One of the more common injuries of the paediatric shoulder is the fractured clavicle. This is normally well seen as in image 1 but can prove difficult when there is little or no displacement as in image 2. Image 3 is the same patient as image 2 but with a 15 degree cephalic angle on the beam, and it can be seen that the fracture is now demonstrated. The reporter should be careful however, as on some views of the clavicle the foramen for the supraclavicular nerve is demonstrated in a similar fashion to image 3, and can be mistaken for a fracture by the inexperienced. The difference, as always, is that the normal will appear corticated, the fracture will not.

It is very important to produce accurate "true" A.P. and lateral radiographs of the paediatric elbow, this can not be stressed enough. There are two not uncommon injuries and one very common injury which may be missed if good radiographs are sacrificed for speed or a wish to get rid of the screaming child at all costs.

The first to discuss is the avulsed medial epicondylar apophysis of the humerus into the humero-ulna joint space. To check this the reporting radiographer needs to know the "CRITOL" rule relating to the chronological order of the appearances of the epiphyses/apophyses around the elbow joint. Look at images 4 to 7 on the left.

They almost always appear in this order and the important thing to remember is that "I" comes before "T". The Internal (medial) epicondyle always appears before the Trochlear. Therefore, if on a good A.P. radiograph the reader thinks they can see the Trochlear and not the Internal (medial) epicondyle then they should suspect an avulsion of the epicondyle into the joint space.

Of course there is always an exception to any rule and this is demonstrated by image 8 which is an AP view of a paediatric elbow showing quite clearly that the Internal (medial) epicondyle has appeared before the Radial head.

The second injury to discuss is the "pulled elbow" where the arm has been pulled and the head of radius has been pulled from its annular ligament and is now subluxed from the capitellum.

To assess this injury the reader needs to trace a straight line along the proximal radius, which should pass through the centre of the capitellum on both the A.P. and lateral views, see images 9 and 10 on the left. If it does not then suspect a "pulled elbow". Have a look at images 11, 12 and 13. The A.P. view is very suggestive of a pulled elbow but it is essential to have a decent lateral view to be sure. Images 12 and 13 are poor attempts at a lateral but are highly suggestive of a pulled elbow as the head of radius does not appear to be articulating with the capitellum. However this may be a projectional anomaly and these views should be repeated.

The third and most common of the three is the supracondylar fracture of the distal humerus. If the fracture passes through the bony humerus and is displaced at all then the reporting radiographer may stand a chance of seeing it on not so accurate radiographs. This is still not good for the surgeon who may well ask for repeat views. If however the fracture is a Salter-Harris 1 through the growth plate of the capitellum then this may not be seen without good radiographs.

The guide here is to trace a straight line down the anterior surface of the humerus on the lateral radiograph, see image 10. This line should pass through the centre or anterior third of the capitellar epiphysis. If it is more anterior than that, then the capitellar epiphysis has possibly been displaced posteriorly. Elevation of the anterior and probably posterior humeral fat pads should also be seen. Image 14 demonstrates this nicely, although this should be an obvious supracondylar fracture. Image 15 is not obvious at all, in fact there was no visible bony trauma on this lateral view or the A.P. However, if the rule is followed, it can be seen that the capitellar epiphysis is displaced posteriorly and both anterior and posterior fat pads are elevated. This is almost certainly a Salter-Harris type one fracture.

Image 16 is a more unusual supracondylar fracture where the displacement is anterior. The anterior humeral line rule still applies here but it is obviously passing posterior to the capitellar epiphysis.

Image 17 demonstrates nicely the importance of getting a "true" A.P. view of the elbow. The appearances are very suggestive of a dislocated ulna but this is entirely due to a projectional anomaly caused by the elbow being slightly rotated.

Images 18 and 19 show an unusual fracture of the lateral epicondyle. Note also the apparent lack of any elevated fat pads, although this fracture is obvious the lack of any fat pad sign does not exclude a bony injury.

Images 20 and 21 show a fracture across the olecranon area of the proximal ulna which should not be confused with the olecranon epiphysis as seen in image 7. Remember the "CRITOL" rule, the olecranon is the fifth epiphysis to appear, and it can be seen in these images that only the capitellum and radial head have appeared and so this must be a fracture.

There should be no difficulty in seeing a dislocation of the elbow, they are usually one of the most dramatic looking injuries. There is however one associated injury the reporting radiographer should be careful not to miss. Occurring in older children and adolescents, it is the avulsion of the medial epicondylar apophysis. Images 22 and 23 show the initial injury with the apophysis lying in the humero-ulna joint space. It is a little difficult to see the avulsed medial epicondyle on the A.P. view, but it is conveniently bisected by a linear artifact from a positioning pad. Image 24 shows the repair.

Avulsion of the medial epicondyle apophysis can occur without a dislocation, see image 25. It can be seen that there is an abnormally wide gap between the humerus and the apophysis. Also there is a small bony fragment lying in the gap. This is a small fragment from the diaphysis.

Generally, apart from occult fractures which usually affect the long bones of the leg, mid shaft fractures of the long bones tend not to pose many problems. There are however two fracture dislocations of the forearm which are pretty much exclusive to paediatrics. Those being the Monteggia and Galliazzi fracture dislocations.

The Monteggia fracture dislocation is a fracture of the proximal or mid third of the ulna with a dislocation of the radial head from the capitellum, see image 26. The dislocation of the radial head is quite obvious on the lateral view but can be deceiving on the A.P. view, see image 27. Here again the need for accurate radiography can be seen, anything less than a good lateral and it may be possible to miss the dislocation of the radial head.

The Galliazzi fracture dislocation is a fracture of the mid or distal third of the radius with disruption of the distal radio-ulna joint. Again, accurate views of the wrist joint are needed to be sure of not missing the disruption of the radio-ulna joint. See image 28, courtesy of Nick Oldnall of www.xray2000.co.uk.

Children will present with Colles and Smith's fractures, and carpal dislocations as adults do, and the appearances in general remain the same although they can be variations of Salter-Harris fractures. See the sections on the wrist and Salter-Harris fractures.

The Greenstick is so named because, if a green stick is bent it will break on one side but not the other. See images 29 and 30. It can be seen that the cortex is disrupted on one side but remains intact on the other.

A lot of the paediatric hand injuries seen in the trauma department are the hyper flexion or hyper extension injuries. These tend to result in Salter-Harris fractures of the fingers. These can be quite subtle as in the type 2 fractures seen at the metacarpal head in image 33 and the phalangeal base as in image 34. Image 35 shows a very missable type 3 fracture of the phalangeal base while image 36 shows an obvious type 4 fracture of the base of phalanx.

Image 37 shows the normal epiphyseal appearance of the paediatric humeral head. The physis is quite tortuous and can be mistaken for a fracture. Do not fall into this trap! Image 38 is a Salter-Harris type 1 fracture of the shoulder the appearance of which is not very dissimilar to that of the normal image 37. Image 39 is the lateral view of the fracture and it can be seen that the epiphysis has displaced from the diaphysis.

Images 44 and 45 show a small accessory secondary centre of ossification of the olecranon which will almost certainly fuse and go unnoticed in later life. Note also in image 44, the epiphyseal line of the trochlear appearing like a fracture through the distal humerus.

Image 46 shows an odd depression in the olecranon giving the appearance that the olecranon epiphysis has been avulsed from it. This is purely developmental and will fill in with age.

Images 47 to 49 show the appearances of the early ossification of the pisiform. In image 47 a small fragment of bone can be seen adjacent to the triquetrium. Due to the fact that is an early ossification centre it is not well corticated. This may lead the viewer to think it is a fracture. It is in fact the pisiform. Image 48 is the lateral view and the early pisiform can just be seen anterior to the scaphoid. Image 49 shows a more developed pisiform anterior to the lunate, again, not well corticated but not to be mistaken for a fracture. Compare these images to the fractured pisiform on the wrist page.

Images 50 and 51 show the appearance of a bipartite scaphoid. This will almost certainly fuse and go unnoticed later in life, but could remain bipartite. The difficulty with these images is that the appearance does resemble a fracture. However, fractures of the scaphoid in this age group are quite unusual and in this case there was no pain in the carpus.

Image 52 shows what looks like an oblique fracture of the proximal half of the third metacarpal. This is in fact a skin fold artefact caused by air trapped in a fold of skin between the thenar eminence and the palm. Look closely and it can be seen that the "fracture" line extends beyond the bone and towards the head of the second metacarpal. Take note also that there is no break in the cortex and no trabecula disturbance. There is another example of this to be seen on the foot page.

Images 53 and 54 show the unusual appearance of secondary ossification centres at the base of the second metacarpal and the head of the first metacarpal, the latter being more subtle as it is well fused but more obvious on image 54. Note also the subtle fracture of the base of the fifth metacarpal in image 53.