What is the next step for imaging in a patient with bicep pain, elbow pain, and pain with movement after a traumatic injury to the right arm, which was injured when it hit a door frame and the patient fell on a box?

Initial Imaging for Acute Traumatic Elbow and Bicep Injury

Order plain radiographs of the right elbow (anteroposterior, lateral, and oblique views) as the initial imaging study. 1

Rationale for Initial Radiography

Plain radiographs are the mandatory first-line imaging for acute traumatic elbow and forearm pain, as they effectively exclude fractures, dislocations, and provide critical diagnostic information that guides subsequent management. 1

What Radiographs Can Detect

• Fractures and dislocations: Radial head/neck fractures (most common, accounting for 50% of adult elbow fractures), olecranon fractures, coronoid process fractures 1
• Joint effusion: Posterior and anterior fat pad elevation suggests occult fracture even when no obvious fracture line is visible 1
• Avulsion fractures: At tendon and ligament attachment sites, including potential olecranon avulsion from triceps tears or biceps-related avulsions 1
• Soft tissue abnormalities: Calcifications or heterotopic ossification 1

How to Order

Order as: "Right elbow radiographs, 3 views (AP, lateral, oblique), acute trauma" 1, 2

If Radiographs Are Normal or Indeterminate

The next imaging step depends on your clinical suspicion:

Suspect Occult Fracture (Persistent Bony Tenderness, Limited Extension)

Order CT elbow without IV contrast 1, 2

• CT detects occult fractures in 12.8% of patients with normal radiographs and positive elbow extension test (inability to fully extend elbow while sitting with shoulders at 90° flexion) 1, 3
• CT identifies radial head, olecranon, and coronoid process fractures missed on plain films 1
• CT clarifies fracture morphology, fragment size, displacement, and angulation—critical information for surgical planning 1

Suspect Soft Tissue Injury (Biceps Tear, Ligament Injury, Tendon Pathology)

Order MRI elbow without IV contrast 1, 2

Given this patient's bicep pain after trauma, soft tissue injury is a significant concern:

• Biceps tendon tears: MRI has superior sensitivity for detecting partial and complete distal biceps tears 1

  • Partial rupture of the long head with intact short head is the most common pattern 1
  • Traumatic ruptures have significantly higher association with short head involvement 1
  • Consider requesting FABS view (flexion-abduction-supination) for challenging cases of high-grade partial versus complete tears, though standard sequences are usually sufficient 1

• Ligament injuries: MRI demonstrates 87.5% concordance with surgical findings for medial collateral ligament injuries and 90.9% for lateral collateral ligament injuries 1

• Muscle injuries: MRI effectively visualizes muscle tears and hematomas 1

Common Pitfalls to Avoid

• Don't skip radiographs: Even with high suspicion for soft tissue injury, radiographs must be obtained first to exclude fracture, dislocation, and avulsion injuries 1, 2
• Watch for fat pad signs: Elevated fat pads on lateral radiographs indicate joint effusion and should raise suspicion for occult fracture even without visible fracture line 1
• Coronoid fractures signal soft tissue injury: If coronoid process fracture is identified, assess for associated tendon and ligament injuries as these commonly occur together 1
• Don't order contrast: There is no evidence supporting IV contrast for either CT or MRI in acute elbow trauma evaluation 1
• Ultrasound has limited role: Point-of-care ultrasound studies are too small to support routine use in acute elbow trauma 1

Clinical Decision Algorithm

1. Start with plain radiographs (AP, lateral, oblique) 1, 2
2. If fracture/dislocation identified: Manage accordingly; consider CT for surgical planning if complex 1
3. If radiographs normal but suspect fracture (bony tenderness, positive elbow extension test): Order CT without contrast 1, 2
4. If radiographs normal but suspect biceps/tendon/ligament injury (mechanism consistent with soft tissue injury, palpable defect, weakness): Order MRI without contrast 1, 2
5. If both fracture and soft tissue injury suspected: Start with CT to rule out fracture, then proceed to MRI for soft tissue characterization 2