snapshot is part of the Bone Sense™ series and is designed to help general practitioners and Emergency doctors build confidence in assessing paediatric elbow injuries. You learnt when to suspect a fracture, how to interpret paediatric elbow radiographs, and what red flags to look for. Our goal is to bridge the gap between uncertainty and early recognition—because not all fractures are obvious, but the consequences of missing one can be.

For more Paediatric  Orthopaedic Tips and  X-ray Guide, follow us on Instagram: @bonesense.my