Initial Imaging for Elbow Symptoms or Trauma
Plain radiographs (AP and lateral views) are the recommended initial diagnostic imaging modality for all patients presenting with elbow-related symptoms or trauma. 1, 2
Why Radiographs First
Radiographs serve as the first-line imaging to exclude fractures, dislocations, and osseous pathology before considering any advanced imaging modalities. 1
Conventional radiographs effectively identify:
- Fractures (radial head/neck fractures account for 50% of adult elbow fractures) 1
- Joint effusions via posterior and anterior fat pad elevation, which implies occult fracture in the trauma setting 1
- Avulsion fractures at tendon and ligament attachment sites 1
- Intra-articular loose bodies 2
- Heterotopic ossification 2
- Osteochondral lesions 2
- Soft tissue calcification 2
- Osteoarthritis 2
Comparison views with the asymptomatic contralateral elbow are often useful for better evaluation, particularly when findings are subtle. 2, 3
What NOT to Order Initially
The American College of Radiology explicitly states there is no evidence to support the following as initial imaging studies for acute elbow pain: 1
- MRI (with or without contrast)
- CT (with or without contrast)
- Bone scan
- Ultrasound as sole initial modality
When to Advance Beyond Radiographs
If Radiographs Are Normal or Indeterminate BUT Fracture Still Suspected:
CT without contrast is the next appropriate study for clarifying fracture morphology, detecting occult fractures, and assessing fragment size/displacement. 1
CT demonstrates 93% sensitivity for detecting loose bodies and excels at evaluating complex fracture patterns. 2, 4
One study found that 12.8% of patients with elbow trauma, a positive elbow extension test (inability to fully extend the elbow at 90° shoulder flexion), and normal radiographs had occult fractures on CT (radial head, olecranon, or coronoid process). 5
If Soft Tissue Injury Is Suspected:
MRI without contrast is indicated when radiographs are normal but clinical concern exists for tendon tears, ligament injuries, or nerve entrapment. 2, 6
MRI shows 90-100% sensitivity for medial epicondylitis and ulnar collateral ligament injuries. 2
T2-weighted MR neurography is the reference standard for ulnar nerve entrapment imaging. 2, 6
For Suspected Intra-articular Pathology with Mechanical Symptoms:
MR arthrography (3T) offers 100% sensitivity for detecting intra-articular bodies and evaluating osteochondral lesion stability. 2, 6
CT arthrography provides 93% sensitivity for loose bodies and excellent assessment of heterotopic ossification. 2, 6
Common Pitfalls to Avoid
Never order MRI before obtaining plain radiographs—this wastes resources and MRI is less sensitive than radiographs for detecting calcifications and ossifications. 3
Do not rely on a single radiographic view—always obtain both AP and lateral projections to fully characterize the pathology. 3
Failing to recognize that coronoid process fractures should prompt assessment for associated tendon or ligament injuries, as these commonly occur together. 1
Missing that a joint effusion on radiographs in the acute trauma setting strongly implies an occult fracture, even if no fracture line is visible. 1
Overlooking that pain may be referred from cervical spine pathology or radial tunnel syndrome when initial elbow imaging is negative. 2, 6