Objective <p>To conduct a systematic review on the imaging diagnosis and modality-specific characterization of distal humerus physeal fractures among children under 3&#xa0;years of age.</p> Methods <p>A literature search was performed to identify peer-reviewed publications that included imaging descriptions on distal humerus physeal fractures in children &lt; 3&#xa0;years. Study quality and risk of bias were evaluated. Demographic information, mechanisms of injury, imaging workup and findings, radiographic diagnosis, diagnostic imaging modality, treatment, and outcome were collected and summarized using descriptive statistics.</p> Results <p>Thirty-seven studies (published, 1963–2023) included 24 case reports and 13 case series, yielding 101 children (102 elbows), who underwent 175 imaging examinations (102 initial, 7 repeat radiographs; 48 initial, 1 repeat ultrasounds; and 17 MRI examinations). Excluding 3 elbows that underwent concurrent ultrasound, physeal fracture was suspected on radiographs in 55.6% (55/99) and the most common misdiagnosis was joint subluxation-dislocation (53.8%, 21/39). Physeal fractures were identified on ultrasound and/or MRI in 97.9% (47/48) and 94.1% (16/17) of the examinations, respectively. The most reported radiographic finding was posteromedial forearm malalignment (68.6%, 48/70). Most (63.5%, 61/96) elbows were treated with immobilization and residual findings were reported in 44.8% (43/96) of the elbows with the most common findings including cubitus varus (39.5%, 17/43), residual deformity (27.9%, 12/43), and limited range of motion (25.6%, 11/43).</p> Conclusion <p>Radiographs were the most often used initial imaging to screen for distal humerus physeal fractures in children under 3&#xa0;years, whereas ultrasound and MRI were reserved for workup and confirmation. Nearly half of these elbows had complications.</p>