Case 1
A 2-year-old girl presented to the ED with arm pain. Her mother stated that her daughter was playing with a 5-year-old sibling when she heard the child cry- out in pain and noticed she was holding her right arm by her side, not wanting to move it. Neither child gave a reliable story of the injury.
Nursemaid’s Elbow
Nursemaid’s elbow, also known as pulled elbow, subluxation of the radial head, and most recently annular ligament displacement, is a common injury in children younger than age 6 years. One study estimates that the condition represented about 1% of injury-related ED visits in 2005.1
Patients with nursemaid’s elbow typically present holding the injured arm at their side, slightly flexed and pronated. These patients appear relatively comfortable until moved actively or passively. The classic history of nursemaid’s elbow includes a traction mechanism, with the child being pulled up by one arm or being grabbed by the arm suddenly to keep him or her out of harm’s way.2 Due to the laxity of connective tissues in children of this age, the head of the radius slips out of the annular ligament causing acute pain and decreased function.
Nursemaid’s elbow is usually diagnosed by history and examination alone, with special consideration to the mechanism of injury. There is rarely swelling or bruising.3 Passive flexion and extension at the elbow may be normal, but rotational maneuvers can be painful or fully resisted.
Reduction Techniques
In 2012, Cochrane updated its earlier review on nursemaid’s elbow and in 2013 followed up with an article in Pediatrics in Review.3,4 Each covered research on reduction techniques, summarizing studies comparing supination-flexion (SF) versus hyperpronation (HP) as the initial reduction maneuver. Given that these maneuvers are difficult to camouflage, studies tend to be pseudorandomized with assessment by a nonblinded healthcare provider, decreasing the strength of the studies. In the Cochrane review, four different trials that included 379 children under age 7 years were selected for the review. In all four studies, pronation was found to have the least chance of failed first attempt, the chosen outcome for this meta-analysis. The risk ratio of failure of reduction for pronation was 0.45 (95% confidence interval [CI], 0.28-0.73).
There is some data supporting hyperpronation to be less painful as well; however, the Cochrane reviewers felt there may have been reporting bias.4 Since the time of each of these reviews, another study comprised of 150 children was conducted and also favored similar practice styles, as the hyperpronation maneuver had 95% success rate on first attempt versus 68% first-time success with supination and flexion.5
Complications and Recurrence
In a small study aimed at identifying recurrence rates for nursemaid’s elbow, Teach and Schultzman6 studied 93 children for 1 year after probable or definite diagnosis of nursemaid’s elbow. Of these children, 23.7% had recurrent radial head subluxation. Children younger than age 2 years were found to have a relative risk of 2.6 (95% CI, 1.04-6.30) for one or more recurrences when compared to children older than age 2 years.
While the great majority of children with nursemaid’s elbow do not need referral to an orthopedist, those with two or more occurrences should be considered for referral to a specialist.
Case 2
A 6-year-old boy was presented to the ED by his father, who had placed the boy’s arm in a home-made sling. The child tearfully told the provider that he fell trying to catch himself after tripping over the house pet.
FOOSH Injury
The above case depicts a very common presentation in the ED—the so-called “FOOSH” (fall onto an outstretched hand) injury. This type of injury occurs with such frequency in both adults and children that it is one of the only injury patterns with a commonly used acronym. The bony injuries seen with FOOSH in children, however, have a different pattern than those in adults.
Pediatric fractures are unique due to the difference in the structure of the bones themselves. A child’s bones are more elastic than an adult’s bones, allowing them to bow and bend before they fracture.7 Despite this malleability, pediatric bones have been noted to have a thicker periosteum. For this reason, compression or impact may interrupt the periosteal sleeve, minimally yielding an incomplete interruption of the cortex unilaterally.
One fracture pattern commonly seen in children is the torus fracture. This type of fracture is also referred to as a buckle fracture as the bone cortex on radiographic imaging appears “buckled” as a result of the compressive forces on that side of the bone (Figure 1). Since the bone itself is minimally affected, these fractures are quite stable and not at risk for complications.