Author:
Roger M.Barkin
Description
The most common elbow injury in children <5 yr old. Peak incidence is between 2-3 yr of age. It has been reported in children as old as 9 yr
Etiology
- Sudden traction on the distal radius leads to a portion of the annular ligament slipping over the radial head and becoming trapped between the radius and the capitellum. Longitudinal traction while the elbow is pronated and extended can cause subluxation by swinging the child, wrestling, and lifting the child by the arms
- By the time the child is 5 yr, the annular ligament is thick and strong and resists tearing and /or displacement
- Often referred to as “pulled elbow” or subluxation of the radial head
Signs and Symptoms
- Child refuses to use arm
- Elbow is slightly flexed, with forearm held close to the trunk
- Pain with flexion of the elbow
- Pain with forearm usually in pronation
- Absence of point tenderness
- Minimal to no swelling
History
- Child not using affected arm
- 50% report the classic history of pulling the arm
- Can also be due to a fall, minor trauma to the elbow, or twisting of the forearm
- In children <6 mo, can be due to the child rolling onto the arm
Physical Exam
- Affected arm is held close to the body
- Arm is usually pronated
- Elbow is either fully extended or slightly flexed
- Child will not extend or flex the elbow
- Can be mildly tender over anterolateral radial head, but the rest of the elbow is nontender
- Painless passive range of motion
- Painful with supination
Essential Workup
Clinical diagnosis:
- Classic history, passive position of arm, and physical exam are sufficient for diagnosis
Diagnostic Tests & Interpretation
Imaging
Radiographs:
- Not routinely indicated
- Obtain to exclude or diagnose other injuries if any of the following are present:
- Point tenderness
- Soft-tissue swelling
- Deformity
- Ecchymosis of the elbow
- Failed reduction
- Child continues to favor extremity after reduction maneuver
- May be indicated before reduction attempts if significant pain, swelling, deformity, or ecchymoses are present
- Point of care ultrasonography may be useful in cases of atypical presentation and postreduction confirmation. The annular ligament may be seen in the joint space forming a pathologic “hook sign” formed by the displacement of the annular ligament into the joint space
Differential Diagnosis
- Must be considered if fail to reduce after several attempts
- Humerus, radius, ulna, or clavicle fracture
- Elbow dislocation
- Joint infection
- Osteomyelitis
- Tumor
Prehospital
Cautions:
- Place ice on the injured elbow to reduce pain and swelling
- Immobilize in a sling or splint to facilitate transport and prevent further injury
- Assess distal neurovascular status
Initial Stabilization/Therapy
Assess distal motor, sensory, and vascular function
ED Treatment/Procedures
- Supination/flexion technique:
- More commonly used
- Grasp child's hand in hand shake position and apply mild axial traction
- Stabilize injured elbow with the other hand with the thumb over the radial head exerting moderate pressure
- In one smooth, swift motion, fully supinate the forearm and flex the elbow
- Hyperpronation/extension technique:
- Some perceive as less painful
- Grasp child's hand in hand shake position and apply mild axial traction
- Stabilize injured elbow with the other hand with the thumb over the radial head exerting moderate pressure
- Hyperpronate the arm and extend if arm is not already extended
- Placing the examiner's thumb over the radial head may allow palpation of a click
- Child may cry during the reduction, but is frequently pain free using the arm shortly thereafter. Period of immobility may be somewhat prolonged if reduction delayed:
- Arm may not return to normal function for a prolonged period of time if the subluxation has been present over several hours
- Attempt reduction a second time if the child does not use arm 15 min after first attempt
- Consider the alternative technique for second reduction attempt if first fails since there is no clear data regarding the relative effectiveness of the two techniques
- Radiographic studies indicated if the second reduction attempt is unsuccessful. Evaluate for fractures
- Perform postreduction neurovascular assessment
Medication
Disposition
Discharge Criteria
- Discharge after child regains full, unrestricted use of the arm
- Patient instructions:
- Inform parents not to pull or lift the child by the hand , wrist, or forearm
- Recurrence rate of up to 39% until the child reaches 5 yr of age
- Analgesics rarely needed
Issues for Referral
Unsuccessful reduction or child not using arm with normal function:
- If radiologic evaluation is also negative, child should be referred to an orthopedist
- Place arm in a posterior splint with the elbow kept at 90° and the forearm in supination for outpatient follow-up
- No long-term sequelae have been reported with short delay in reduction
Follow-up Recommendations
- None required for successful reduction
- Orthopedics within 24 hr for unsuccessful reduction