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Elbow Injuries

July/August 2013 issue of Radiologic Technology

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Introduction

The elbow is a complex joint that supports forearm
movement and consequently is at risk for various
injuries and disorders. Elbow disorders can range from
chronic to acute problems, many of which can be
debilitating.
This article explains the functional anatomy of the
elbow joint and discusses the most common elbow
disorders and injuries. It also presents the most
common diagnostic imaging choices, along with typical
acquisition methods.

supination.Elbow The functionality of the upper extremity relies on elbow motion. flexion. and extension of the forearm. upper extremity impairment increases by as much as 80%. Supination of the forearm brings the palm of the hand face up with the forearm extended. This position brings the radius and ulna parallel with each other. . If a person’s elbow motion decreases by 50%. This position causes the paths of the radius and ulna to cross at the midpoint of the shafts. Pronation positions the forearm with the palm facing down and the arm extended. The elbow controls pronation.

Pain at the elbow also can result from problems not related to the elbow joint. or problems affecting many joints. also play a role in elbow disorders. Chronic elbow injuries can be attributed . Polyarticular causes. elbow pain is due to periarticular causes or problems specific to the elbow joint. Pronation and supination depend on the radial head and capitulum of the humerus. Most commonly. A fully working elbow should allow the forearm to extend 145°from full extension to full flexion and permit a 180°rotation during pronation or supination. Elbow pain can be caused by a number of issues with the joint or surrounding anatomy. such as cervical radiculopathy or referred shoulder pain.Elbow The elbow joint’s ability to flex and extend depends on the articulation of the ulna and humerus.

The proximal radius includes the radial head. medial epicondyle. Each bone is designed to allow the elbow to act as a hinge joint. The coronoid fossa and radial fossa both . coronoid fossa. and radial tuberosity. and lateral epicondyle. The capsule has an internal synovial layer and a superficial fibrous layer. and radioulnar joints. The proximal ulna comprises the olecranon process. and ulna are the 3 bones that make up the elbow. The distal humerus contains the trochlea. radial notch. radial fossa. olecranon fossa. coronoid process. radial neck. Within the elbow are the ulnohumeral. Within these layers are 3 fat pads. capitulum. radiocapitellar.Functional Anatomy The humerus. all of which lie within the same joint capsule. and trochlear notch. radius.

Functional Anatomy The largest of the elbow joints is the ulnohumeral articulation. which is a modified hinge joint. The trochlear groove of the humerus holds the ulnohumeral articulation. The radioulnar joint is a pivot type of synovial joint (a freely movable joint that contains fibrocartilage and hyaline cartilage layers and synovial fluid) divided into superior and inferior sections. The superior section contains the articulation between the radial head and the radial notch of the ulna. The radiocapitellar joint is a ball and socket joint composed of the radial head and humeral capitulum. which allows for movement between the ulna and the humerus. the joint rotates within the annular ligament during . This joint is lateral to the ulnohumeral joint and allows for forearm supination and pronation.

The bicipitoradial bursa. The brachialis muscle attaches at the coronoid process. lies between the radial tuberosity and the biceps tendon. The interosseous medial bursa lies medially between the bicipitoradial bursa and the interosseous membrane of the forearm. Below the neck of the radius. the radial tuberosity lies at the insertion point of the biceps tendon. or cubital bursa. whereas the radial notch articulates with the radial . The olecranon bursa is a fluid-filled sac that provides a cushion between the bone and the slack skin directly over the olecranon process.Functional Anatomy The olecranon process is the bony prominence of the ulna and also is where the triceps muscle attaches to the elbow joint.

The MCL also is called the ulnar collateral ligament (UCL). The annular ligament loops around the radial head. . The medial collateral ligament (MCL) attaches the ulna to the medial epicondyle of the humerus. and posterior bundles. it has 3 separate bundles and is essential to stabilizing the ulnohumeral articulation of the elbow.Elbow Ligaments Ligaments provide stability for the elbow joint. The most important of the elbow stabilizing ligament bundles is the anterior bundle. The lateral ligament attaches the lateral epicondyle to the annular ligament. The ligament bundles are the anterior. The medial and lateral collateral ligaments supply most of the stabilization. transverse.

The accessory lateral collateral ligament derives from the inferior portion of the annular ligament and connects to the supinator crest of the ulna. The radial collateral ligament begins at the lateral epicondyle and inserts into the annular ligament. The lateral ulnar collateral ligament begins at the lateral epicondyle and also attaches to the ulna’s supinator crest. The annular ligament encompasses the radial head and stabilizes the radial notch of the ulna by banding the proximal radius to the proximal ulna. and the radial collateral ligament.Elbow Ligaments The lateral collateral ligament has 4 separate structures: the annular ligament. the lateral ulnar collateral ligament. . the accessory lateral collateral ligament.

and the brachialis muscles. extensor digitorum. extensor carpi ulnaris. extensors. as well as the tendons. The triceps muscle and part of the anconeus muscle control forearm extension. extensor carpi radialis longus and brevis. Three muscles within the flexor group primarily act upon the elbow: the biceps brachii. and the flexor pronator group. supinator. The muscle groups are flexors. The extensor supinator group contains the brachioradialis. The extensor group contains the triceps and anconeus muscles. The brachialis muscle and the biceps brachii are the most powerful elbow flexor muscles. and extensor digiti .Elbow Muscles Four muscle groups. work together to move the elbow joint. the brachioradialis. the extensor supinator group.

The brachial artery is lateral to the median nerve and lies within the cubital fossa of the elbow. This nerve sits along the olecranon groove and crosses the elbow through the cubital tunnel of the . The brachial plexus of the elbow is very complex. They are the musculocutaneous nerve. The most accessible nerve is the ulnar nerve. and ulnar artery. and radial nerve. radial artery. filled with a network of peripheral nerves. and the major arteries involved with the elbow are the brachial artery. the brachial artery then bifurcates into the radial and ulnar arteries.Blood Supply and Elbow Nerves The blood supply through the elbow is extensive. Four nerves control elbow function and sensation. median nerve. ulnar nerve. Within the cubital fossa.

The musculocutaneous nerve traverses the elbow through the lateral antecubital fossa. At the elbow. . the posterior interosseous nerve branches off of the radial nerve. The median nerve runs medially to the biceps tendon and crosses the elbow from within the antecubital fossa. Radial nerve compression also is possible because the nerve is susceptible to tightening of the fibrous band that surrounds it.Blood Supply and Elbow Nerves The radial nerve crosses the elbow forward of the lateral epicondyle.

it is important to understand the ossification centers or the order in which the elbow joint and bones begin to develop. internal [medial] epicondyle. adolescence.Bone Development Bones develop in 3 distinct stages: during childhood. When viewing a radiograph of a pediatric patient’s elbow. olecranon process. The order of bone growth is the same for all pediatric patients. radial head. and the commonly accepted mnemonic for this order is CRITOE (capitulum. Ossification centers typically appear in girls 1 to 2 years before they appear in boys. . trochlea. and external [lateral] epicondyle). and young adulthood.

This line should begin at the anterior portion of the humerus and extend vertically through the middle third of the capitulum. . The coronoid line also can be seen on the lateral image. A lateral radiograph also should display the anterior humeral line. several important anatomical lines are essential in assessing possible elbow damage in patients. The radiocapitellar line should be centered through the long axis of the radius and extend through the radial neck to the center of the capitulum. This line should proceed from the top of the coronoid process of the ulna and proximally intersect the anterior portion of the capitulum and trochlea.Radiographic Anatomy Radiographically.

If the posterior fat pad is noted by the radiologist. this is known as a positive fat pad sign and indicates a probable fracture in approximately 90% of fracture cases.  Fat pads appear in the presence of a joint effusion when the capsule that holds the fat pads distends. Radiographically. The distal humerus contains 2 fat pads that make contact with the joint capsule on the anterior and posterior portion of the joint. this fat pad appears as a darker density next to the bone with a grayer density of tissue surrounding the edges. A minor extension of the arm . Correctly positioning the patient’s elbow at 90°is imperative when imaging fat pads.Radiographic Anatomy The lateral projection of the elbow also is essential in evaluating the fat pads.

arthritis. radiocapitellar.Diagnostic Imaging Modalities: Radiography The most common findings are fractures. and destructive processes. Radiologic technologists should obtain a minimum of 2 projections with 90°of differentiation because the elbow anatomy appears normal in some projections even when the patient has a disorder or injury in the area. loose bodies. Other common elbow projections include the medial and lateral oblique. and the Jones method. For the elbow. . an anteroposterior (AP) projection and a lateral projection should be taken. also known as the distal humerus acute flexion projection.

For the second projection. Positioning for both projections is similar to the AP projection. the first projection places the posterior surface of the humerus flat and parallel to the cassette. the patient’s elbow is extended over the cassette. The x-ray beam is perpendicular and centered to the elbow joint. A slight lateral tilt of the forearm can place the anatomy in the correct position. However. When the patient cannot completely straighten the elbow. the technologist places the patient’s arm so that the posterior forearm is flat and .Radiography In the AP projection. Supination of the hand prevents the forearm bones from crossing. 2 images replace the AP projection. in that the central ray is perpendicular to the joint.

and the radiologic technologist should rotate the patient’s hand into a true lateral position.Radiography Lateral images of the elbow require that the patient flex the elbow 90°. but the arm should be rotated laterally until the elbow is at a 45°angle to the cassette. . The central ray should be directed perpendicular to the elbow joint. The internal oblique projection is positioned similarly. Both the forearm and the humerus should be parallel to the surface of the cassette during contact. The medial oblique projection requires the patient to extend the elbow over the cassette as in the AP projection but with the arm and hand in a pronated position.

centering on the elbow joint. The radiocapitellar projection shows an oblique angle of the lateral elbow separating the proximal radius and ulna. The Jones method acquires images of the elbow in complete flexion.Radiography The radiocapitellar projection requires that the forearm be imaged using a lateral projection but that the hand and arm remain in a neutral rotation. . The x-ray beam should be perpendicular to the cassette and centered approximately 2 inches above the olecranon process. The x-ray beam points at a 45°cephalic angle toward the shoulder. The posterior aspect of the humerus lies on the cassette with the forearm superimposed over the top.

the supine position is used more frequently. Patients do not tolerate this position well. coronal.and T2-weighted images. therefore. For elbow MR. The ability to evaluate much of the elbow anatomy would make MR an optimal imaging choice except that positioning the elbow is difficult using MR imaging. the patient can lie on his or her stomach with the arm positioned above the head. The classic MR acquisition for the elbow involves axial. and sagittal images with T1. .Magnetic Resonance Magnetic resonanceImaging (MR) imaging helps display the joint’s muscle and tendon attachments.

MR using gadolinium contrast enhances the tissue’s signal intensity. MR images of an injured ligament might show thickening or thinning of the ligament. The signal intensity is slightly higher with T2weighted images.Magnetic Resonance MR images of the 3 Imaging major nerves of the elbow generally appear the same intensity as muscle on T1-weighted imaging. atrophy. increased signal intensity. Joint fluids increase with diseases that produce synovial inflammatory changes. . slackness. fatty changes. hemorrhage. and edema. and other abnormalities. Muscle injuries on MR scans show morphological changes. but outlining and visualizing the nerves depend somewhat on adjacent fat.

and other bony abnormalities well. Planning for elbow surgery also benefits from CT’s ability to reformat images in any plane required and to provide 3-D volume renderings. Aside from fracture fragment evaluation. CT arthrography can highlight the joint capsule and filling defects from synovitis or loose bodies. osteochondral lesions. loose bodies. Similar to conventional arthrography of the elbow. CT arthrography also is helpful in evaluating MCL tears. . CT displays fractures.Computed Tomography The rapid scanning and helical imaging of modern CT scanners make accurate and prompt imaging of elbow trauma possible. CT with IV contrast also is beneficial for blood vessel evaluation following trauma.

Ultrasonography

Ultrasonography is not a typical choice for imaging the
elbow, but the modality offers a less expensive
alternative for evaluating tendons, ligaments, and
nerves. Ultrasonography is useful in diagnosing softtissue diseases of the elbow. It is also a good choice
when imaging infants and young patients to evaluate
unossified epiphyses that might not be noticeable on
radiographs.
Color-flow Doppler imaging can highlight soft-tissue
inflammation by showing increased blood flow to areas
of the elbow. Doppler imaging also can help distinguish
cystic from solid masses by displaying the vascular
components of the mass.

Elbow Disorders:
Olecranon
Bursitis
Inflammation of the olecranon bursa is called olecranon
bursitis. It is also referred to as student’s elbow because
the condition can be caused by leaning excessively on
the elbow. Chronic olecranon bursitis is seen in people
who throw repetitively, such as baseball pitchers; acute
cases usually occur after a direct fall onto a hard
surface.
Patients with bursitis are easily identified by the large
amount of swelling and masslike appearance of the
elbow. In nontraumatic situations, imaging may not be
required if the bursa fluid can be aspirated. In traumatic
situations, however, the bursa can become inflamed
because of an olecranon fracture. Fluid aspiration

Cubital Bursitis

Cubital bursitis also is known as bicipitoradial bursitis,
and symptoms include antecubital fossa swelling and
tenderness.
MR imaging of cubital bursitis shows high-signal fluid
that emerges between the radial tuberosity and biceps
tendon distally. The fluid normally appears on T2weighted images, which can lead to misdiagnosis of a
soft-tissue tumor. In questionable cases, IV contrast
assists in the diagnosis. If the fluid collection does not
enhance, bursitis is the likely diagnosis.
During sonography, elbow extension is routine.
Sonograms of cubital bursitis can show fluid or
hypoechoic tissue that causes active distention of the

This condition commonly occurs after lifting heavy objects and results in tenderness near the biceps rupture site. When the distal end of the biceps muscle ruptures.” near the distal bicep. the patient can experience a snapping sensation followed by the appearance of a bulbous deformity. or “Popeye sign.Tendonitis and Tendon Tendonitis of the elbow isTears due to inflammation of the tendons. Tendonitis of the biceps muscle can lead to rupture on either end. When the rupture occurs. especially during supination. Radiographs may show an avulsion fracture of the radial tuberosity in cases of complete tears. tendonitis of the biceps occurs in men aged 45 to 60 years. but enlargement or abnormality of the radial tuberosity is the most common . symptoms include proximal elbow pain and weakness. On average.

. The individual often experiences a sensation on the medial border of the elbow that patients describe as something snapping into place. As with bicep tears. MR and ultrasonography images can help physicians distinguish tears from other pathology.Tendonitis and Tendon Triceps tendonitis is common with repetitive elbow use Tears in young athletes.

The mechanism of injury depends on repeated. forceful contraction of the wrist extensor muscles. Estimates show that 90% of lateral epicondylitis patients develop the disorder from activities other than tennis.Lateral Epicondylitis Lateral epicondylitis is the most common sports-related injury of the elbow and a primary cause of elbow pain. many other repetitive motions can cause epicondylitis. contraction occurs with frequent forearm pronation and supination. . The abuse of the extensor muscles causes inflammation at the lateral epicondyle. Although the condition is associated with tennis. Lateral epicondylitis is frequently referred to as tennis elbow. along with wrist extension.

Lateral Epicondylitis The pain felt with lateral epicondylitis normally occurs at the lateral epicondyle or slightly outside the elbow. Radiographic evidence of lateral epicondylitis is rarely found. This is known as the “coffee cup” sign. radiographs differentiate lateral epicondylitis from other disease processes of the elbow such as arthritis or loose bodies. . In any case. Gripping items may become difficult because of weakness and increased pain within the forearm.

In cases of chronic lateral epicondylitis.Lateral Epicondylitis Regardless of whether the tendonosis is located medially or laterally. the best modality for diagnosing capsular tears is arthroscopic techniques. the capsule below the extensor carpi radial brevis (ECRB) tendon should be examined for tears. CT arthrography has shown excellent success at . Although MR falls short of accurately imaging capsular tears of the ECRB tendon. MR imaging demonstrates the same epicondylitis features on either side. Ultrasonography can find calcifications or hypoechoic areas in the lateral epicondyle region and may be useful in diagnosing tendonosis. Currently.

Medial epicondylitis primarily affects the insertion point of the flexor carpi radialis. radiographic evidence of medial epicondylitis can be difficult to find. medial epicondylitis is common in individuals who overuse their wrist flexors and forearm pronator but is seen far less frequently than lateral epicondylitis. but small calcifications or spurs next to the medial epicondyle are common. As with lateral epicondylitis. The patient presents with pain at the medial aspect of the elbow. .Medial Epicondylitis Known to patients as golfer’s elbow. MR imaging most often is used for diagnosis.

the initial stages of pain management include pain medication and physical therapy. . There are varying kinds of arthritis. corticosteroid injections are used for pain management. but physicians must use caution to ensure that the injections do not lead patients into a false sense of treatment and overuse of the elbow joint. causing further deterioration. Regardless of the type of elbow arthritis. Occasionally. each exhibiting different causes and symptoms.Arthritis Arthritis is a joint disorder that results in inflammation of the joints within the body.

Radiographs can monitor structural changes caused by rheumatoid arthritis. but radiography is not the preferred method for early disease assessment. . Rheumatoid arthritis commonly begins in the radiocapitellar joint. The radial head may move out of its regular position and cause problems with other elbow anatomy.Rheumatoid Arthritis Rheumatoid arthritis is a severe form of arthritis that progressively affects the body’s joint tissues. Bone erosion from rheumatoid arthritis is better displayed on CT images than on MR images or radiographs. Joint erosion and destruction are common because of the severity of rheumatoid arthritis.

and in the interphalangeal joints of the hand. such as knees and hips. MR and CT images of the elbow help show the joint surfaces and detect loose bodies or spurs. but osteoarthritis of the elbow is rare.Osteoarthritis Arthritic conditions of the elbow are not uncommon. Patients with osteoarthritis affecting the elbow experience the most pain during terminal flexion and extension of the joint. Osteoarthritis is much more prevalent in weight-bearing joints. Radiographic evidence of osteoarthritis includes osteophyte formation. These osteophytes usually are near the ulnohumeral joint and occasionally impinge on the ulnar nerve. .

MR images are better for evaluating synovial involvement. Gout usually is found in the joint spaces of the toes but can appear at the elbow.Gout Elevated uric acid levels can result in monosodium urate crystals to infiltrate the synovial fluid of joint spaces and lead to gout. along with inflammation. . Ultrasonography also can highlight thickening of the synovial fluid. and CT is better for displaying intraosseous lesions. Evidence of gout is obvious in patients with advanced disease but is not often apparent on images of early cases.

and osteochondritis dissecans. Examples of these problems. Panner disease.Overuse Conditions in Children Children also can have elbow injuries and conditions related to overuse of the elbow joint. . include traction apophysitis of the medial epicondyle. sometimes referred to as Little League elbow.

Approximately 97% of elbow problems in baseball pitchers are associated with symptoms of the medial elbow. Because of the timing of ossification in children. but this can be missed easily if the radiologist does not review comparison radiographs of . traction apophysitis is the most common elbow injury in young children.Traction Apophysitis of the Medial Epicondyle Traction apophysitis of the medial epicondyle is inflammation of the medial epicondyle due to an avulsion tear or trauma. The main symptom of apophysitis of the medial epicondyle is pain immediately after a repetitive motion such as throwing. Radiographs of the elbow might show slight widening of the apophysis.

producing excessive calcification in some areas. Panner disease is a form of osteochondrosis that affects the capitulum of the elbow.Panner Disease Osteochondrosis affects the ossification centers of children when the bone degenerates and then begins to regenerate. Panner disease is most common in preadolescent boys and children younger than 10. An MR series with T1-weighted images might show fragmentation with decreased signal intensity at the capitulum surface.  Panner disease is the most common reason for lateral elbow pain in young children and routinely affects the dominant arm. Radiographs can display sclerosis and areas of decreased density at the capitulum. .

an inflamed lining of the radiocapitellar joint. Patients with these osteochondritis dissecans lesions often have plica. These lesions result from death of the articular cartilage or subchondral bone of the capitulum due to a lack of blood supply. . radiocapitellar plica commonly is misdiagnosed as lateral epicondylitis. If the subchondral bone or cartilage is slightly fractured. Subchondral bone provides cartilage support at articulation sites. it is known as osteochondritis dissecans. Because the pain is located on the lateral side of the elbow.Osteochondritis Dissecans A more advanced form of osteochondrosis is osteochondritis dissecans.

Osteochondritis dissecans is characterized by a dull ache with no centralized location. If fragments are loose in the area.Osteochondritis Dissecans Osteochondritis dissecans typically affects adolescent athletes aged 11 to 21 years. The pain may disappear when the child is resting then reappear during strenuous activities. the joint may routinely catch or cause a popping sensation. .

Osteochondritis Dissecans Radiographs typically are not very sensitive for identifying loose bodies. Arthroscopy is used most often because it remains a safe and effective way to diagnose and evaluate osteochondritis dissecans or lesions of the . On MR images. Ultrasonographic imaging of osteochondritis dissecans is rare. osteochondral lesions can be confused with normal osseous variants of the elbow. and less than 30% of positive loose bodies are found using radiography. CT of the elbow joint can help physicians locate and count loose bodies found throughout the elbow compartments before the patient undergoes arthroscopic procedures to remove the fragments.

Damage to the ulnar nerve can lead to numbness and tingling of the hand. An ulnar nerve injury typically is associated with supracondylar fractures when the arm is in hyperflexion. but most ulnar nerve injuries occur because of direct blows to the nerve. symptoms can last for years after the trauma. This inflammation of the nerve can cause radiating pain from the posterior medial elbow to the hand and fingers. In severe cases of ulnar nerve injury. This is commonly known as . Compression of the elbow nerves is attributed to a wide range of abnormalities.Nerve Damage The most common nerve condition in the elbow is ulnar neuritis.

the elbow becomes extremely unstable except when fully extended. If the anterior bundle of the elbow’s MCL is injured. a sagittal projection is the best . it is not the method of choice for viewing partial tears. CT arthrography has a higher rate of identifying partial tears. Although MR imaging is highly sensitive for complete tears of the MCL.Elbow Injuries: Ligament or Tendon Injury About 50% of the medial and lateral plane of the elbow is stabilized by ligaments. Gadolinium contrast often is used during MR imaging to help enhance MCL injuries. In either modality. Radiography can assess ligament tears and joint stability. particularly with valgus or varus stress applied during a fluoroscopic examination.

Elbow dislocations can occur as a result of many situations but most often arise from a fall on an outstretched hand. The MCL is routinely compromised in elbow dislocation. Elbow dislocations often present with other injuries. With MCL damage. A patient with an elbow dislocation most often . The most common dislocation involves displacement of both the ulna and radius. the elbow joint might remain unstable unless the ligament heals or is surgically repaired.Dislocations The elbow is the joint that is dislocated most often among pediatric patients. with 50% of cases resulting from sports activities. It is the second most dislocated joint in adult patients.

A neurovascular examination should be performed and results noted before and after reducing the elbow joint dislocation.Dislocations An AP and lateral radiograph elbow series is sufficient to diagnose an elbow dislocation. Once the dislocation is reduced. the elbow should be tested for mobility and examined with radiography to ensure satisfactory reduction of the joint and exclude any further bone injury. An elbow reduction most often is completed by having the patient’s upper arm held in place while applying a steady pull on the forearm and hand. extension may become compromised and the elbow may be . Following an elbow dislocation.

Heterotopic bone growth at the elbow can be associated with traumatic injury of the elbow. The formation of juxta-articular bone at the elbow joint can cause problems because of decreased full range of motion. but heterotopic bone formation of the elbow also can be caused by central nervous system trauma or excessive burns.Heterotopic Bone Formation of boneFormation or calcification that is not in the normal bone growth area is called heterotopic bone formation. Once elbow motion has been compromised by heterotopic bone formation. . the only treatment for restoring motion is surgical resection of the bone.

” If the patient’s arms and hands are not observed within the acceptable ranges. When both arms hang normally at the patient’s sides. it could indicate an elbow fracture. Any variation of the angle that is more than 15°is known as cubitus valgus. muscle. although open fractures are at higher risk for adverse .Fractures The proximity of nerves. there should be a 5° to 15°separation of the forearms and hands from the body. arteries. This arm-to-body separation is known as “the carrying angle. and bones in the elbow contributes to the elbow being considered one of the most complex fracture sites. Angles less than 5°are called cubitus varus. All fractures are serious and should be treated as such. Clinical examination begins by observing the patient’s arm. tendons.

Flexion of the arm may produce crackling or popping sounds from bone fragments. These fractures can appear in both condyles and often continue into the joint space. and pain. .Distal Humerus Fractures Distal humerus fractures represent only 2% of adult fractures. Location determines the classification of distal humerus fractures. Patients with distal humerus fractures experience extensive swelling. These fractures also can produce bruising of the skin. deformities.

affects the orientation of the anterior humeral line seen on the lateral image. often seen in fractures. Posterior displacement of the humerus. A lateral oblique projection is helpful for diagnosing lateral condyle fractures or displacement. It is important to retake radiographs of the elbow after several .Distal Humerus Fractures A 2-projection radiographic examination usually is sufficient to evaluate distal humerus fractures. An oblique radiograph of the elbow might help identify nondisplaced fractures of the condyle in children. Displaced fractures are generally stabilized with surgery. a fracture is possible. Splinting is sufficient in nondisplaced fractures. If the anterior humeral line passes through the anterior portion of the capitulum or does not meet the capitulum at all.

nondisplaced transverse and nondisplaced oblique fractures. Swelling and extensive bruising often are noted following an olecranon process fracture. AP and lateral radiographs can usually demontrate olecranon process fractures. . resulting in a comminuted fracture.Olecranon Process The olecranon process is at high risk for fracture Fracture because of its prominent position directly under the surface of the skin. Other fractures of the olecranon process include avulsion. with a lateral projection providing the best view of the fracture. and fracture-dislocations. Olecranon process fractures generally occur when an individual falls directly onto the flexed elbow.

Even after healing. If fixating hardware is used. screws. Displaced fractures require internal fixation with plates. causing more pain. pins. Follow-up for this treatment includes radiography to ensure that the fracture remains nondisplaced. a Fracture posterior splint to flex the elbow 90°usually is the first step in treatment. or wires to align the bone properly. an olecranon process fracture can produce loss of motion regardless of treatment. the hardware can irritate the tissues around the fracture site. .Olecranon Process If an olecranon process fracture is nondisplaced.

. Antecubital fossa tenderness and swelling are common symptoms of coronoid fracture. An avulsion fracture of the coronoid is possible if the brachialis muscle is subjected to forceful contraction. The lateral projection best demonstrates coronoid fractures. and also highlights avulsion fractures.Coronoid Process Fracture Fractures of the coronoid process typically occur in conjunction with posterior elbow dislocations. The radial head or oblique projection of the elbow highlights possible fractures of the coronoid. however.

Standard 2-projection radiographs of the elbow are routine for suspected radial head fractures because . Patients who have radial head fractures experience pain on the outer surface of the elbow and may not be able to pronate or supinate the forearm. The elbow can show signs of swelling. radial head fractures tend to occur when patients fall with a forearm turned inward and land on an outstretched hand. These are the most common elbow fracture among adults. limiting the amount of flexion and extension.Radial Head Fracture The radial head is believed to be the secondary stabilizing source for the elbow during valgus stress. As a result.

Determining the degree of displacement in capitulum .Capitulum Fractures Fractures of the capitulum are not very common. but when they occur. The AP projection can hide a fracture fragment behind the humerus. Results of routine radiography often are misleading in cases of capitulum fracture. they share a similar mechanism of fracture as radial head fractures because of the axial alignment of the capitulum. but radiographers should acquire a radiocapitellar projection to better demonstrate any fracture fragments. and any rotation or a slight oblique lateral positioning often obscures a capitulum fracture. nearly 50% of capitulum fractures are accompanied by a radial head fracture. In fact. Radiographs of the elbow consistently show a positive fat pad sign on the lateral projection.

a gravity stress . Avulsion fractures often are found in adolescents aged 9 to 12 years.Avulsion Fracture Stress to the elbow joint can cause avulsion fractures. Occasionally. The pain often is felt immediately after making a hard pitch or throw. and they are the most common type of elbow fracture in adolescent athletes who participate in throwing as part of their sport. Images obtained following the injury might show a disconnection of the medial epicondyle apophysis or subtle displaced fractures. A common symptom of avulsion fractures is an acute popping sensation in the elbow followed by pain. Avulsion fractures most often are found before the secondary ossification centers fuse.

and a coronoid process fracture. EssexLopresti fracture-dislocation consists of a radial head fracture that is comminuted and a distal subluxation or dislocation of the radioulnar joint. The “terrible triad” is a devastating elbow injury that includes a radial head fracture. an MCL injury. Galeazzi fracture-dislocations combine a distal radial head disruption with a distal radial fracture.Combined Fractures and Monteggia fracture-dislocations involve a fracture of the Dislocations ulnar shaft and displacement of the radial head. If the alignment of the radiocapitellar line does not point to the capitulum on all radiographic projections. a Monteggia fracture or lateral condyle fracture is likely. .

decreased skin temperature. If the brachial artery is damaged. and the skin of the affected arm may appear pale. the patient may have a decreased pulse. radiating pain.Arterial Injuries Specific trauma. carry such a high risk for arterial injury that arterial injury should be suspected in most cases. arterial injury is likely. A CT examination with IV contrast can display any occlusions or hematomas. such as supracondylar fractures. If the skin appears pale or the pulse is noticeably low or absent. A pulse should be detectable distal to the fracture. Arterial injuries are very serious and can lead to contracture or loss of the affected limb. .

This can benefit fracture healing. however. but care must be taken when managing any fracture that extends into the growth plate because the .Fractures in Children Fractures of the elbow are not uncommon in children. a radiographic image using the Jones method image can confirm adequate reduction. constituting up to 60% of cases. Roughly 35% of pediatric skeletal injuries involve a growth plate. The bone in the growth plate grows rapidly. given their typical behavior. During the growth process. After the reduction of a supracondylar fracture. Supracondylar fractures are the most common elbow fracture in the pediatric population. the long bones of pediatric patients contain a physis or growth plate that allows the bone to grow longitudinally.

About 76% of follow-up radiographs of pediatric patients show healing fractures in the elbow area. common . Radiologic technologists and care providers should be aware of specific elbow fractures that might indicate child abuse. A transphyseal fracture of the humerus. If a hairline or small fracture is suspected after a negative radiographic examination.Fractures in Children If a posterior fat pad is seen on a lateral radiograph and no other abnormality is seen. it is likely that the patient has a nondisplaced intracapsular fracture. pediatric patients can return sooner than adult patients for repeat images because children have faster callus formation. These findings support the decision to manage these situations as though a fracture existed in the original radiograph.

Child abuse victims often have fractures in multiple areas of their bodies.Fractures in Children The routine 3-projection radiograph of the elbow is not always helpful to diagnose a transphyseal fracture because of a lack of ossification in pediatric patients. The types of child abuse fractures that might be seen in addition to the transphyseal fracture are diaphyseal or long-bone shaft . the provider might want to order additional radiographs. If a transphyseal fracture is found and child abuse is suspected. ultrasonography. MR imaging. Comparison radiographs of the opposite elbow can assist the radiologist in diagnosing transphyseal fractures. or arthrography may be required to confirm a diagnosis. If radiographs of the elbow are not definitive.

Radiographs of the forearm confirm cross-synostosis of the proximal radius and ulna. This condition can be bilateral or unilateral.Congenital Radial-Ulnar Bones sometimesSynostosis can fail to form as they should in children. When the proximal radius and ulna are not freely mobile. . supination and pronation of the forearm is limited. the radius and ulna fail to grow apart at their proximal locations. This appearance of the bony union is easily seen by the increased bony formation. In congenital radial-ulnar synostosis.

Problems with the radial head develop when a young child’s arm is pulled with forearm extension and pronation. This injury often occurs when a child is pulled up by the arm or suddenly drops to the floor to tug away from being held. radial head subluxation affects the left arm of children who are between the ages of 2 and 3 years. Diagnosis of radial head subluxation is complicated by young children’s inability to describe their symptoms in detail. Radial head subluxation sometimes is called nursemaid’s elbow and is the most common elbow injury in younger children. Radiographs of the elbow do not always show a . Most often.Radial Head Subluxation Children who have loose ligaments are at risk for subluxation of the radial head.

. Understanding the anatomy of the elbow and medical diagnostic imaging methods to best demonstrate elbow injuries and disorders helps radiologic technologists enhance the diagnostic process and directly benefits patient care.Conclusion Elbow disorders and injuries can be painful and problematic for patients and complex for the medical professionals providing imaging and care.

Discuss the most common elbow disorders and injuries. Discuss some of the differences between pediatric and adult elbow anatomy as well as different elbow disorders and injuries specific to children and adults. .Discussion Questions Explain the radiologic modality choices for diagnosing elbow disorders and injuries.

.Additional Resources Visit www.org/students to find information and resources that will be valuable in your radiologic technology education.asrt.