Paediatric elbow fractures - imaging and ED approach
Paediatric elbow injuries are common and frequently subtle. A methodical radiographic review combined with careful clinical assessment reduces missed fractures, ensures timely management of neurovascular risk (especially with supracondylar fractures) and meets radiation‑safety/reporting obligations (IR(ME)R, NICE) (NICE NG38; IR(ME)R guidance; RCEM Learning).
Initial imaging and radiation governance
- Minimum imaging for suspected bony injury: elbow anteroposterior (AP) and a true lateral. Aim for a true lateral - rotational malpositioning invalidates key alignment checks.
- Justify and optimise every radiograph in children (ALARP / IR(ME)R). Use local paediatric imaging protocols and the lowest dose needed for diagnostic quality.
- When a fracture is suspected, request a definitive (“hot”) radiology report before ED discharge where possible (NICE NG38). If prompt reporting is not available, document the plan, immobilise the limb and arrange follow‑up or specialist review.
Systematic radiograph review - a simple routine
Always review every paediatric elbow film for: joint effusion (fat‑pad signs), bone alignment on the lateral (anterior humeral line), ossification centres (CRITOE) and cortical continuity. If any of these are abnormal, treat the film as potentially positive for fracture even if no cortical break is obvious.
Joint effusion and fat‑pad signs
- Haemarthrosis is a common sign of an occult intra‑articular fracture.
- On a true lateral:
- A posterior fat pad visible in the olecranon fossa...