2-year-old Alfie presents to the Emergency department having sustained an injury jumping on the sofa and falling off at home an hour ago. His older sister says she thinks he put his right hand out as he fell, landing on the carpet. Alfie’s mum gave him a dose of paracetamol after the injury and brought him straight to the ED because his elbow looked so swollen. Alfie looks pale and tearful.
As with any clinical examination in paediatrics, try to observe the child without them being aware of you, if possible. This may involve watching them in the waiting room for a few minutes if they are able to play or seeing how they and their arm are positioned on their parent’s lap or on the trolley. The degree of movement and their preferred position will give valuable information about the likely diagnosis. A child with the arm hanging by their side who is essentially pain free until it is moved is likely to have a pulled elbow. Those who have significant elbow pathology are unlikely to have much movement and will often cradle the affected arm in about 90 degrees of flexion. Putting this initial observation together with history is a useful starting point.
Once you have established a rapport with the child and their parent, start by looking at the limb without touching. Ideally the child will have at least the lower two thirds of the upper arm and the entirety of their forearm exposed. Obvious deformity will make things easy, but often the signs are subtler. Chubby arms in younger children can be mistaken for swelling: look for symmetry and use the dimples of the elbow to help you assess this. Often there is no bruising around a fractured elbow, but there is almost always a degree of swelling.
Examine the unaffected side first; this will allow you to get a feel for the child’s normal range of movement and it may help them to trust you. Ideally keep them chatting throughout the examination – it won’t mask true tenderness, but it will reduce anxiety-induced reports of pain. Remember to examine from the shoulder to the wrist and have a systematic approach to examining the whole elbow: humerus, medial and lateral condyles, olecranon, radius and ulna. Attempt to move the elbow through the full range of flexion, extension, pronation and supination. Pain elicited on extension, supination and pronation in particular should be considered abnormal and should prompt an x-ray request, unless there is a clear history of pulled elbow, in which case it will not be required. In a deformed elbow there is no need to cause further pain by assessing movement, but neurovascular status should be evaluated, along with any concerns about critical skin, as these will need urgent referral to orthopaedics.
Alfie is unable to tolerate full extension, supination or pronation. He has a strong radial pulse and no obvious neurological deficit. Based on your clinical examination, you prescribe Alfie some more analgesia and request AP and lateral X-rays.When Alfie returns to the department and you review his X-rays:
You recognise that the anterior humeral line does not dissect the middle third of the capitellum as seen on the lateral view and you spot the fracture that is visible on the AP view. You discuss with Ortho, arrange for him to have an above elbow backslab, and re x-ray. Ortho are happy with conservative management and they book a fracture clinic follow-up. At 6-week review he is out of plaster, pain free and has normal movement of his elbow. He is able to climb back onto the sofa for another bounce.
Davies FCW, Bruce CE and Taylor-Robinson K. Emergency are of minor trauma in children. 2011. London: Hodder & Stoughton
Thank you for making this scenario so easy and filled with fun ways to recall!