Use Of POCUS for the Paediatric Patient with an Undifferentiated Upper Limb Injury.

A 2-year-old girl presented to the Paediatric Emergency Department following an unwitnessed injury to her left arm while playing at nursery limiting further examination. On assessment she was reluctant to use her left arm and further examination was difficult. In cases of unwitnessed and undifferentiated elbow injuries point of care ultrasound (POCUS) can be used to evaluate for elbow joint effusion, fracture, or radial head subluxation, also known as nursemaid's elbow. Pulled elbow is a commonly encountered paediatric injury but based on the history and examination findings it may not always be obvious. We present an approach to the child with an undifferentiated elbow injury incorporating POCUS as a means of increasing the reliability of findings on clinical examination.

Role of the supinator muscle in the pathophysiological mechanism of a pulled elbow.

A pulled elbow is a common childhood orthopaedic injury that is usually caused by longitudinal traction on the hand. The pathophysiological mechanism of a pulled elbow involves interposition of the annular ligament into the radiohumeral joint. Recent ultrasonographic studies have shown that both the supinator muscle and annular ligament were trapped into the radiohumeral joint. This paper discusses why pulled elbows can occur during pronation and how a pulled elbow can be reduced either by hyperpronation or supination followed by elbow flexion based on the function of the supinator muscle.

Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow.

INTRODUCTION: Pulled elbow (PE) is one of the most common injury in children under the age of five years. Diagnosis of PE is usually based on the typical anamnesis and clinical symptoms. A simple reduction maneuver without the need of any imaging modality can eliminate the problem. Certain fractures however can mimic the physical findings of PE and in this cases reduction should not be attempted. The aim of our prospective diagnostic study was to evaluate the accuracy of a sonographic testing method in the differential diagnosis of PE. METHODS: 205 children aged 0-5 with clinical suspicion for PE were enrolled in our study. Inclusion criteria were the typical clinical sign of PE: painful, motionless, extended or slightly flexed and pronated arm following a traumatic event under the age of five. We excluded older children and patients with pronounced elbow swelling and initially flexed and supinated upper arm position. A two plane point of care sonographic examination was carried out at each patient immediately after history taking and primary physical survey. Presence of the elevated dorsal sonographic fat pad sign(FPS) and the synovial fringe enlargement (SFE) were examined from dorsal and ventral longitudinal planes. Children with FPS positivity and/or unsuccessful reduction were x-rayed. Suspected occult fractures with persistent complains were also x-rayed on the 3rd week. Sonographic pictures and x-rays were analyzed and compared to clinical findings. RESULTS: The diagnosis of PE was confirmed in 196 cases. (95.6%). 9 children had type I. supracondylar humerus fractures. (4.39%) Out of these 2 proved to be occult fractures.(0.97%). SFE positivity was detected only in the PE group (156 cases, 76%) fractures have not shown this sign. Elevated FPS was negative in all but one PE cases, while all fractures showed FPS positivity without exception. Evaluating the two parameters together both sensitivity, specificity, negative and positive predictive value were 100%. CONCLUSIONS: The two plane sonographic point of care method is an effective tool for confirming the diagnosis of PE and excluding the presence of fractures. It is an easy, standard and objective procedure which can be used as a fast diagnostic test before reduction attempts.

Fifteen-minute consultation: Assessing the child with an elbow injury.

This article aims to provide a concise summary of the key considerations when assessing a child with an elbow injury. Elbow injuries are common with acute elbow trauma, accounting for 2%-3% of all visits to the emergency department. This article will cover history, examination and key X-ray findings, along with a brief guide to management. It is hoped this article will help healthcare professionals who assess children with elbow injuries. Our work is applicable to those both in the hospital and community setting.

The usefulness of ultrasound and the posterior fat pad sign in pulled elbow.

INTRODUCTION: A pulled elbow is a common cause of acute elbow pain that is generally managed by a reduction maneuver without radiographic examination. However, children with atypical presentation with no history of abrupt longitudinal traction should undergo elbow imaging. This study aimed to investigate plain radiography findings and determine the usefulness of ultrasonography (US) in atypical pulled elbow. MATERIALS AND METHODS: We retrospectively reviewed the medical records and images of 37 (22 males) consecutive patients with pulled elbow who presented with an atypical history or failed reduction between April 2015 and September 2018. Mean age at presentation was 4.34 years (range, 1.25-9.5 years). Of the 37 elbows, 20 were left elbows. The injury mechanism, incidence of the posterior fat pad sign on plain radiographs, and characteristic US findings, pre- and post- reduction, were investigated. RESULTS: The original mechanisms of injury included slipping (n = 14), rolling over the arm (n = 7), vague history (n = 6), falling down (n = 6), abrupt longitudinal traction (n = 2), and direct injury (n = 2). On plain radiographs, six of the 37 elbows (16%) showed the posterior fat pad sign. Before the reduction, an entrapped supinator, a pathognomonic sign of pulled elbow, was identified on US in all cases. After reduction, the characteristic US findings showed a disentangled and swollen supinator (100%) and restored annular ligament (100%) in all successful cases. Although a click was not felt in three cases, the reductions were considered successful because the annular ligament was restored on US with free elbow motion. CONCLUSION: Pulled elbow may be caused by atypical mechanisms of injury, such as slipping and rolling over the arm. Clinicians should be aware of the possibility of the posterior fat pad sign on plain radiographs of pulled elbow to prevent unnecessary immobilization. In such circumstances, US is a useful method for detecting an entrapped supinator and confirming adequate reduction via restoration of the annular ligament in children with atypical pulled elbow.

Nursemaid's Elbow - Supination-flexion Technique Versus Hyperpronation/forced Pronation: Randomized Clinical Study.

BACKGROUND: Nursemaid's elbow (NE) represents the most common pathology met in the pediatric orthopedics ambulatory. There are two techniques of reducing the NE: the supination-flexion technique and the hyperpronation or forced pronation technique. MATERIALS AND METHODS: In this randomized clinical study, we aim to compare the two reduction techniques of the NE, by measuring the effectiveness of each and scaling the pain felt by the child, by using the Faces Pain Scale. The study included 116 patients with typical presentation for NE with age under 7 years old (mean age ~3 years old), 45% of males and 55% of females. RESULTS: Hyperpronation was found to be more successful than supination-flexion technique as a first attempt (85% vs. 53%), second attempt (50% vs. 28%), and as a crossover technique (100% vs. 50%) when supination-flexion failed. CONCLUSIONS: This study concludes that hyperpronation technique should be used as a first maneuver reduction in treating NE, a simple one-movement technique.

Parental questionnaire study showed that annular ligament displacement was common in three-year-old children and almost a half had reoccurring episodes.

AIM: This study sought to determine the incidence of annular ligament displacement (ALD), also known as nursemaid's elbow, in the first 3 years of life. METHODS: A questionnaire was sent to 1098 families between August 2014 and July 2015 before their child attended a routine health check at 3 years of age in Izumo, Shimane prefecture, Japan. The questionnaire included a brief description about ALD, the age when ALD occurred and how the condition was managed. RESULTS: We received 784 (71.4%) responses and these showed that 61 (7.8%) children had a history of ALD and 31 (51%) were girls. The incidence was 2.6%, calculated by multiplying the number of children by the 3-year observation period. The mean and median ages of the first ALD occurrence were both 25 months. In addition, 28 (46%) children with ALD had a recurrence and the mean number of ALD episodes was 1.8 (range 1-5). The total number of ALD episodes was 108, and of these, 33 (30%) were seen at the hospital emergency department and 17 (16%) spontaneously resolved. CONCLUSION: This study confirmed that ALD was a common occurrence in 3-year-old children and that there was a high rate of recurrence.

Radial Head Subluxation Among Young Children in the United States Associated With Consumer Products and Recreational Activities.

This study investigated the epidemiology of children treated in US emergency departments for radial head subluxation (RHS) associated with consumer products and recreational activities using data from the National Electronic Injury Surveillance System. An estimated 430 766 (95% confidence interval: 341 194-520 339) children ≤5 years of age were treated for RHS in US emergency departments from 1990 to 2011. The mean patient age was 2.1 years, and 56.5% of patients were girls. The most common mechanism of injury was a fall (43.2%), followed by arm pull (39.4%). The annual rate of RHS increased significantly by 190.1% during the 22-year study period. This is the largest study of RHS to date and the first to use a nationally representative sample to investigate secular trends and mechanisms of injury for RHS associated with consumer products and recreational activities. Events associated with consumer products and recreational activities are an important increasing source of RHS.

Investigation on 2331 cases of pulled elbow over the last 10 years.

Pulled elbow is a common upper extremity injury in children. We present a retrospective study of 2331 pulled elbow cases examined in our hospital over the last ten years. All pediatric patients with a diagnosis of pulled elbow from January 2002 to December 2011 were retrospectively reviewed according to sex, age, affected arm, recurrence rate, mechanism of injury and treatment outcomes. There is no significant sex difference. The frequency of injury peaked for both boys and girls at 6 months and 2 years of age. The left arm was more affected than the right. The recurrence rate was 14%. In about 50% of cases, the cause of injury was forcible traction to the forearm. Almost all of the splinted patients, caused by severe pain or lack of mobility of the affected limb following reduction, recovered within 2 weeks, but 2 were later diagnosed with a fracture. For infants less than 1 year old, injury can often occur when rolling over. For children 1 year old or older the left arm is more commonly affected, and the frequency of injuries to the left arm increases with age, possibly because the left hand is commonly held by the guardian's dominant right hand and faster development of muscle strength in the child's dominant right arm works toward preventing injury to that arm with age.

Obscure pathology of pulled elbow: dynamic high-resolution ultrasound-assisted classification.

AIM: Pulled elbow or nursemaid's elbow is a radial head subluxation caused by a sudden pull on the extended pronated forearm. Children with pulled elbow usually respond dramatically for reduction, yet others show delayed improvement with no clear pathologic explanation. The aim of our study is to propose an explanation for the varying clinical response after the reduction of pulled elbow aided by ultrasound classification of the underlying pathology and its impact on management. PATIENTS AND METHODS: Fifty children with a mean age of 3.8 ± 1.1 (standard deviation [SD]) years with pulled elbow were scanned by static and dynamic ultrasound utilizing the other elbow as the standard. The radial annular ligament (RAL) was examined for integrity and interposition, with measurement of the radiocapitellar distance. Reduction was performed following the hyperpronation technique, and postreduction splinting was guided by ultrasound findings. Postreduction scans and 1-year follow up were performed. RESULTS: Of the 50 included children, 39 (78%) had intact, yet interposed annular ligament (classified as type I) and 11 (22%) had torn annular ligament (classified as type II). The latter underwent splinting for 7 days. Three out of the 50 children had recurrent subluxation and constituted false-negative cases for the detection of torn ligament and represented the reoccurrence rate of 6%. The sensitivity, specificity, and accuracy for the ultrasound diagnosis of torn RAL were 76.9, 92.3, and 92%, respectively. CONCLUSION: PULLED ELBOW IS CLASSIFIED AS FOLLOWS: type I, with an interposed RAL, and type II, with torn ligament.