Always X–ray an injured elbow. Ask for an AP and a lateral view. Minor fractures such as small chips off the capitulum are difficult to diagnose without an X–ray. In a severe elbow injury the medial epicondyle is easily detached, so it is the first thing to look for. The films of a child’s injured elbow are not easy to interpret, so X–ray his other elbow in the same position, and compare the two. Also consult the diagrams inside the back cover, but remember that these apply to Caucasians, and that African epiphyses unite later. If you are still in doubt, X–ray the patient again in a week. The fracture, if there is one, will then be easier to see. Note that: (1) in children a mildly oblique X–ray can both resemble and disguise a dislocation, and (2) that the head of the radius and the medial and lateral epicondyles can be displaced before their centres of ossification appear. This makes diagnosis difficult.
If a child’s injured elbow looks normal on X–ray, the three bony points are in their normal places, and diagnosis is difficult, consider pulled elbow (72.16). Some of these injuries are mild subluxations. Try gently manipulating the elbow under anaesthesia. You may feel a sudden click after which it moves normally.