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.
Annie is a 2 year old who has a painful arm. Her mum was holding her hand as she walked along the pavement. Annie tripped and Annie’s mum tried to stop the fall. Since then she hasn’t been using the arm as much.
Thanks to Simon Craig for his post-publication contribution.
The medial and lateral collateral ligaments each hold the humerus and ulna together (one on either side).
The annular ligament hold the radius and ulna together.
In a pulled elbow, the annular ligament slips of the head of the radius and can get trapped in between the radius and humerus. This causes restriction of movement and pain on pronation and supination.
The mechanism is usually from a pull of the arm e.g. when the child fall down while holding the parent’s hand and the parent tries to stop them falling by pulling the arm.
The child most commonly presents as not using their arm and on assessment has the arm hanging limply by their side. When asked, they may point to distal radius as the point of pain, which can lead us to suspect a buckle fracture. There will be pain on pronation and supination.
And as Simon Craig nicely illustrated – the Yin and Yang of pulled elbows:
Sevencan et al (2015) looked at 66 patients presenting with pulled elbows. 57 were successfully reduced on first attempt. A first attempt successful reduction was more likely in patients presenting within 2 hours of the injury. After two year follow up 24% had recurrence (but they will eventually grow out of it).
After a successful reduction, the child should be using the arm normally within 10-15 minutes. If the reduction fails on the first attempt, then try again using the other technique. If the child is still not using the arm, then get an x-ray.
Sometimes you feel like the reduction was successful (you may have felt a click) but the child is not using the arm normally. This may be because the annular ligament was torn when the elbow was pulled and it may take time to heal. In these cases, put the child in a broad arm sling and review them again in a few days.
Annie’s pulled elbow was successfully reduced on the first attempt using the hyper-pronation technique. Five minutes later she was using her arm normally. She was discharged from ED.
With millions upon millions of journal articles being published every year, it is impossible to keep up. Every month we ask some of our friends from the world of paediatrics to point out something that has caught their eye.