Anatomy and 

Development
of the Pediatric Elbow
1
Julio J. Jauregui and Joshua M. Abzug

Introduction movement, the radiohumeral articulation provid-

ing a pivoting movement, and the proximal radio-
Trauma and injury to skeletally immature patients ulnar joint providing a rotational movement
represent a common challenge to the orthopedic (Fig.  1.1). As opposed to simple joints, a com-
surgeon. Of these, injuries to the pediatric elbow plex joint, such as the elbow, can give way to
are extremely common in children, representing more stress being placed on adjacent joints.
from 15 to over 40% of all fractures observed in While variations are seen in timing for every
children [1]. Although relatively common, these individual due to gender/race, etc., there is an
injuries can be one of the most elusive to detect.
Therefore, understanding the anatomy and devel-
opment of the pediatric elbow will aid in the detec-
tion of fractures, even in their subtle form [2]. This
chapter will discuss the anatomy of the pediatric
elbow as well as its ossification development.

Background: Elbow Development

The elbow joint includes three types of articula-

tions making it a complex joint. These are the
ulnohumeral articulation providing a hinge-type

J.J. Jauregui, M.D.

Department of Orthopaedics, University of Maryland
Medical Center, 110 South Paca Street, 6th Floor,
Suite 300, Baltimore, MD 21201, USA
e-mail: JJauregui@umoa.umm.edu
J.M. Abzug, M.D. (*) Fig. 1.1  Lateral radiograph of an elbow depicting the
Departments of Orthopedics and Pediatrics, various motions about the elbow including flexion-­
University of Maryland School of Medicine, extension through the ulnohumeral articulation and fore-
Baltimore, MD, USA arm rotation through the proximal radioulnar articulation
e-mail: jabzug@umoa.umm.edu (Courtesy of Joshua M. Abzug, MD)

© Springer International Publishing AG 2018 3

J.M. Abzug et al. (eds.), Pediatric Elbow Fractures, https://doi.org/10.1007/978-3-319-68004-0_1
4 J.J. Jauregui and J.M. Abzug

Table 1.1  Order for sequential appearance and fusion of the ossification centers in the elbow
Mnemonic Site Age at appearance (years) Age at physeal fusion (years)
C Capitellum 1 14
R Radial head 4–5 16
I (M) Medial (internal) epicondyle 6–7 15
T Trochlea 8–10 14
O Olecranon 10 14
E (L) Lateral (external) epicondyle 11 16

overall predictable pattern of ossification in the
pediatric elbow [3, 4]. Between the ages of 6 and
12 months, the capitellum ossification center is
visible on plain radiographs. Girls tend to have
their ossification centers visible earlier than boys,
and their physes may close anytime up to 2 years
sooner than in boys. Although there is up to a
2-year disparity between males and females, the
elbow ossification patterns are well known and
follow the mnemonics described by Hansman,
Garn, and Girdany [5–7]. The sequence of ossifi-
cation follows the mnemonic word CRITOE, in
which the first center to ossify is the Capitellum
at a mean of 3 months, then the Radial head at
5 years, the Internal (medial) epicondyle at
7 years, the Trochlea at 9 years, the Olecranon at
11 years, and the External (lateral) epicondyle at
13 years (Table 1.1). In general it is thought that
the fusion of the elbow growth centers is c­ omplete
by 13 years of age in girls and 15 years of age in
boys [8] (Figs. 1.2 and 1.3).
There are subtle variations by gender in which
these ossification centers develop, whereas they
typically develop sequentially in boys and more
often do not develop simultaneously in girls. The
capitellum fuses first with the trochlea and lateral
condyle. Later in development, there is fusing of
the olecranon, radial head, and lastly the medial
epicondyle. The closure of the medial epicondyle
apophysis is the final growth center about the
pediatric elbow to fuse, which typically occurs
between 15 and 20 years of age, marking skeletal
maturity of the elbow [3] (Table 1.1).
Motion
There are many studies evaluating the range of
motion in pediatric patients with acquired or
genetic conditions, but only a paucity of studies
have described elbow range of motion in the non-­
pathologic pediatric elbow. A recent study by
Barad et al. [9] recorded motion data on 1361
normal pediatric elbows. These patients had a
mean age of 4.9 years (range, 1–16 years; SD,
2.6 years), with a mean weight of 47.5 lb (range,
12–183 lb; SD, 19.8 lb). The mean amount of
flexion was 142° (range, 125°–155°; SD: 4.0°),
and the mean extension was −11° (range, −35° to
0°; SD, 4.3°). The mean total arc of motion was
153° (range, 127°–175°; SD, 6.0°).
When stratified by gender, boys had a mean
amount of flexion, extension, and total arc of
motion of 141°, −11°, and 152°, respectively.
1  Anatomy and Development of the Pediatric Elbow 5

a c

b
d

Fig. 1.2 Radiographs at various developmental ages
demonstrating the progression of ossification. (a) AP and
(b) lateral elbow radiographs of an 18-month-old child.
(c) AP and (d) lateral elbow radiographs of a 3-year-old
child. (e) AP and (f) lateral elbow radiographs of a 6-year-­
old child. (g) AP and (h) lateral elbow radiographs of a
9-year-old child. (i) AP and (j) lateral elbow radiographs
of a 12-year-old child. (k) AP and (l) lateral elbow radio-
graphs of a 15-year-old child (Courtesy of Joshua
M. Abzug, MD)
6 J.J. Jauregui and J.M. Abzug

e g

Fig. 1.2 (continued)
1  Anatomy and Development of the Pediatric Elbow 7

i k

l
j

Fig. 1.2 (continued)
8 J.J. Jauregui and J.M. Abzug

Fig. 1.3 Schematic
showing the various
ossification centers
about the elbow and
Age for Ossification
their average age of Pediatric Elbow
appearance on plain
radiographs (Courtesy of
Joshua M. Abzug, MD)

Medial epicondyle
6–7 years Lateral epicondyle
11–12 years

Capitellum
Olecranon 1 year
10 years
Radial head
4 years
Trochlea
8–10 years

In girls, the mean amount of elbow flexion, exten-
sion, and arc of motion was higher, at 143°, −12°,
and 154°, respectively (p < 0.01). Although sig-
nificantly different, the authors concluded that
these differences were not clinically relevant as
they are all under 2°. The authors also described
that the range of motion when plotted by age
increased until 6 years for boys and until 8 years
for girls; however these findings were not statisti-
cally significant. In contrast, a study by Golden
et al. [10] analyzed the measurements of range of
motion of 600 elbows from 300 children and con-
cluded that the amount of elbow flexion corre-
lated positively with age, whereas the amount of
elbow extension did not.
Specific Development and Anatomy
Bony Anatomy
Three articulations make up the elbow joint.
First, the distal humerus articulates with the
ulna at the trochlea. The trochlea groove of
the ulna articulates at the distal humerus’
medial articular end and is characterized by its
rounded and grooved appearance. The trochlea
groove of the ulna is composed of articular car-
tilage and is bounded proximally by the olecra-
non process and distally by the coronoid
process. Flexion and extension of the elbow
occur through this ulnohumeral or ­ulnotrochlear
1  Anatomy and Development of the Pediatric Elbow
joint. This motion occurs in a single plane due
to this hinged articulation. It is noteworthy
to point out that the ulna fractures in a differ-
ent pattern than many other pediatric and
­adolescent bones about the elbow, with frac-
tures occurring in the metaphysis as opposed to
about a physis [2].
The next articulation is the capitellum met
by the radius’ concave head. The capitellum
forms the distal humerus’ convex lateral artic-
ular surface. In this articulation, the proximal
radius moves in relation to the distal humerus
by a paired concavity and convexity, thus
­p ermitting a pivoting motion. The last articu-
lation about the elbow is the proximal radio-
ulnar joint, where the radial head articulates
with the proximal ulna. This permits rotation
of the forearm with the aid of the interosseous
membrane and distal radioulnar joint [11]
(Fig. 1.1).
Anatomy: Muscles and Ligaments
Integrated stabilization is provided to the
elbow joint when muscles of the arm and fore-
arm transverse the elbow. Stemming from the
medial e­ picondyle is the flexor-pronator mus-
cle group, which aids in resisting valgus stress.
Static stability of the elbow is accomplished by
Ligaments of the Pediatric Elbow
Anterior capsule
Radial collateral
ligament
Annular ligament
Transverse ligament Posterior capsule
Fig. 1.4  Schematic of the elbow depicting the ligamentous structures. The drawing on the left is looking at the lateral
structures, and the drawing on the right depicts the medial structures (Courtesy of Joshua M. Abzug, MD)
9
the bony and ligamentous structures about the
elbow (Fig. 1.4). This stability primarily comes
from the ulnohumeral articulation and the
medial and lateral collateral ligaments. At 90°
of flexion, approximately 55% of the valgus
stability of the elbow occurs due to the ulnar
collateral ligament (UCL). This ligament origi-
nates from the medial epicondyle and is com-
posed of three main elements; the anterior,
posterior, and transverse bundles. The main
valgus stabilizing bundle of the elbow is the
anterior bundle of the UCL, which is dis-
tinctly separate from the anterior joint cap-
sule. The anterior bundle of the UCL is
comprised of anterior and posterior bands that
function separately. While the tightness and
stability in extension is due to the anterior
band, as the elbow is flexed, there is increas-
ing stability provided by the fan-­shaped poste-
rior band [3] (Fig. 1.4).
In contrast, varus stress is resisted mainly by
the bony articulation of the radiocapitellar joint
in flexion and extension, as the lateral collateral
ligament (LCL) only contributes a minimal
amount of stability (9–14%). The lateral collat-
eral ligament complex originates from the lateral
epicondyle and is comprised of the radial collat-
eral ligament, lateral ulnar collateral ligament,
accessory lateral collateral ligament, and annular
ligament [3] (Fig. 1.4).
Anterior bundle (MCL)
Annular ligament
Transverse bundle (MCL)
Posterior bundle (MCL)
10
Centers of Ossification
Many studies have evaluated the formation of the
growth centers within the pediatric elbow [4, 12].
Of these, a recent study by Dwek utilized pediat-
ric elbow images to evaluate multiple growth cen-
ters about the elbow. There are four secondary
ossification centers seen in the distal humerus: (1)
the capitellum, (2) the trochlea, (3) the medial epi-
condyle, and (4) the lateral epicondyle. It is worth
pointing out that at birth, not one of these centers
is ossified [5, 6]. In terms of laterality, studies
describe no difference in timing or ossification
pattern between the right and left elbow [4].
A single smooth center is how the capitellum
develops with ossification. A jagged and non-­
regular appearance is seen in the trochlear ossifi-
cation. A single center is seen in development for
the medial epicondyle; however, this physis is a
spherical growth plate that engulfs the whole
medial epicondyle, which allows for the normal
circumferential growth to take place [12]. A sin-
gle elongated center or even multiple centers can
be seen in the ossification of the lateral epicon-
dyle. The ossification center of the radial head
starts out oval and later becomes disk shape and
flat. The olecranon commonly starts as two sec-
ondary centers which ossify into the olecranon
but can also start as multiple centers which should
not be mistaken for fracture fragments [4, 11]
(Figs. 1.2 and 1.3).
The lateral condyle forms from the fusion of
the lateral epicondyle to the distal humeral epiph-
ysis, which then later fuses to the metaphysis.
The fusion of the epiphysis and metaphysis is the
last step of the lateral epicondyle’s ossification,
which is a peripheral process. This forms a large
gap between the lateral epicondyle ossification
center and the lateral condyle, with the former
having a linear pattern and the latter often mis-
taken for an avulsion fracture.
Soft Tissue
Multiple fat pads exist about the elbow and are
typically located within bony fossae that exist
to permit flexion and extension of the elbow.
J.J. Jauregui and J.M. Abzug
These fat pads can be pushed up and outward
from the fossae when the joint space is filled
with fluid, such as blood following a fracture.
There are many studies that have evaluated this
finding and have described that the posterior fat
pad sign could be predictive of an occult frac-
ture of the elbow following trauma. Skaggs and
Mirzayan described this fat pad sign in a pro-
spective series of 45 children with a traumatic
history about the elbow who had an elevated
posterior fat pad and had no other radiographic
evidence of fracture. The authors reimaged the
elbows in these children and noted that perios-
teal reaction from an occult fracture was pres-
ent in 76% of patients [13].
Nerve Anatomy
The nerve anatomy of the pediatric elbow is
similar to that of the adult counterpart. In pedi-
atric patients, the ulnar nerve crosses the elbow
posterior to the medial epicondyle, the median
nerve crosses the elbow with the brachial
artery, and the radial nerve runs between the
brachialis and brachioradialis muscles before
crossing the elbow and penetrating the supina-
tor muscle. The radial and median nerves are
vulnerable to injury following supracondylar
humerus fractures which occur after an elbow
hyperextension injury. In contrast, the ulnar
nerve is vulnerable to injury after a supracon-
dylar fracture with elbow hyperflexion or when
a direct blow to the posterior aspect of the
elbow occurs.
Pediatric patients may have instability of the
ulnar nerve, which is important to recognize
due to the potential risk for nerve injury during
medial percutaneous pinning of supracondylar
humerus fractures. Zaltz et al. [14] evaluated
328 ulnar nerves (164 children) and noted that
17.7% of children between the ages of 0–5 had
ulnar nerve instability. 7.7% of the children
between 6 and 10 years of age and 5.7% of the
children between 11 and 18 years of age had
ulnar nerve instability. The rate of ulnar nerve
instability is significantly increased in children
with ligamentous laxity.
1  Anatomy and Development of the Pediatric Elbow
Vascular Anatomy
The brachial artery runs superficial to the brachia-
lis muscle along the anteromedial aspect of the
humerus. Subsequently, this artery passes anterior
to the distal humerus while an extensive collateral
circulation develops. As the artery extends into
the forearm, it splits into the radial and ulnar arter-
ies. Following a supracondylar humerus fracture,
the brachial artery is especially prone to injury.
The distal extent of the proximal bony fragment
may cause intimal damage to the vessel leading to
subsequent thrombosis and vascular insufficiency.
Due to the extensive collateral circulation present
at the elbow, arm ischemia caused by complete
occlusion of the brachial artery is infrequent.
Conclusion
Knowledge of the development of the pediat-
ric elbow is necessary for the proper manage-
ment of children with an elbow fracture.
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