Management Fracture diagnosis requires plain radiographs of the elbow, with both anteroposterior and lateral views Comparison views of the elbow may be useful in diagnosis of fracture due to the complexity of the joint with its three points of articulation, numerous growth centers, and variable timing of ossification ( Table 111.7 ) After initial examination, patients should be splinted prior to imaging The lateral view should be with the elbow at 90 degrees of flexion to avoid a false-positive posterior fat pad sign In addition, radiographs of the forearm should be obtained, as there is a 10% to 15% risk of ipsilateral concurrent distal radius forearm fracture Interpretation of the radiographs for occult fracture requires attention to subtle changes in three regions: the fat pads (anterior and posterior), the anterior humeral line, and the radiocapitellar line In the normal lateral radiograph, the anterior fat pad is readily seen but the posterior fat pad is hidden within the olecranon fossa ( Fig 111.16 ) The presence of hemarthrosis and edema in the joint following trauma will elevate the anterior fat pad creating the “sail sign” and displace the posterior fat pad from the fossa creating a lucency posterior to the distal humerus on lateral view ( Fig 111.17 ) The presence of a posterior fat pad sign is abnormal and is 75% sensitive for the presence of an occult elbow fracture The anterior humeral line is a line drawn along the anterior cortex of the humerus and should intersect the capitellum in its middle third; however, in the presence of an extension-type injury this line will pass anteriorly Finally, a line drawn along the axis of the radius should pass through the capitellum irrespective of the degree of elbow flexion or extension on the radiograph If this is not visualized, there may be either a lateral condyle fracture or a dislocation of the radial head (as in a Monteggia fracture) ( Fig 111.18 )