Original article 385
Pulled elbow in children: a case series including 66 patients Adnan Sevencana, Ümit Aygünb, Ulukan İnana and Hakan Ömeroğlua The aim of this case series was to assess the data of 66 children (mean age 28 months) with a diagnosis of pulled elbow. The most common time interval of injury was 12–6 p. m. and spring was the peak season. Children younger than 2 years of age had a higher rate of atypical injury history. A successful reduction by supination and flexion maneuver was achieved at the first attempt in 57 of 66 patients. The patients admitted to the hospital within the first 2 h following the injury had a higher rate of successful reduction at the first attempt. The rate of radiographic examination was considerably high and a well-defined algorithm to avoid the complicacy in ordering a plain radiograph in such cases was suggested. All patients
Introduction Subluxation of the radial head in younger children is also called ‘pulled elbow’ or ‘nursemaid’s elbow’. It is one of the most common pediatric musculoskeletal injuries referred to the pediatric emergency department between 1 and 4 years of age. The mechanism of injury is a sudden pull or axial traction to the upper limb while the forearm is pronated. This is commonly followed by a variable elbow or wrist pain and limitation of forearm supination. The child refuses to use the affected upper limb while the elbow is held slightly flexed and the forearm is fixed in pronation. It is a diagnosis of exclusion and the diagnosis can usually be made from the assessment of history and clinical examination. The reduction is easy and no long-term sequelae have been reported [1–3]. The aim of this case series was to assess the epidemiology including age, sex, laterality, time, and mechanism of injury, associated injuries, as well as results of the outpatient management process including time of admission to hospital after injury, need for plain radiography for diagnosis, waiting time for the reduction at the emergency department, success rate of initial and subsequent reduction attempts, and the rate of short-term complications including recurrence and limitation of motion in younger children with a diagnosis of pulled elbow.
Patients and methods The design and content of the study were initially approved by the Institutional Ethical Committee. Among 1103 consecutive children (age range from 2 months to 15 years and 11 months) who were referred to our This study was presented as a free paper at the 19th Congress of the Federation of European Societies for Surgery of the Hand in Paris, France, 18–21 June 2014, and as a poster at the 23rd National Turkish Congress of Orthopaedics and Traumatology, Antalya, Turkey, 29 October–3 November 2013. 1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
achieved full clinical recovery after a mean follow-up of 2 years, and recurrence was observed in 16 of 66 children. J Pediatr Orthop B 24:385–388 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Journal of Pediatric Orthopaedics B 2015, 24:385–388 Keywords: children, pulled elbow, radial head, subluxation a Department of Orthopaedics and Traumatology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir and bİzzet Baysal State Hospital, Clinics of Orthopaedics and Traumatology, Bolu, Turkey
Correspondence to Hakan Ömeroğlu, MD, Department of Orthopaedics and Traumatology, Faculty of Medicine, Eskişehir Osmangazi University, 26480 Eskişehir, Turkey Tel: + 90 2222397691; e-mail: [email protected]; [email protected]
department because of skeletal injury, either fracture or dislocation, and were treated by either conservative or surgical methods within a 3-year period, 71 had the diagnosis of ‘pulled elbow’. Seventy-one children were invited for follow-up examination at a certain time period. Among 71 children, five were immediately lost to follow-up after the initial treatment, did not come back for re-examination, and were therefore excluded from the study. Thus, 33 girls and 33 boys, a total of 66 children whose mean age was 28 ± 17 (5–84) months at the time of hospital admission and whose final appointed examination was performed, constituted the study group. The left side was affected in 42 children and the right side was affected in 24 children. The medical records of these children were reviewed to assess the epidemiologic features (injury time and mechanism, age, sex, laterality) affecting the occurrence of pulled elbow and the variables affecting the outpatient treatment process and the development of resubluxation. The typical injury was defined as an accidental and sudden pull of the pronated upper limb while the child was playing, walking, or running. The atypical injury was defined as fall inside or outside without having a typical traction history or an unclear event. The diagnosis was primarily made by clinical examination, but radiographic examination of the elbow joint was performed to avoid missing an additional elbow injury in case of any doubt in the history and/or clinical examination. Supination, followed by flexion was the preferred reduction maneuver in all children. If the first reduction attempt failed, a second reduction maneuver was performed within 15 min following the initial attempt. A postreduction immobilization was not applied in any of the children. At the latest follow-up, the history of resubluxation and the existence/absence of pain and limitation of motion DOI: 10.1097/BPB.0000000000000182
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
386
Journal of Pediatric Orthopaedics B 2015, Vol 24 No 5
around the elbow joint in the daily life of children were determined from the parents, and the range of motion of the humeroulnar and proximal radioulnar joints was examined. The χ2 and Fisher’s exact tests were used to compare the categorical data between independent groups. A P value less than 0.05 was considered significant.
Results Most of the injuries occurred between the hours of 1200 and 1800 h (Table 1). About one-third of the injuries occurred in April and May, and spring was the peak season for pulled elbow injury (Table 1). Injury time did not correlate with sex and age, but the rate of right-side injury was somewhat higher between the hours of 1200 and 1800 h (Table 2). The mechanism of injury, on the basis of the history obtained from the parents, siblings, or other accompanying adults, was typical in 40 children and atypical in 26 children. Younger age group had a statistically significantly higher rate of atypical injury mechanism than the older age group (Table 2). The mechanism of injury did not correlate with sex and laterality (Table 2). No associated injuries were observed in any of the children. The time of admission to the pediatric emergency department after injury was 0–2 h in 50 children and more than 2 h in 16. The radiographic examination was performed in 38 of 66 children. Among 16 children admitted to the emergency department later than 2 h, 12 underwent a radiographic examination. No evidence of fat pad sign, an indication of intra-articular injury, was observed in any of the 38 children who underwent a radiographic examination. There was no statistically significant correlation between the need for a radiographic examination and sex, age, laterality, injury time, injury mechanism, and time from injury to admission to hospital (P > 0.05). The waiting time from the hospital admission to the first attempt for reduction by a staff from the Orthopaedics Department was less than 30 min in 58 children, between 30 and 60 min in seven children, and 2 h in one child. A successful reduction by supination and flexion maneuver was performed by a staff from the Orthopaedics Table 1
Injury occurrence hours and months of 66 children
0000–0600 h 0600–1200 h 1200–1800 h 1800–2400 h
1 5 38 22
January February March April May June July August September October November December
3 2 7 10 11 7 0 4 4 7 5 6
Correlation between injury time, mechanism and sex, age, and laterality
Table 2
Sex Variables
Age group (years)
Side
Girls
Boys
0–2
2–7
20 12 1
18 10 5
20 10 2
18 12 4
18 20 4 18 2 4 0.076
21 13
13 26 11 16 0.539
9 25
12 14 12 28 0.183
Injury (h) 1200–1800 h 1800–0000 h 0000–1200 h P value Injury season Spring–summer Autumn–winter P value Injury mechanism Atypical Typical P value
0.228 19 14
0.640 20 13
18 14
0.802 13 20
0.649 13 20
17 15
1.000
0.027*
Right
Left
Used test: χ -test. *Significant difference. 2
Department in all cases. This could be achieved at the first attempt in 57 of 66 patients and at the second attempt in the remaining nine patients. There was a significant correlation between the occurrence of successful reduction at the first attempt and the time from injury to hospital admission. The patients admitted to the hospital within the first 2 h following the injury had a statistically significant higher rate of successful reduction at the first attempt (Table 3). No other variable affected
Table 3 Correlation between successful reduction at the first attempt and several factors Successful reduction at the first attempt Variables
Yes
Sex Girls 30 Boys 27 P value Age group (years) 0–2 27 2–7 30 P value Side Right 21 Left 36 P value Injury mechanism Atypical 22 Typical 35 P value Injury (h) 1200–1800 h 32 1800–2400 h 20 0000–1200 h 5 P value Injury season Spring–summer 34 Autumn–winter 23 P value Time from injury to hospital admission (h) 0–2 46 >2 11 P value Used test: Fischer’s exact test. *Significant difference.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
No 3 6 0.475 5 4 0.730 3 6 1.000 4 5 0.730 6 2 1 0.747 5 4 1.000 4 5 0.032*
Pulled elbow in children Sevencan et al. 387
the rate of successful reduction at the first attempt (Table 3). Complete clinical recovery, which was defined as immediate pain relief and free elbow flexion/extension and forearm pronation/supination within a couple of minutes after successful reduction, was observed in 64 of 66 children, whereas the other two children with a history of delayed admission to the hospital (about 24 h following injury) took more than 1 h for complete clinical recovery. All children were treated as outpatients. After a mean follow-up of 24 ± 8 (7–41) months, clinical examination of the elbows of all children was completely normal. Sixteen children had a history of at least one radial head subluxation before the hospital referral or recurrence during follow-up. Recurrent subluxation did not correlate with sex and laterality (Table 4).
Discussion Pulled elbow is known to be one of the most common skeletal injuries in children [1]. The incidence rate in children between 5 and 66 months of age was found to be 1.2% in an epidemiologic study [4]. In the present study, among the skeletally injured children (0–16 years of age) who were admitted to the pediatric emergency department within a 3-year period, 6.4% had a diagnosis of pulled elbow. This considerably higher rate of occurrence has led authors to assess the epidemiological and therapeutic features of this injury in detail. The authors believe that the exact occurrence rate can be higher than the observed one as the reduction of radial head subluxation can accidentally or intentionally be performed by parents, siblings, and other people before the children are taken in an emergency department. In the present study, the most common time interval for the injury was between 1200 and 1800 h, when about 60% of the injuries occurred. This injury rarely occurred at late night and early in the morning. Besides, nearly half of the injuries occurred in the spring season. The authors believe that younger children have the highest level of activity especially between feeding intervals in the afternoon and in a warmer climate following the winter season and this may explain why children are more Table 4
Correlation between the history of recurrence and sex and
laterality History of recurrence Variables Sex Girls Boys P value Side Right Left P value
Yes
No
8 8
25 25 1.000
7 9
17 33 0.480
Used test: χ -test. 2
vulnerable to injury like pulled elbow during the mentioned time intervals. The most common causes of pulled elbow are a sudden pull of the pronated and extended upper limb by someone else while playing, walking, or running as well as continuing to hold onto a fixed object to prevent fall while playing or grabbing [5–8]. The occurrence rate of this typical history in affected children ranges from 67 to 92% in different studies [8–11]. The results of the present study showed that the history of an atypical injury mechanism was present in about 40% of the cases, and it was more common in children younger than 2 years of age and in the right upper limb. The authors believe that the presence of an atypical history, especially in children younger than 2 years of age, is mainly because of parents’, siblings’, or nursemaids’ reluctance to state that they have somehow harmed the child or to avoid a possible legal liability, even though the typical pulling or traction injury occurs accidentally. Child abuse should also be kept in mind, particularly in children younger than 2 years of age. It has been stated that the occurrence rate of pulled elbow is higher in girls than in boys and the left side is more commonly affected than the right side [5–8,10,12 –16]. In the present study, in contrast to the previous studies, girls and boys had equal distribution and this can be a result of geographical variation. A considerable predominance of left-side injury in the present study as in the previous studies may primarily be because of the habit of walking or playing of the parent, sibling, or nursemaid with the child. During these activities with children, the adult’s dominant right hand is commonly used to hold the child’s left upper limb. However, the rate of right-side injury was somewhat higher than leftside injury especially between 1200 and 1800 h The authors suggest that the right side may be more vulnerable to injury during feeding time because during feeding, the individual feeding the child commonly uses her/ his right hand to feed and the free left hand to calm the child’s dominant hand, which is usually the right one. About 75% of the patients were admitted to the emergency department within 2 h following the injury and an orthopedic intervention for reduction was performed within 1 h following hospital admission in about 98% of the patients. Such an acceptable waiting time can increase the parents’ satisfaction level at the emergency department and the waiting time for reduction in the present study is comparable with a previous study reporting a 1.3 h mean waiting time at the triage [10]. Although radiographic examination is usually considered normal and there are no universally accepted quantitative radiographic findings in pulled elbow, a radiographic examination can be a valuable tool to rule out other possible injuries [1–3]. The rate of radiographic examination was considerably high in this case series. We have
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
388
Journal of Pediatric Orthopaedics B 2015, Vol 24 No 5
been performing radiographic examination in case of any doubt in the history or clinical examination. However, the presence of a doubtful history or a suspicious clinical examination can be considered a subjective concept. Numerous and various staff performed an assessment of history and the clinical examination of the patients in the present study. The authors believe that this significant variability in the approach between examiners may be an explanation for excessive radiographic examination, although some previously defined variables in terms of the history or clinical examination might be within the normal limits in some of the cases. The results of the present study also showed that a radiographic examination was performed in about 75% of the patients, with a delay in the hospital admission for more than 2 h. A possible more striking clinical picture could be the main reason for the increase in the need for a radiographic examination in delayed cases. The authors suggest that the indication for a radiographic examination in a child with a probable diagnosis of pulled elbow should be restricted in case of an atypical history as well as a suspected more severe injury around the elbow joint. Therefore, an algorithm to perform a radiographic examination in pulled elbow should be well defined and applied in the pediatric emergency departments. A controversy still exists in terms of the best reduction maneuver in pulled elbow. Supination of the forearm, followed by the flexion of the elbow has been reported to be the more preferred technique in the classical textbooks [2,3]. However, the hyperpronation maneuver has also yielded promising results in some of the studies. [12, 15]. It is not possible for us to compare the success rate of reduction at the first attempt of these two techniques as we have only been using the supination–flexion maneuver for many years, and the rate of successful reduction at the first and the second attempts using this maneuver was found to be 86 and 100%, respectively. The results of the present study showed that neglected cases had lower success rates of first reduction attempt and such cases might also have the risk of delayed clinical relief. The probable increase in pain accompanied by an upper limb muscle contracture with time in such delayed cases may have an unfavorable effect on the success rate of first reduction. The recurrence rate of pulled elbow was reported to be 5 and 20% in two different studies [6,16]. The recurrence rate in the present case series was 24% and it was not correlated with sex and laterality. As we did not have more detailed data on the other possible factors
influencing the development of recurrence, the comments on the recurrence are limited. In conclusion, pulled elbow usually occurs in the afternoon, especially in the spring. Nearly half of the cases are younger than 2 years of age and the left side is at greater risk. An atypical injury history is more common in children younger than 2 years of age. All cases can be reduced following a maximum of two attempts by the supination–flexion maneuver. However, a delay from injury to hospital admission can have an unfavorable effect on the success rate of reduction at the first attempt. A higher rate of unnecessary radiographic examinations still exists and should be avoided by obtaining a welldefined algorithm in the pediatric emergency departments. There is no major risk factor affecting the recurrence rate.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2
3
4
5 6 7 8 9 10
11 12
13
14 15
16
Herring JA. Tachdjian’s pediatric orthopaedics, 4th ed. Philadelphia: Saunders Elsevier; 2008. Pring M, Wenger DR, Rang M. Elbow-proximal radius and ulna. In: Wenger DR, Pring ME, editors. Rang’s children’s fractures, 3rd ed. Philadelphia: Lippincott Williams &Wilkins; 2005. pp. 119–134. Skaggs DL, Frick S. Upper extremity fractures in children. In: Weinstein SL, Flynn JM, editors. Lovell and Winter’s pediatric orthopaedics, 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. pp. 1694–1772. Jongschaap HC, Youngson GG, Beattie TF. The epidemiology of radial head subluxation (‘pulled elbow’) in the Aberdeen city area. Health Bull (Edinb) 1990; 48:58–61. Broadhurst BW, Buhr AJ. The pulled elbow. BMJ 1959; 1:1018–1019. Illingworth CM. Pulled elbow: a study of 100 patients. BMJ 1975; 2:672–674. Hardy RH. Pulled elbow. J R Coll Gen Pract 1978; 28:224–226. Sankar NS. Pulled elbow. J R Soc Med 1999; 92:462–464. Sacchetti A, Ramoska EE, Glascow C. Nonclassic history in children with radial head subluxations. J Emerg Med 1990; 8:151–153. Toupin P, Osmond MH, Correll R, Plint A. Radial head subluxation: how long do children wait in the emergency department before reduction? CJEM 2007; 9:333–337. Walsh S, Kidner N. Pulled elbow. J R Soc Med 2000; 93:336–337. Bek D, Yildiz C, Köse O, Sehirlioğlu A, Başbozkurt M. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial. Eur J Emerg Med 2009; 16:135–138. Diab HS, Hamed MM, Allam Y. Obscure pathology of pulled elbow: dynamic high-resolution ultrasound-assisted classification. J Child Orthop 2010; 4:539–543. Dohi D. Confirmed specific ultrasonographic findings of pulled elbow. J Pediatr Orthop 2013; 33:829–831. García-Mata S, Hidalgo-Ovejero A. Efficacy of reduction maneuvers for ‘pulled elbow’ in children: a prospective study of 115 cases. J Pediatr Orthop 2014; 34:432–436. Snellman O. Subluxation of the head of the radius in children. Acta Orthop Scand 1959; 28:311–315.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Pulled elbow in children: a case series including 66 patients Adnan Sevencana, Ümit Aygünb, Ulukan İnana and Hakan Ömeroğlua The aim of this case series was to assess the data of 66 children (mean age 28 months) with a diagnosis of pulled elbow. The most common time interval of injury was 12–6 p. m. and spring was the peak season. Children younger than 2 years of age had a higher rate of atypical injury history. A successful reduction by supination and flexion maneuver was achieved at the first attempt in 57 of 66 patients. The patients admitted to the hospital within the first 2 h following the injury had a higher rate of successful reduction at the first attempt. The rate of radiographic examination was considerably high and a well-defined algorithm to avoid the complicacy in ordering a plain radiograph in such cases was suggested. All patients
Introduction Subluxation of the radial head in younger children is also called ‘pulled elbow’ or ‘nursemaid’s elbow’. It is one of the most common pediatric musculoskeletal injuries referred to the pediatric emergency department between 1 and 4 years of age. The mechanism of injury is a sudden pull or axial traction to the upper limb while the forearm is pronated. This is commonly followed by a variable elbow or wrist pain and limitation of forearm supination. The child refuses to use the affected upper limb while the elbow is held slightly flexed and the forearm is fixed in pronation. It is a diagnosis of exclusion and the diagnosis can usually be made from the assessment of history and clinical examination. The reduction is easy and no long-term sequelae have been reported [1–3]. The aim of this case series was to assess the epidemiology including age, sex, laterality, time, and mechanism of injury, associated injuries, as well as results of the outpatient management process including time of admission to hospital after injury, need for plain radiography for diagnosis, waiting time for the reduction at the emergency department, success rate of initial and subsequent reduction attempts, and the rate of short-term complications including recurrence and limitation of motion in younger children with a diagnosis of pulled elbow.
Patients and methods The design and content of the study were initially approved by the Institutional Ethical Committee. Among 1103 consecutive children (age range from 2 months to 15 years and 11 months) who were referred to our This study was presented as a free paper at the 19th Congress of the Federation of European Societies for Surgery of the Hand in Paris, France, 18–21 June 2014, and as a poster at the 23rd National Turkish Congress of Orthopaedics and Traumatology, Antalya, Turkey, 29 October–3 November 2013. 1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
achieved full clinical recovery after a mean follow-up of 2 years, and recurrence was observed in 16 of 66 children. J Pediatr Orthop B 24:385–388 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Journal of Pediatric Orthopaedics B 2015, 24:385–388 Keywords: children, pulled elbow, radial head, subluxation a Department of Orthopaedics and Traumatology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir and bİzzet Baysal State Hospital, Clinics of Orthopaedics and Traumatology, Bolu, Turkey
Correspondence to Hakan Ömeroğlu, MD, Department of Orthopaedics and Traumatology, Faculty of Medicine, Eskişehir Osmangazi University, 26480 Eskişehir, Turkey Tel: + 90 2222397691; e-mail: [email protected]; [email protected]
department because of skeletal injury, either fracture or dislocation, and were treated by either conservative or surgical methods within a 3-year period, 71 had the diagnosis of ‘pulled elbow’. Seventy-one children were invited for follow-up examination at a certain time period. Among 71 children, five were immediately lost to follow-up after the initial treatment, did not come back for re-examination, and were therefore excluded from the study. Thus, 33 girls and 33 boys, a total of 66 children whose mean age was 28 ± 17 (5–84) months at the time of hospital admission and whose final appointed examination was performed, constituted the study group. The left side was affected in 42 children and the right side was affected in 24 children. The medical records of these children were reviewed to assess the epidemiologic features (injury time and mechanism, age, sex, laterality) affecting the occurrence of pulled elbow and the variables affecting the outpatient treatment process and the development of resubluxation. The typical injury was defined as an accidental and sudden pull of the pronated upper limb while the child was playing, walking, or running. The atypical injury was defined as fall inside or outside without having a typical traction history or an unclear event. The diagnosis was primarily made by clinical examination, but radiographic examination of the elbow joint was performed to avoid missing an additional elbow injury in case of any doubt in the history and/or clinical examination. Supination, followed by flexion was the preferred reduction maneuver in all children. If the first reduction attempt failed, a second reduction maneuver was performed within 15 min following the initial attempt. A postreduction immobilization was not applied in any of the children. At the latest follow-up, the history of resubluxation and the existence/absence of pain and limitation of motion DOI: 10.1097/BPB.0000000000000182
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
386
Journal of Pediatric Orthopaedics B 2015, Vol 24 No 5
around the elbow joint in the daily life of children were determined from the parents, and the range of motion of the humeroulnar and proximal radioulnar joints was examined. The χ2 and Fisher’s exact tests were used to compare the categorical data between independent groups. A P value less than 0.05 was considered significant.
Results Most of the injuries occurred between the hours of 1200 and 1800 h (Table 1). About one-third of the injuries occurred in April and May, and spring was the peak season for pulled elbow injury (Table 1). Injury time did not correlate with sex and age, but the rate of right-side injury was somewhat higher between the hours of 1200 and 1800 h (Table 2). The mechanism of injury, on the basis of the history obtained from the parents, siblings, or other accompanying adults, was typical in 40 children and atypical in 26 children. Younger age group had a statistically significantly higher rate of atypical injury mechanism than the older age group (Table 2). The mechanism of injury did not correlate with sex and laterality (Table 2). No associated injuries were observed in any of the children. The time of admission to the pediatric emergency department after injury was 0–2 h in 50 children and more than 2 h in 16. The radiographic examination was performed in 38 of 66 children. Among 16 children admitted to the emergency department later than 2 h, 12 underwent a radiographic examination. No evidence of fat pad sign, an indication of intra-articular injury, was observed in any of the 38 children who underwent a radiographic examination. There was no statistically significant correlation between the need for a radiographic examination and sex, age, laterality, injury time, injury mechanism, and time from injury to admission to hospital (P > 0.05). The waiting time from the hospital admission to the first attempt for reduction by a staff from the Orthopaedics Department was less than 30 min in 58 children, between 30 and 60 min in seven children, and 2 h in one child. A successful reduction by supination and flexion maneuver was performed by a staff from the Orthopaedics Table 1
Injury occurrence hours and months of 66 children
0000–0600 h 0600–1200 h 1200–1800 h 1800–2400 h
1 5 38 22
January February March April May June July August September October November December
3 2 7 10 11 7 0 4 4 7 5 6
Correlation between injury time, mechanism and sex, age, and laterality
Table 2
Sex Variables
Age group (years)
Side
Girls
Boys
0–2
2–7
20 12 1
18 10 5
20 10 2
18 12 4
18 20 4 18 2 4 0.076
21 13
13 26 11 16 0.539
9 25
12 14 12 28 0.183
Injury (h) 1200–1800 h 1800–0000 h 0000–1200 h P value Injury season Spring–summer Autumn–winter P value Injury mechanism Atypical Typical P value
0.228 19 14
0.640 20 13
18 14
0.802 13 20
0.649 13 20
17 15
1.000
0.027*
Right
Left
Used test: χ -test. *Significant difference. 2
Department in all cases. This could be achieved at the first attempt in 57 of 66 patients and at the second attempt in the remaining nine patients. There was a significant correlation between the occurrence of successful reduction at the first attempt and the time from injury to hospital admission. The patients admitted to the hospital within the first 2 h following the injury had a statistically significant higher rate of successful reduction at the first attempt (Table 3). No other variable affected
Table 3 Correlation between successful reduction at the first attempt and several factors Successful reduction at the first attempt Variables
Yes
Sex Girls 30 Boys 27 P value Age group (years) 0–2 27 2–7 30 P value Side Right 21 Left 36 P value Injury mechanism Atypical 22 Typical 35 P value Injury (h) 1200–1800 h 32 1800–2400 h 20 0000–1200 h 5 P value Injury season Spring–summer 34 Autumn–winter 23 P value Time from injury to hospital admission (h) 0–2 46 >2 11 P value Used test: Fischer’s exact test. *Significant difference.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
No 3 6 0.475 5 4 0.730 3 6 1.000 4 5 0.730 6 2 1 0.747 5 4 1.000 4 5 0.032*
Pulled elbow in children Sevencan et al. 387
the rate of successful reduction at the first attempt (Table 3). Complete clinical recovery, which was defined as immediate pain relief and free elbow flexion/extension and forearm pronation/supination within a couple of minutes after successful reduction, was observed in 64 of 66 children, whereas the other two children with a history of delayed admission to the hospital (about 24 h following injury) took more than 1 h for complete clinical recovery. All children were treated as outpatients. After a mean follow-up of 24 ± 8 (7–41) months, clinical examination of the elbows of all children was completely normal. Sixteen children had a history of at least one radial head subluxation before the hospital referral or recurrence during follow-up. Recurrent subluxation did not correlate with sex and laterality (Table 4).
Discussion Pulled elbow is known to be one of the most common skeletal injuries in children [1]. The incidence rate in children between 5 and 66 months of age was found to be 1.2% in an epidemiologic study [4]. In the present study, among the skeletally injured children (0–16 years of age) who were admitted to the pediatric emergency department within a 3-year period, 6.4% had a diagnosis of pulled elbow. This considerably higher rate of occurrence has led authors to assess the epidemiological and therapeutic features of this injury in detail. The authors believe that the exact occurrence rate can be higher than the observed one as the reduction of radial head subluxation can accidentally or intentionally be performed by parents, siblings, and other people before the children are taken in an emergency department. In the present study, the most common time interval for the injury was between 1200 and 1800 h, when about 60% of the injuries occurred. This injury rarely occurred at late night and early in the morning. Besides, nearly half of the injuries occurred in the spring season. The authors believe that younger children have the highest level of activity especially between feeding intervals in the afternoon and in a warmer climate following the winter season and this may explain why children are more Table 4
Correlation between the history of recurrence and sex and
laterality History of recurrence Variables Sex Girls Boys P value Side Right Left P value
Yes
No
8 8
25 25 1.000
7 9
17 33 0.480
Used test: χ -test. 2
vulnerable to injury like pulled elbow during the mentioned time intervals. The most common causes of pulled elbow are a sudden pull of the pronated and extended upper limb by someone else while playing, walking, or running as well as continuing to hold onto a fixed object to prevent fall while playing or grabbing [5–8]. The occurrence rate of this typical history in affected children ranges from 67 to 92% in different studies [8–11]. The results of the present study showed that the history of an atypical injury mechanism was present in about 40% of the cases, and it was more common in children younger than 2 years of age and in the right upper limb. The authors believe that the presence of an atypical history, especially in children younger than 2 years of age, is mainly because of parents’, siblings’, or nursemaids’ reluctance to state that they have somehow harmed the child or to avoid a possible legal liability, even though the typical pulling or traction injury occurs accidentally. Child abuse should also be kept in mind, particularly in children younger than 2 years of age. It has been stated that the occurrence rate of pulled elbow is higher in girls than in boys and the left side is more commonly affected than the right side [5–8,10,12 –16]. In the present study, in contrast to the previous studies, girls and boys had equal distribution and this can be a result of geographical variation. A considerable predominance of left-side injury in the present study as in the previous studies may primarily be because of the habit of walking or playing of the parent, sibling, or nursemaid with the child. During these activities with children, the adult’s dominant right hand is commonly used to hold the child’s left upper limb. However, the rate of right-side injury was somewhat higher than leftside injury especially between 1200 and 1800 h The authors suggest that the right side may be more vulnerable to injury during feeding time because during feeding, the individual feeding the child commonly uses her/ his right hand to feed and the free left hand to calm the child’s dominant hand, which is usually the right one. About 75% of the patients were admitted to the emergency department within 2 h following the injury and an orthopedic intervention for reduction was performed within 1 h following hospital admission in about 98% of the patients. Such an acceptable waiting time can increase the parents’ satisfaction level at the emergency department and the waiting time for reduction in the present study is comparable with a previous study reporting a 1.3 h mean waiting time at the triage [10]. Although radiographic examination is usually considered normal and there are no universally accepted quantitative radiographic findings in pulled elbow, a radiographic examination can be a valuable tool to rule out other possible injuries [1–3]. The rate of radiographic examination was considerably high in this case series. We have
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
388
Journal of Pediatric Orthopaedics B 2015, Vol 24 No 5
been performing radiographic examination in case of any doubt in the history or clinical examination. However, the presence of a doubtful history or a suspicious clinical examination can be considered a subjective concept. Numerous and various staff performed an assessment of history and the clinical examination of the patients in the present study. The authors believe that this significant variability in the approach between examiners may be an explanation for excessive radiographic examination, although some previously defined variables in terms of the history or clinical examination might be within the normal limits in some of the cases. The results of the present study also showed that a radiographic examination was performed in about 75% of the patients, with a delay in the hospital admission for more than 2 h. A possible more striking clinical picture could be the main reason for the increase in the need for a radiographic examination in delayed cases. The authors suggest that the indication for a radiographic examination in a child with a probable diagnosis of pulled elbow should be restricted in case of an atypical history as well as a suspected more severe injury around the elbow joint. Therefore, an algorithm to perform a radiographic examination in pulled elbow should be well defined and applied in the pediatric emergency departments. A controversy still exists in terms of the best reduction maneuver in pulled elbow. Supination of the forearm, followed by the flexion of the elbow has been reported to be the more preferred technique in the classical textbooks [2,3]. However, the hyperpronation maneuver has also yielded promising results in some of the studies. [12, 15]. It is not possible for us to compare the success rate of reduction at the first attempt of these two techniques as we have only been using the supination–flexion maneuver for many years, and the rate of successful reduction at the first and the second attempts using this maneuver was found to be 86 and 100%, respectively. The results of the present study showed that neglected cases had lower success rates of first reduction attempt and such cases might also have the risk of delayed clinical relief. The probable increase in pain accompanied by an upper limb muscle contracture with time in such delayed cases may have an unfavorable effect on the success rate of first reduction. The recurrence rate of pulled elbow was reported to be 5 and 20% in two different studies [6,16]. The recurrence rate in the present case series was 24% and it was not correlated with sex and laterality. As we did not have more detailed data on the other possible factors
influencing the development of recurrence, the comments on the recurrence are limited. In conclusion, pulled elbow usually occurs in the afternoon, especially in the spring. Nearly half of the cases are younger than 2 years of age and the left side is at greater risk. An atypical injury history is more common in children younger than 2 years of age. All cases can be reduced following a maximum of two attempts by the supination–flexion maneuver. However, a delay from injury to hospital admission can have an unfavorable effect on the success rate of reduction at the first attempt. A higher rate of unnecessary radiographic examinations still exists and should be avoided by obtaining a welldefined algorithm in the pediatric emergency departments. There is no major risk factor affecting the recurrence rate.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
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