System for Reading Pediatric Elbow Xrays

System for Reading Pediatric Elbow Xrays

  • Verify patient name and side

  • Quality of views

  • Follow cortices and medullary canals proximal to distal humerus, ulna, then radius

  • Anterior humeral line

  • Radiocapitellar line

  • Assess joint line for varus valgus

  • Assess Physes

  • Soft tissue shadows

  • Look closely at point of maximal tenderness (based off your physical exam)

Assessing quality of elbow xrays:


  • The true lateral elbow has a minimal AP dimension.

  • Semi-circular surfaces of condyles aligned.

  • Space visible across ulnohumeral joint


Anterior humeral line:

  • Should cross middle third of capitellum, if it doesn’t the lateral view is off or that a fracture is likely


Radiocapitellar line (aka. Proximal radial line)

  • Line should bisect the capitellum into halves (if it doesn’t that means radial head dislocation)

  • The proximal radial line should always bisect the capitellum in any projection

Varus valgus of elbow:



  • Varus means the distal segment is going towards midline

  • Valgus means the distal segment is going away from midline

  • The above picture shows the carrying angle (Cubitus angle)

    • If it is inferior to 5 degrees : Cubitus varus

    • And when it is superior to 15 degrees: Cubitus valgus


Physes in pediatric elbow:


Ossification center (bone is added to cartilage scaffold) – CRITOE is an important acronym

Age at ossification (appears on xrays) – goes up by odd numbers, +/- 1 year between boys/girls





Internal (medial) epicondyle






External (lateral) epicondyle



Soft tissue shadows:



  • Fat pad sign does not equal fracture, it indicates increased chance of fracture

  • Anterior fat pad: Probability is 70-80% for intra-articular fracture

  • Posterior fat pad: Probability is 90% for intra-articular fracture

Example Case

Image reference: Twitter @davembmd


  • Practice with the image above! Check the comments for the answer!

  • Does anyone know what the image is showing?



Twitter @davembmd–pediatric


This Post Has One Comment

  1. Mohammad

    Dislocated radial head

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