All of the fractures described here are closed, isolated pediatric elbow injuries that are neurovascularly intact with normal compartments. Here are four cases in which correctly applying the CRITOE mnemonic can lead to better outcomes. This option should be used selectively after reviewing X-rays of the injured elbow and not as a matter of routine. Comparative films can help confirm suspicious X-ray findings (ossification centers, lucencies, alignment, and so forth). Each elbow should be a very close copy (within 3 to 4 months) of its pair. Since it can be these ages ☑8 months, CRITOE crudely predicts the age of appearance.Ī far more accurate indicator of normal however, is comparing the injured to the uninjured elbow. These are rough estimates due to significant child-to-child variability. For a boy, the trochlea (T) should appear at 8 years but can range from 6.5 to 9.5 years (8 years ☑8 months).
Table 1: Approximate Age (☑8 Months) at Which Six Elbow Ossification CentersĪppear on X-ray for Girls and Boys Ossification Centersįor example, for a girl, the radial head (R) ossification center should appear at 3 years but can range from 1.5 to 4.5 years (3 years ☑8 months). For girls, use odd years starting at 1 for boys, use even years starting at 2 (see Table 1). O: Olecranon (best seen on the lateral view)īecause ossification always appears in this exact sequence, the presence of any single ossification center mandates the radiographic identification of those that precede it.ĬRITOE can also approximate the age at which the six ossification centers often appear, albeit these are rough estimates due to significant child-to-child variability. T: Trochlea (distal neighbor of I, at medial aspect of distal humerus) R: Radial head (distal neighbor of capitellum) Their clinical relevance rests on knowing the order and approximate ages in which they ossify, and therefore appear on X-ray (See Figures 1A and 1B).Ĭ: Capitellum (lateral aspect of distal humerus) CRITOE reminds us of their names and the specific order in which they ossify. 1) capitellum 2) radial head 3) internal (medial) epicondyle 4) trochlea 5) olecranon and 6) external (lateral) epicondyle. ( Note the nomenclature: medially, an avulsion of the ossification center that sits on top of the condyle ( epi is Greek for “on top of”)-medial epicondyle fracture laterally, a fracture involving the metaphysis of the distal lateral humerus-lateral condyle fracture.)īy knowing CRITOE and the approximate ages of appearance, a fracture fragment in a younger child will not be mistaken for an ossification center.įigures 1A and 1B: Normal X-rays, 13-year-old male. These are typically seen in older kids (ages 10 to 16) and are often missed. ME fractures are avulsions of the ossification center that sits on the medial condyle. These fractures are typically seen in 4- to 10-year-olds and are often misdiagnosed as supracondylar fractures. LC fractures are fractures of the metaphysis of the lateral aspect of the distal humerus. This implies that we should diagnose one LC or ME fracture for every two to three supracondylar fractures. Two diagnoses make up the bulk of nonsupracondylar pediatric elbow fractures: lateral condyle (LC) fractures (~15 percent) and medial epicondyle (ME) fractures (~10 percent). Two Commonly Missed Pediatric Elbow Fractures 2,3 Knowing the clinical relevance of CRITOE helps identify this pair of less common, subtle pediatric elbow injuries that are often operative. Recognizing the other 30 to 40 percent requires awareness of those diagnoses and their clinical presentations. Supracondylar fractures comprise 60 to 70 percent of pediatric elbow fractures the bulk of the rest are two commonly missed fractures. We look for effusions on lateral X-rays, think about the anterior humeral line, and possibly recall the mnemonic CRITOE (see below).
Those of us who manage kids with acute elbow injuries undoubtedly see pulled elbows and supracondylar fractures. Tips for Diagnosing Occult Fractures in the Emergency DepartmentĮxplore This Issue ACEP Now: Vol 39 – No 08 – August 2020.Emergency Medicine Pearls, Pitfalls for Treatment of Pediatric Distal Radius Fractures.
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