#ortho #radiology see also: [[pulled elbow]], [[Supracondylar humerus fractures]], [[Monteggia fracture-dislocation]], [[Galeazzi fracture dislocation]], [[Soft tissue signs of a fracture]] - [Schwartz Emergency radiology CRITOE](x-devonthink-item://2A71AF1A-4715-4D5F-9841-03401D8E6C4E?page=250&start=4&length=6&search=CRITOE) and [ossification centers of the elbow](x-devonthink-item://2A71AF1A-4715-4D5F-9841-03401D8E6C4E?page=253&start=27&length=33&search=Ossification%20Centers%20of%20the%20Elbow) - [CRITOE elbow ossification centers tutorial youtube](https://www.youtube.com/watch?v=_PBhCQB4tMQ) # CRITOE ![[Pasted image 20240220184054.png]] > the **ossification centers** will appear around the above ages; ## capitelum - 1 ![[Pasted image 20240221132345.png| note that there is no radial head ossification centre yet because this is a 1 year old]] ## Radial head - 3 ![[Pasted image 20240221132430.png| this child has a capitellum and a radial head ossification centre (red dot). note no internal condyle ossification centre yet!]] ## internal epicondyle (medial/ulnar side) - 5 ![[Pasted image 20240221132749.png| red dot. overlapping distal humerus]] ## Trochlea - 7 ![[Pasted image 20240221132904.png| red dot , super-imposed over the ulna. This patient also has an olecranon ossification centre]] ## Olecranon - 9 ![[Pasted image 20240221133013.png| same as above trochlea patient, has both. however, does not have an external epidydondyle visible yet]] ## External epicondyle (lateral/radial side) - 11 ![[Pasted image 20240221133111.png]] **the normal paediatric elbow must have the following for clearance** - full extension, supintaion, and pronation - no swelling or significant focal bony tenderness - no abnormal anterior or posterior fat pad sign on radiographs - normally placed and age-appropriate ossification centres - an intact radio-capitellar relationship # Anatomical lines - anterior humeral line important for [[Supracondylar humerus fractures]] - radiocapitellar line important for radial head dislocation eg in [[Monteggia fracture-dislocation]] ## Anterior humeral line ![[Pasted image 20250124002701.png]] **Normal alignment:** - when drawn along anterior cortex of humerus, in most normal patients at least *1/3 of the ossifying capitellum lies anterior to this line* - NOTE: in very young children, the ossification within the cartilage of the capitellum might be minimal (eg normal and age related) and so is insufficiently calcified and does not allow application of the above rule - helps detect [[Supracondylar humerus fractures]] with posterior displacement **Abnormal** the abnormal anterior humeral line suggests a supracondylar fracture ![[Pasted image 20250124003847.png]] ![[Pasted image 20250124003959.png]] ## Radiocapitellar line (AP and lateral) ![[Pasted image 20250124003052.png]] **Normal alignment:** - On the latearl XR, a line drawn along central axis of the proximal 2-3 cm of radius should pass through the centre of the capitelllum. - If it fails to do so, the radius is [[Monteggia fracture-dislocation#Type I monteggia fracture-dislocation with plastic deformation of ulna|dislocated]] at the elbow joint (important check point for [[Monteggia fracture-dislocation]]) **Abnormal** radiocapitellar line would not pass through the capitellum; radial head is dislocated ![[Pasted image 20250124004506.png]] # Injuries ## epicondyle avulsion **12 year old fell playing football, left arm** ![[Pasted image 20240221133341.png]] ^ he has capitellum, radial head, and external epicondyle, trochlea, and olecranon ossification centres, but *internal epicondyle is missing* from expected location > ==the extra bone fragment on medial aspect above olecranon represent the internal epicondyle avulsed== > - the **internal epicondyle** is the most common of the ossification centres to become fractured and avulsed ## lateral condyle fracture ![[Pasted image 20241030234636.png]] know this is a 5 ear old because the capitellum, radial head, and beginning of internal epicondyle (ulnar side) are present. no trochlear or olecranon ; *∴ lateral epicondyle should not be present* > **complications associated with this injury** > - elbow stiffness -- most common ; can be an early sign of non-union or delayed union. usually self-resolving > - delayed union -- fracture not healing within 6 weeks of immobilisation > - non-union -- if non-operative tx of displaced lateral condyle, ↑ risk of non-union w/ ↑ degree of displacement/ angulation of fragment. has a higher rate of non-union than other elbow fractures > - growth disturbance -- rare > - lateral overgrowth/prominence (spurring) of the lateral condyle can cause a visible bump deformity on the lateral aspect of the elbow > - cubitus valgus +/- tardy ulnar nerve palsy -- incidence 10%, due to lateral physical arrest or a non-union. slow, progressive [[Neurovascular assessment|ulnar nerve palsy]] caused by stretch > - AVN # Related Questions ## elbow ossification - [ ] 2Q: [Elbow injury](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=6) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=2) -- [prop](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=62) ## xr - [x] 15Q: [Sore elbow, missed diagnosis](x-devonthink-item://B9C99BB4-DAF8-4D15-BBD3-40E82B279902?page=8) -- [Answer](x-devonthink-item://DF848F67-27AB-450A-988B-159784B72957?page=8) -- [prop](x-devonthink-item://D2415799-57A6-4B32-BE9A-0120DF5500A1?page=1)