Elbow Plain Film Views for Traumatic Lateral Epicondyle Pain
For a patient with left elbow pain for 1 month after injury with pain on palpation and swelling about the lateral epicondyle, a standard three-view radiographic series should be obtained, consisting of anteroposterior (AP), lateral, and oblique views of the elbow. 1, 2
Recommended Radiographic Protocol
- Anteroposterior (AP) view: Evaluates the joint space, medial and lateral aspects of the elbow
- Lateral view: Assesses the anterior and posterior aspects of the elbow joint
- Oblique view: Provides additional perspective of the radiocapitellar joint and lateral epicondyle
Rationale for Three-View Series
- The American College of Radiology (ACR) Appropriateness Criteria for acute elbow pain recommends radiographs as the initial imaging assessment 1
- Conventional radiographs are the first-line imaging modality to exclude fractures or dislocations that may require urgent intervention 1, 2
- A three-view series provides comprehensive evaluation of bony structures and can identify:
- Fractures of the lateral epicondyle
- Joint effusions (indicated by fat pad signs)
- Avulsion injuries at tendon attachment sites
- Arthritic changes
Clinical Considerations
- The patient's presentation with lateral epicondyle pain for 1 month after injury suggests possible lateral epicondylitis (tennis elbow), but traumatic injuries must be ruled out first 3
- Radiographs can detect:
- Avulsion fractures at the lateral epicondyle
- Calcific tendinopathy
- Joint effusion (indicated by positive fat pad sign)
- Arthritic changes that may contribute to symptoms
When Additional Imaging May Be Needed
If the three-view radiographic series is normal or indeterminate and symptoms persist:
- Consider MRI without contrast for better soft tissue evaluation, particularly if suspecting tendon or ligamentous injury 2
- Ultrasound may be considered as an alternative for evaluating tendon pathology with high sensitivity (95%) for complete versus partial tears 2
- CT without contrast may be considered if complex fracture patterns are suspected but not well visualized on plain films 1
Common Pitfalls to Avoid
- Inadequate views: Failing to obtain all three standard views may miss important findings
- Improper technique: Poor positioning can lead to misinterpretation
- Overlooking subtle findings: Small avulsion fractures or joint effusions may be missed if not specifically evaluated
- Premature advanced imaging: Starting with MRI or CT before appropriate radiographs is not cost-effective and may delay diagnosis
By following this standardized three-view approach to elbow radiography, clinicians can effectively evaluate traumatic lateral epicondyle pain and determine appropriate next steps in management.