hello everybody and welcome back to another Anatomy tutorial last week we looked at the anatomy of the elbow joint on X-rays and I mentioned in that video that we would have a separate video looking at the elbow ossification centers so here's that video I'm going to show you how to recognize the six different ossification centers and in which order they should appear in the normal development of a child and at what age we should expect those different ossification centers to appear now why do we even bother learning these ossification centers is it just to be asked in exams or to show off to colleagues that we know the order in which they appear obviously it's neither of those and the main reason we learned these ossification centers is because when children fracture around elbow joint many of the ossification centers one can look like fractures and evolves sections of Bones can look like ossification centers and if we know the order that those ossification centers appear we can confidently say yes this is a fracture or no this is actually an ossification sensor so you may have heard the mnemonic critone I'm not a great believer of mnemonics but here's a time when learning a mnemonic is really going to help you so as we learned in last week's lecture about the elbow joint if you haven't watched it I'll link it above we have six different sections here the first is our capitalum that's mentioned by C then we have our radial head our internal epicondyle Ultra clear our electron and our external or lateral epicondyle now I'm going to show you how to identify them now on these different images and then mention the order in which they appear so the first one that appears is our capitalum small head Capital our main one it's an easy way to remember that that comes first the capital we can see the capitalum here this is a two-year-old child there's no other ossification centers this is all cartilaginous tissue here then as the child gets older we develop our radial head so our capitalism is what articulates with our radial head we've got that shallow radial head fossa around it capitellin articulating like that we mentioned in the last lecture that the radius allows for that pivot joint this is our capitalism and radial head so they go together the capital comes first then the radial head doesn't make sense then we develop our internal or medial epicondyle here now we know that the radius is lateral and our ulna is medial so it's always remember that it's going to be easy to start thinking that this is medial here no this is medial on this side so capital M radial head internal or medial epicondyle and then we have our trochlea and our electron developing at very similar times how trochlia here is part of the humerus remember it's not part of the ulna chocolate here part of the humerus and then our electron is part of the ulna that electron goes into that electron on fossa posteriorly it's an attachment for our tricep muscles and our trochlea allows for the trochlear notch of the ulna to like a pulley rotate in that hinge joint allowing that smooth hinging motion of our elbow joint and then lastly we end off with our external epicondyle or lateral epicondyle remember that's on the side of the radius so it's really easy you just follow that order and another easy way to remember this is that our capitalism and our radius they articulate with one another our trochlia and our electron are also in the same articular surface there so those are joined together it leaves us with our internal epicondyle and our external epicondyle I'm going to show you why that becomes important the order of this becomes important later now what ages are we expecting these centers to appear many people learn it in a simple way by going one going up the odd number so one three five seven nine eleven and you'll get by by doing that it's not as accurate as a method I'm going to show you now and I would recommend trying to learn this especially if you're going to write a primaries exam or core exam to learn the slightly more complicated way because you're going to be a little bit more accurate maybe in your practice once you've had years and years of experience you're going to have the age of the child on the scan already that's fine but for exams maybe learn this method which is 1 5 7 10 10 11. and you can see that our trochlea and our lecronon often develop at a very similar time the way I can remember this is tno makes two so these two develop at the same time 10. so our capitalum develops first and there's quite a period of time before a radial head and our internal epicondyle develop and then our trochlea olecranon and external or lateral epicondyle developed between the ages of 10 and 11 you're going to be a bit more accurate in that assessment of bone age now girls often develop earlier than boys up to two years earlier so that goes without saying that these numbers are very flexible and we're never going to be super accurate when trying to determine age from an elbow radiograph so if you're going to take one thing from this talk let it be this that your internal epicondyle should always develop before your external epicondyle it should actually always develop before the trochlear electron and the external epicondyle but if you can't see an internal epicondyle and you can see an external epicondyle then there's something wrong you need to go looking for a fracture most likely an avulsion of that internal epicondyle now there's a saying in English I before E except off to C this is a good way to remember it I comes before E so we have this saying in in English I before E it's not a very good thing because there's actually more words that have E before I but when it comes to remembering that the internal comes before the external it's a great way to remember that so we're going to have a look at two different cases so the first case here we're going to go through together we're going to look at the different ossification centers and see if there's any abnormality that we can find so here we have our humerus coming to our radius and our ulna we can see our large capitellum here and that articulates with our radial head those are both normal then we should look for our internal epicondyle now the internal epiconder normally overlaps slightly with this medial portion of the humerus can't see an internal epicondyle here so we know can we see an external epicondyle yes we can so we know I before E there should be an internal epicondyle we can see here now you might be tempted to say this is the trochlea but it is a little bit far away from the humerus so let's have a look at the lateral radiograph here we can see our capitellim that articulates with our radial head we can also see our electron on here and if you look here now we can see our trochlea forming here so we know that this bony fragment that we see here is not our trochlea and you can see on the previous x-ray we were missing our internal or our medial epicondyle here is our medial epicondyle it used to be here and it's a vast got a whole flexes of the forearm and pronators of the forearm and when we land on an outstretched arm that can evolve that medial epicondyle or if this ulnet dislocates posteriorly we can also get this a version of our internal or our medial epicondyle so it's really important this patient is going to need surgery they're probably going to need an orif an open reduction an internal fixation and missing something like this has severe consequences for the growth and development of that child in the elbow joint let's look at one last case now this is the kind of case that could come up in your primies or part one exams they ask you to estimate the age of this child so again let's go through it together we can see our capitalism here so we know that they're older than the age of one let's identify it on the lateral there's our capitellum you can see our radial head radial head here so we know that they're older than the age of five can see our internal or our medial epicondyle on the side of the element you see how it just overlaps that humeral head on the external often we don't get an overlapping like that that's another thing to note when you're looking at scans here I can't see a trochlear and I can't see an electron there's definitely no electron on the lateral x-ray so if we go by our age classifications one five seven one five seven so they're older than the age of seven and likely under the age of 10 we've got no trochlia and no electron so in the exam I would answer that this patient is between the ages of 7 and 10. now if we were to use that other system the 135 the odd numbers going up we'd go one three five we would estimate that this patient is between the age of five and seven you can see how there's a lot of variation and really for an exam learn the slightly more complicated system get more accurate in this patient in fact was eight years old so it's not that difficult we're going to go through step by step c-r-i-t-o-e make sure that your internal epicondyle your medial epicondyle appears before the trochlear electron and external epicondyle your lateral epicondyle so I hope that's helped whenever you're faced with a pediatric x-ray of the elbow go through your mnemonic if there's something that's awry look for an avoc fragment or look for a fracture within the elbow joint and then look for other signs of a fracture that we mentioned in our previous X-ray on elbows look at the radio capitella line the anterior humeral line and the raised fat pads and those can be used as extra evidence that there's something a mess within this x-ray so until next time I'll see you all in the next anatomy video goodbye everybody