normal 2 year old elbow x ray

An elbow joint effusion without a visible fracture seen on radiographs can suggest an occult fracture and should prompt further evaluation. Some of the fractures in children are very subtle. This is a Milch I fracture. Anterior humeral line (on lateral). It is however not uncommon that these dislocations are subtle and easily overlooked. Injury to the elbow joint is usely the result of hyperextension or extreme valgus due to a fall on the outstretched arm. Check for errors and try again. After placement of the splint, check that the extremity is neurovascularly intact. At birth the ends of the radius, ulna and humerus are lumps of cartilage, and not visible on a radiograph. Credit: Arun Sayal . window.WPCOM_sharing_counts = {"https:\/\/radiologykey.com\/paediatric-elbow\/":39650}; Is the medial epicondyle slightly displaced/avulsed? older than 2.5 years old due to the small size. The right lower image shows an obvious dislocation of the radius. Bilateral hemotympanum as a result of spontaneous epistaxis. An arm or elbow injury that causes severe pain, bruising, or swelling might be a sign of an elbow fracture (broken bone). Occasionally a minor variation in the sequence may occur. Especially associated fractures of the olecranon are very common (figure). It is closely applied to the humerus, as shown below. ?476 [Google Scholar] 69. trochlea. You can use Radiopaedia cases in a variety of ways to help you learn and teach. An elbow X-ray is a medical test that produces an image of the inside of your elbow. 97% followed the CRITOL order. A normal Baumann angle is generally considered to be in the range of 70-80. Fractures lines can be difficult to visualize after acute elbow injury, particularly in children. On the left the anterior humeral line passes through the anterior third of the capitellum. They found evidence of fracture in 75%. A visible fat pad sign without the demonstration of a fracture should be regarded as an occult fracture. Since most of the structures involved are cartilageneous, it is very difficult to know the exact extent of the fracture. Look for the fat pads on the lateral. Examination reveals that the elbow is in slight flexion and the forearm pronated but further examination is limited secondary to pain. This line is called the Anterior Humeral line . CRITOE is a mnemonic for the sequence of ossification center appearance. On the left a couple of examples of lateral condyle fractures. There is no evidence of fracture, dislocation, . }); Fracture of the lateral humeral condyle109, Avulsion of the lateral epicondyle, Dislocation of the head of the radius, Monteggia injury112. Creatine kinase CK-MM Male 60-400 units/L Female 40-150 units/L Uric acid Male 4.4-7 mg/dL, Female 2.3-6 mg/dL. Typically these are broken down into . This fracture is the second most common distal humerus fracture in children. A bone age study helps doctors estimate the maturity of a child's skeletal system. The Trochlea has two or more ossification centres which can give the trochlea a fragmented appearance. Posterolateral displacement of the distal fragment can be associated with injurie to the neurovascular bundle which is displaced over the medial metaphyseal spike. A diagnosis of osteoporosis is made if a person's T-score is -2.5 or lower. The case on the left shows a lateral condyle fracture extending through the ossified part of the capitellum. When the ossification centres appear is not important. } On the AP radiograph a normally positioned epicondyle will be partly covered by some of the humeral metaphysis. Error 2: Wrist lower than elbow The study found that 57% of imaging where the only finding was joint effusion had a fracture and 100% had bone marrow edema on MRI. Typically, girls' growth plates close when they're about 14-15 years old on average. Did you also notice the olecranon fracture? Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) Nerve injurie almost always results in neuropraxis that resolves in 3-4 months. As your child walks, runs, jumps and plays, she may topple and land the wrong way, causing a crack or break in a bone. Rare but important injuries windowOpen = window.open( jQuery( this ).attr( 'href' ), 'wpcomgoogle-plus-1', 'menubar=1,resizable=1,width=480,height=550' ); At the inside of the elbow tip (epicondylar). If the internal epicondyle is not seen in its normal position then suspect that it is trapped within the joint. The surgeons used a wire/pin and a plate to . Lateral epicondyle. You also have the option to opt-out of these cookies. Berlin Heidelberg New York: Springer; 2008. This line helps you to detect a supracondylar fracture with posterior displacement (pp. ADVERTISEMENT: Supporters see fewer/no ads. An elbow X-ray is done while a child sits and places their elbow on the table. For a true lateral view the shoulder should be at the level of the elbow. If the 3 bones do not fit together perfectly due to growth abnormalities, abnormal weight distribution on areas of the joint occur causing . Ossification Centers. Patel NM, Ganley TJ. Anterior humeral line. The rule to apply:On the AP radiograph a normally positioned epicondyle will be partly covered by some of the humeral metaphysis. When the forces have more effect on the humerus, the extreme valgus will result in a fracture of the lateral condyle. Increased synovial mass (1), perichondral osteophyte (2), and enthesophyte formation (3) are common radiographic changes. Alburger PD, Weidner PL, Betz RR. Capitellum Only gold members can continue reading. On an AP-view this fragment may be overlooked (figure). Is the radiocapitellar line normal? The prevalence of ankylosing spondylitis in the general population is about 0.2% to 0.5%. Occasionally a child in pain will hold the forearm in a position of slight internal rotation. tilt closed reduction is performed. Major NM, Crawford ST. Elbow effusions in trauma in adults and children: is there an occult fracture?. Due to the extreme valgus force the joint may temporarily open. These normal bone xrays are NOT intended as bone-age references! The avulsed medial epicondyl was found within the joint and repositioned and fixated with K-wires. Whenever closed reduction is unsuccesfull in restoring tilt or when it is not possible to pronate and supinate up to 60?, a K-wire is inserted to maintain reduction. ManagementIf a fracture is suspected, immediate orthopedic consultation is recommended. But: there were no instances in which the trochlear ossification centre appeared before the medial (internal) epicondylar centre. These cookies will be stored in your browser only with your consent. Elbow X-Rays, Don't Forget the Bubbles, 2013. . Jacoby SM, Herman MJ, Morrison WB, et al. Normal ossification centres in the cartilaginous ends of the long bones. Please understand that this site is not intended to dispense medical advice, provide or assist medical diagnosis. The only clue to the diagnosis may be a positive fat pad sign. Reference article, Radiopaedia.org (Accessed on 05 Mar 2023) https://doi.org/10.53347/rID-28111, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":28111,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/paediatric-elbow-radiograph-an-approach/questions/1937?lang=us"}. The anterior fat pad is seen in most (but not all) normal elbows. Sometimes the medial epicondyl becomes trapped within the joint. There is a fracture of the lateral humeral epiphyseal apophysis that mimics normal development in a patient 3 years older than the patient's true age. Chest Plain radiograph chest radiograph premature (27 weeks): example 1 neonate: example 1 (lateral decubitus) 6-year-old: examp. 5 out of 5 stars . The multiple ossification centers may be difficult to differentiate from fractures in the acute traumatic setting. The anterior fat pad is seen in most (but not all) normal elbows. . It is mandatory to procure user consent prior to running these cookies on your website. A considerable force is required to cause this fracture, and since young infants are not mobile enough to produce this force, non-accidental trauma must be suspected in these cases. 103 So you need to be familiar with the typical picture of these fractures. The radiocapitellar line ends above the capitellum. Ossification Centers Frontal radiograph of elbow in 12 year old girl. There are two important lines which help in the diagnosis of dislocation and fracture . ?s disease: X-ray, MR imaging findings and review of the literature. It is not important to know these ages, but as a general guide you could remember 1-3-5-7-9-11 years. At the end of growth, when the cartilage completely hardens into bone, the dark line will no longer be visible on an x-ray. What is the most appropriate first step in management? Reconstruction of a severe open distal humerus fracture and intercondylar fracture with complete loss of 13 cm humeral bone by using a free vascularized fibular graft: A case report. . The avulsed fragment may become entrapped in the joint even when there is no dislocation of the elbow. The most common injury mechanism is a fall on an outstretched hand. Tap on/off image to show/hide findings. Order of appearance from birth to 12 years: Exceptions are an occasional normal variant3,4. Ages are approximate (generally, at most +/- 1-2 months, but mostly within + / - 15 days - unless stated otherwise). Radial neck fractures aswell as radial head dislocations are in 50% of the cases associated with other elbow injuries. The fat is visualised as a dark streak amongst the surrounding grey soft tissues. 2. What is the next best step in management? Learning Objectives. Forearm fractures are common in childhood, accounting for more than 40% of all childhood fractures. They do this by taking a single X-ray of the left wrist, hand, and fingers. Steps: Hourglass sign/figure of eighty Anterior fat pad evaluation Posterior fat pad evaluation Anterior Humeral line . Medial Epicondyle avulsion (4). Conclusions:When checking the position of the internal epicondyle on the AP radiograph: There was no further testing they could do to conclusively determine it was cancer, but they felt that was much more likely the case than an infection. They are extrasynovial but intracapsular. Eventually each of the fully ossified epiphyses fuses to the shaft of its particular bone. windowOpen = window.open( jQuery( this ).attr( 'href' ), 'wpcomfacebook', 'menubar=1,resizable=1,width=600,height=400' ); Relationship of the anterior humeral line to the capitellar ossific nucleus: Variability with age. Your elbow bones include the upper bone of your elbow joint (humerus) and the lower bones of your elbow joint (radius and . . Interpreting Elbow and Forearm Radiographs. Frontal Normal elbow. There is support for both operative aswell as non-operative management of medial epicondyle fractures with 5-15mm displacement. T = trochlea So the next question is where is the medial epicondyle? elevation indicates gout. Are the fat pads normal? Comput Med Imaging Graph 1995; 19:473?? If there is less than 30? Radial head }); Pediatric Elbow Trauma. But opting out of some of these cookies may have an effect on your browsing experience. The growth plate usually has a different oblique course compared to a fracture-line. 3% (132/4885) 5. Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. The other important fracture mechanism is extreme valgus of the elbow. A line drawn on a lateral view along the anterior surface of the humerus should pass through the middle third of the capitellum.. The lines assess the geometric relationship of one bone to the other. Treatment is usually closed reduction with either a supination or a hyperpronation technique. The wrist should be higher than the elbow to compensate for the normal valgus position of the elbow. . . Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. 1. (black line), with normal area passed on the capitulum of the humerus colored in green in a 4 year old child. Positive fat pad sign (2)Any elbow joint distention either hemorrhagic, inflammatory or traumatic gives rise to a positive fat pad sign. Displacement of the anterior fat pad alone however can occur due to minimal joint effusion and is less specific for fracture. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Aizawa growled, tired already from the reports awaiting him at the end of this. WordPress theme by UFO themes The atlas is based on data from many other kids of the same gender and age. . It is difficult to distinguish between these and medial epicondylar fractures, however, these usually are NOT related to dislocation. The common injuries The anterior humeral line is drawn along the anterior cortex of the humerus and should bisect the middle third of the capitellum. of the capitellum or in front of the capitellum due to posterior bending of the distal humeral fragment. On some of the images you can click to get a larger view. Copyright 2019 Bonexray.com - All rights reserved. Lateral "Y" view8:48. 1% (44/4885) L 1 Sometimes, the first attempt at reduction does not work. 3% showed a slightly different order. Normal elbow X-ray - 10 year old. This is a repository of radiograph examples (X-rays) of the pediatric (children) skeleton by age, from birth to 15 years. Here are the most common causes of fractured bones in toddlers and babies: [2] Falls. It is not important to know these ages, but as a general guide you could remember 1-3-5-7-9-11 years. Following a successful reduction the child should return to normal within a few minutes. windowOpen = window.open( jQuery( this ).attr( 'href' ), 'wpcomtwitter', 'menubar=1,resizable=1,width=600,height=350' ); This order of appearance is specified in the mnemonic C-R-I-T-O-E Seto Adiantoro et al., Journal of Dentomaxillofacial Science, 2017. A common dilemma. According to NewChoiceHealth.com, the average cost for a finger X-ray is $100, for a hand $180, for a wrist $190, for a knee $200, for a thigh $280, for a pelvis $350, for a chest $370, and for a full body $1,100. Slips and falls are the most common reason a baby or toddler fractures a bone. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, How to Differentiate Carotid Obstructions, Elbow injuries in children in www.orthotheers, Pediatric Elbow fractures in Wheeless on line textbook on Orthopaedics. (SBQ13PE.4) A 7-year-old with a history of an elbow injury treated conservatively presents for evaluation of ongoing elbow pain. You may also need an Radiology appGet it nowShoulderWrist & distal forearmAdult elbowKneeThoracic & lumbar spineHip & proximal femurAnkle & hindfootCervical spine when obtained, elbow radiographs are normal. Once displaced fractures consolidate in a malunited position, treatment is difficult and fraught with complications. R - Radial head (2-4 yrs) I - Medial (Internal) epicondyle (4-6 yrs) T - Trochlea (8-11 yrs) . The mechanism is an acute valgus stress due to a fall on the outstretched hand or sometimes due to armwrestling. This website uses cookies to improve your experience while you navigate through the website. Tags: Accident and Emergency Radiology A Survival Guide X-Rays ( Bone density, texture, changes in alignment and relationship, erosion, swelling, intactness, ligamens/tendons) Computed Tomography ( shows slices of bone/soft tissue, joints) Myelogram : contrast . The fat is visualised as a dark streak amongst the surrounding grey soft tissues. The medial epicondyle is an apophysis since it does not contribute to the longitudinal growth of the humerus. This Limited Warranty does not cover normal wear and tear, or any damage, failure or loss caused by improper assembly, maintenance, or storage. Then continue reading. Radiographic Evaluation of Common Pediatric Elbow Injuries. The normal elbow already has a valgus positioning. indications. 7. But X-rays may be taken if the child does not move the arm after a reduction. The medical term for the injury is "radial head subluxation." Because a young child's bones and muscles are still developing, it typically takes very . It is located on the dorsal side of the elbow. AP viewchild age 9 or 10 years Elbow fat pads Bradley JP, Petrie RS. Normal ossification centres in the cartilaginous ends of the long bones. return false; You should ask yourself the following important questions.Is there a sign of joint effusion? Similarly, in children 5 years . A short radius may also be the result since the epiphysis of the radius contributes to the length growth of the radius. Familiarity with age-variable anatomy is crucial for an accurate diagnosis. Vascular injurie usually results in a pulseless but pink hand. Bridgette79. AP and lateral: the CRITOL sequence // If there's another sharing window open, close it. Radiocapitellar lineA line drawn through the centre of the radial neck should pass throught the centre of the capitellum, whatever the positioning of the patient, since the radius articulates with the capitellum (figure). The apophysis has undulating faintly sclerotic margins. Become a Gold Supporter and see no third-party ads. To begin: the elbow. The posterior fat pad is not visible on a normal radiograph because it is situated deep within the olecranon fossa and hidden by the overlying bone. When a major displacement of the internal epicondyle occurs the bone can become trapped within the elbow joint. 2021 Emergency Medicine Residents' Association | Privacy Policy | Website Links Policy | Social Media Policy, Straight to the Source: Local Treatment Options for Low Back Pain Pediatric elbow radiograph (an approach). Treatment Abbreviations O = olecranon Rotation will project the metaphysis of the humerus away from a normally positioned epicondyle. Radial Head and Neck Fractures in children are relatively common traumatic injuries that usually affect the radial neck (metaphysis) in children 9-10 years of age. Fracture lines are sometimes barely visible (figure). The order is important, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Avulsion of the lateral epicondyle, Dislocation of the head of the radius, Monteggia injury. Figures 1A and 1B: Normal X-rays, 13-year-old male. Usually there is some displacement and the anterior humeral line will not pass through the centre of the capitellum but through the anterior third or even anterior to the capitellum (figure). Eventually each of the fully ossified epiphyses fuses to the shaft of its particular bone. On the left some examples of fractures of the olecranon. Avulsions also occur in children who are involved in throwing sports, hence the term little leaguers elbow. In this review important signs of fractures and dislocations of the elbow will be discussed. At the time the article was created Jeremy Jones had no recorded disclosures. if it does not, think supracondylar fracture. Narrative(s) A pediatric (<15 years old) patient presents for elbow radiography after trauma. of 197 elbow X-rays, . Ages are approximate (generally, at most +/- 1-2 months, but mostly within + / 15 days unless stated otherwise). Orthopedics Today | The patient is a 15-year-old right-hand dominant high school sophomore who plays catcher for his varsity baseball team. } The standard radiographs var windowOpen; Be careful: in very young children the ossification within the cartilage of the capitellum might be minimal (ie normal and age related), and so is insufficiently calcified and does not allow application of the above rule. Sometimes this happens during positioning for a . "Keeping the arm immobilized is a key part of successful recovery," Dr. Blanco emphasizes. Forearm Fractures in Children. If the force continues both the anterior and posterior cortex will fracture. do recommend it for any pre-teen and teen. Unable to process the form. A child with nursemaid's elbow will not want to use the injured arm because moving it is painful. Step 2: Elbow Fat Pads 106108). A nondisplaced lateral condylar fracture is often very . This does not work for the iPhone application There are pads of fat close to the distal humerus, anteriorly and posteriorly. On the posterior side no fat pad is seen since the posterior fat is located within the deep intercondylar fossa. Erosion of the subchondral bone surface (4) and joint mice (5) are less common, whereas increased subchondral bone opacity (6) and . From the case: Normal elbow - 10-year-old. X-RAY FILM READING MADE EASY. I before T. Though the CRITOL sequence may vary slightly there is a constant: the trochlear (T) centre always ossifies after the internal epicondyle. The solution is either to lift the examination table which will lift the elbow or to lower the shoulder by placing the patient on a smaller chair. AP view; lateral view96 When the trochlea is not yet ossified the avulsed fragment may simulate a trochlear ossification centre. Scroll through the images on the left to see how hyperextension leads to a supracondylar fracture. After being involved in a motorcycle accident, 19-year-old Anna Handley was transported to the emergency room for treatment. Kissoon N, Galpin R, Gayle M, Chacon D, Brown T. Evaluation of the role of comparison radiographs in the diagnosis of traumatic elbow injuries. MRI can be helpfull in depicting the full extent of the cartilaginous component of the fracture. Ossification center of the Elbow. Find great local deals on second-hand diy tools & workshop equipment for sale in BS32 Shop hassle-free with Gumtree, your local buying & selling community. 7 Notice that there is only minor joint effusion (asterix). This may be attributed to healthcare providers . At the time the article was created Ian Bickle had no recorded disclosures. 18-1 Radiographic signs of joint disease (A) compared with a normal joint (B). Typically these fractures present with medial soft tissue swelling with pain in the condylar region. var themeMyLogin = {"action":"","errors":[]}; In Gartland type II fractures there is displacement but the posterior cortex is intact. (Capitellum - Radius - Internal or medial epicondyle - Trochlea - Olecranon - External or lateral epicondyle). Philadelphia: JB Lippincott, 1991. pp. In children however it's the radial neck that fractures because the metaphyseal bone is weak due to constant remodelling. There are six ossification centres. Acknowledgements However fractures anywhere along the ulna have been reported. These cookies do not store any personal information. (AP) and lateral elbow radiographs of 6-year-old girl with type 2A supracondylar humerus fracture with no rotational deformity on AP view . Wilkins KE. This means that the radius is dislocated. Flexion-type fractures are uncommon (5% of all supracondylar fractures). This is a repository of radiograph examples (X-rays) of the pediatric (children) skeleton by age, from birth to 15 years. The average cost for more specialized X-rays, such as those of various arteries, veins or ducts in the body, can reach $20,000 to . Lateral Condyle fractures (4) . 102 Supracondylar fractures (4)Malunion will result in the classic 'gunstock' deformity due to rotation or inadequate correction of medial collaps. Physical exam demonstrates guarding of the extremity with the elbow held in flexed and pronated position. Notice how subtle some of these fractures are. A major avulsion is easy to overlook when an elbow has been transiently dislocated and then reduces spontaneously5,6 because the detached epicondyle may, on the AP radiograph, be mistaken for the normally positioned trochlear ossification centre (p. 105). Diagnosis can be made clinically with a child that holds the elbow in slight flexion with pain and. In adults fractures usually involve the articular surface of the radial head. Medial Epicondyle avulsion (8).Study the images. Nursemaid's Elbow is a common injury of early childhood that results in subluxation of the annular ligament due to a sudden longitudinal traction applied to the hand. Avulsions also occur in children who are involved in throwing sports, hence the term little leaguers elbow. Conclusions: Traditional teaching that the AHL touches the capitellum on a lateral radiograph of a normal elbow in a child is correct, so if the AHL does not touch the capitellum it is appropriate to look for pathology. X-ray results are normal in someone with nursemaid's elbow. Radiocapitellar line (on AP and lateral) Identify Distal Humeral FracturesDistal humeral fractures in pediatric patients include supracondylar, lateral condylar, medial epicondylar, medial condylar, and lateral epicondylar fractures. By using a systematic approach to reading elbow x-rays delineated below, you can begin to feel more confident and adept at evaluating the subtle signs of pediatric fractures. Fractures and dislocations of the elbow region. The images on BoneXray.com have been quality assured and verified by a senior consultant and specialist in pediatric radiology. A site developed for Postgraduate Orthopaedic Trainees preparing for the FRCS Examination in the United Kingdom. This means that the elbowjoint is unstable. alkune by Tomas Jurevicius; Normal radiographs by Leonardo . . Elbow pain after trauma. {"url":"/signup-modal-props.json?lang=us"}, Jones J, Weerakkody Y, Bell D, et al. Patients present with tenderness over the radial head with pain localized to the lateral aspect of the elbow with pronation and supination. Monteggia injury1,2. 1) capitellum; 2) radial head; 3) internal (medial) epicondyle; 4) trochlea; 5) olecranon; and 6) external (lateral) epicondyle. Nursemaid's elbow is a common injury of early childhood. In children When the forearm is pulled the radial head moves distally and the ligament slips over the radial head and becomes trapped within the joint. Conservative management and vascular intervention have the same outcome. Try to find out what went wrong in the chapter on positioning. (under the age of 4, the line will intersect the anterior 1/3) Check the radiocapitellar line: drawn along the radial neck. Fracture of the lateral humeral condyle109 This is not about possible pathologies, because usually the dose of radiation and the duration of the procedure are adjusted so that they can not cause significant harm. These fractures account for more than 60% of all elbow fractures in children (see Table). Common mechanisms include FOOSH, traction, and rotary forces. These fractures usually occur in children 8-14 years of age after a fall onto an outstretched hand. 1. The anterior fat pad is seen in most (but not all) normal elbows. They will hold the arm straight or with a slight bend in the elbow. Use the rule: I always appears before T. var windowOpen; They are not seen on the AP view. Intro to elbow x-rays0:38. . They occur between the ages of 4 and 10 years. Depending on the patient's unique health history and their treatment needs, the doctor may order additional laboratory tests. About three out of four forearm fractures in children occur at the wrist end of the radius. In every dislocation the first question should be 'where is the medial epicondyle'. }); jQuery( document.body ).on( 'click', 'a.share-facebook', function() { Supracondylar fractures of the humerus in children. info(@)bonexray.com. The highlighted cells have examples. On the left two examples of a 'low wrist positioning' leading to rotation of the humerus. jQuery( document.body ).on( 'click', 'a.share-google-plus-1', function() { Skaggs et al repeated x-rays after three weeks in patients with a positive posterior fat pad sign but no visible fracture. Fracture, lateral condyle of humerus. windowOpen.close(); Occasionally a minor variation in the sequence may occur. Fractures of the medial epicondyle make up approximately 12% of all pediatric elbow fractures. The coronal alignment of her elbows in extension is symmetric. The low position of the wrist leads to endorotation of the humerus. not be relevant to the changes that were made. normal bones, pediatric bones, normal radiograph, normal x-ray. (OBQ07.69) Lateral condyle fractures are classified according to Milch. These fractures require closed reduction and some need percutaneous fixation if a long-arm cast does not adequately hold the reduction. 104 Normal variants than can mislead113