Clinical Case 112: Pulled Elbow Tricks

Your next patient is 2 year old Sadie.  She has presented to the ED with a very guilty looking father.  He says that he was “watching the kids” whilst his wife went to the store.  They were playing in the back yard when thing got a little crazy and he attempted a complete 360 vertical sling whilst holding her by the wrists.  She landed safely but has been refusing to use her right arm ever since…  that was 4 hours ago now.  He was hoping it would all get better before his wife returned from the shops… but no luck.  So here he is now at triage with a quiet little princess – who is cradling her right arm in a semi-flexed position by her side.

After calling his wife to check her date-of-birth and allergy history she is clerked into the ED….

[Seriously: is this an Aussie male thing – or is it a global phenomenon that most fathers cannot recall basic details for their children?  Let me know.  I assume the Swedish Dads are up to the task..]

Diagnosis:  too easy – a classic pulled elbow, “nursemaid’s elbow” or radial head subluxation – as it is formally known.

The mechanism of injury is usually a sudden traction on the extended forearm. See paper below for interesting review of actual activities involved.

Image from imgarcade.com

Image from imgarcade.com

The radius is distracted from its position in the elbow where it articulates with the capitellum. A band of the annular ligament that usually encircles the radial head slips in to the groove. thus a blockage to extension and rotation is in place – the kid will not extend the elbow.

How does this occur?  Well  found this huge [3000 kids]  retrospective case series on pulled elbows that managed to break down the mechanism by physical activity and by “carer gender” – i.e. was it the Mum or the Dad who was doing something with the arm when it popped.  Have a read of – No Longer a “Nursemaid’s” Elbow: Mechanisms, Caregivers, and Prevention by Rudloe et al in Paed Emerg Care 2012

The bottom line: Female carers tended to injury the kid in a more passive mechanism – eg. kid tripped or pulled away; where male carers were more likely to be doing wizzy-dizzies, wrestling, flinging kids about… no surprises really!  Note that there are a a fair percentage with an “uncertain” mechanism – so you may not get the classic traction story.

OK – so after taking the history and having a look at the kid you are happy with the clinical diagnosis.  So how do you fix it?

If you are new to Paeds ED or GP then this is one of those moments – you remember seeing this or maybe even doing it during your training  – but how does it go again?

So there are basically 3 ways to “reduce” a pulled elbow:

  1. Supination / flexion  (SF)
  2. Hyperpronation (HP)
  3. the “2 in A Room” technique – Wiggle it, just a little bit  [No evidence for this one!]

I was always trained (and have trained others) to use the flexion / supination technique – which works OK.  But how does it stack up to an RCT examination?  So what is your “go to” technique when you want to perform the magic and cure the kid with your bare hands?

Well there are a number of small trials in recent years that have looked at this – and they have remarkably consistent findings.  Here are the success rates

 Amer Journ of EM, July 2013. Gunaydin et al:  SF = 68%,  HP = 95%

Nigerian Journ  Clin Pract 2014, Guzel Comparison of hyperpronation and supination-flexion techniques in children   SF = 84 %  HP = 95 %

Cochrane review in 2012 by Krul et al looked at 4 small trials – they found a significantly better success rate with HP over SF with a RR of 0.45 [0.28  – 0.73 ]

So on review – hyperpronation seems to be the best first option.  Significantly higher first attempt success and to meet seems easier to visualise.

Here is a video from the great Dr Larry Mellick – he has heaps of Youtube videos of common ED procedures.  My main tip is to place your thumb over the radial head as you pronate / supinate – this allows you to feel the click as it pops back over the ligament – it is satisfying and usually means a successful outcome.

And in most of these studies where the first attempt failed (either HP or SF) then the other technique succeeded on nearly every occasion. But…

Have you ever had that kid with a dead set, certain Pulled elbow who you go through the motions,pull, reduce and walk away – come back 5 minutes later and they are still not using the limb?  I have – it is one of those moments.  Hmm… am I missing something?  What do I do next?

I reckon there are a few common scenarios where the routine “reduction” might fail.

  1. If the elbow has been “out” for a prolonged time (e.g.. overnight) – I find it takes longer for the kid to get over the apprehension of pain and start using it freely.
  2. If the diagnosis is wrong.  Could be a fracture: radial head, supracondylar..  though these usually present with a fall, trauma history
  3. You are being too gentle with your technique

So what do you do if you have tried, given it a proper wrench, tried the “other” technique and waited a good while for the kid to regain their confidence.  And still no luck?

You could do an Xray… but that is ridiculous!  Have you ever tried to interpret a 2 year old’s elbow Xray – it is really just a series of blobs floating in invisible cartilage!  There is a great guide to “Elbow Ossification in kids” on Radiopaedia here.  At age 2 [the mean age for pulled elbows] only the capitellum is even visible – the rest are ghosts!

Xray may reveal signs of a supracondylar or epicondylar fracture – e.g.. “fat pad sign” of effusion / haemarthrosis – which will make you feel really bad about the recent tweaking and twisting manoeuvres – though this is no reason to Xray every kid with a pulled arm.

So what about ultrasound.  Can we answer any of these questions with the bedside machine?

Interesting small study out of Korea – by Lee, Sohn and Oh in Clin & Exper EM in 2014 – showed that the finding of a displaced annular ligament on US was 100% specific for “pulled elbow” but only modestly sensitive 64.9%.  So US would be useful to “rule in” a pulled elbow – which would be very helpful in ruling out other diagnoses.

If you are worried about a possible occult supracondylar fracture – then ultrasound can be useful here also.  Eckert et al in Europ Journ Trauma Emerg Surg April 2014 looked at the diagnosis of SCFs in kids using US – it was pretty good.  Sensitivity of 100% in a small study using plain Xray read by Radiologist as the standard.

So in summary:

  • Pulled elbow is a clinical diagnosis [the history may not always be classical]
  • Hyperpronation should be the first line manoeuvre
  • Supination / flexion should be plan B
  • IF not winning after a few tries – then we need to consider imaging
  • Ultrasound is useful for ruling in a pulled elbow [using a displaced annual log as the sign of choice]
  • Ultrasound is useful for ruling in supracondylar fractures
  • X-rays can be very confusing – but if you need to then go on….

See you in Chicago

Casey

Clinical Case 111: Toddler’s Tibia Tale

Another quick ultrasound case.

I usually work nights and weekends – and that means that we have no onsite Xray services.  Hence there is always a reason to use ultrasound to enhance our diagnostics!  In fact if you are coming to SMACC Chicago in June this year – you can hear me prattle on about ultrasound in ED. Chris Nickson has given me the title: “No Xray, No Problem!” to talk on… and I cannot wait.  The real reason I enjoy working after hours – I can practice the way I like – using US in place of Xray.  To me that is a heap of fun and very satisfying!

So onto today’s case.

3 year old girl is brought into the ED one Sunday morning.  She was playing with her older cousins at aunty’s house last night when there was a scream and then silence from the bedroom.  Her aunt went into the room and found her crying and holding her leg.  She was carried out and put to bed.

Fast forward to the next morning – and she is still not wanting to walk.  Refuses to put her foot onto the ground, insisting on being carried.

She is well, afebrile, no other symptoms.  She isn’t really yet developmentally able to localise her exact site of pain – but is clearly upset when I touch her lower leg.  There is no lesion, wound or puncture to the sole of the foot and her hip, knee and ankle all move well without much discomfort.

So – being me and it being a Sunday… ultrasound is indicated.

Now be warned – this is outside the realm of “current practice” although there are a handful of case studies looking at long bone fractures in kids with ultrasound.  Most show it is useful.  However toddler’s fractures are subtle – very subtle.  Even with a solid history and a good Xray it can be hard to see those spiral cracks.

So what did our patient’s tibia look like?

tibia fract

Well it is subtle.  This image is the result of a few minutes searching.  It is very easy to miss subtle fracture on ultrasound.  One really needs to be slow and methodical

 

Here is the plain film for comparison:

tib fract toddler The US image here is profiling the anterior surface of the tibia, the fracture was not detectable on lateral views.

  1. So my learning points from this case:
  2. (1)  that one needs to be careful and methodical
  3. (2) Use the contralateral limb for comparison – there are a heap of growth plates etc
  4. (3) Call any subtle anomaly if you see it – confirm on Xray if uncertain

Casey

Clinical Case 111: Toddler’s Tibia Tale

Another quick ultrasound case.

I usually work nights and weekends – and that means that we have no onsite Xray services.  Hence there is always a reason to use ultrasound to enhance our diagnostics!  In fact if you are coming to SMACC Chicago in June this year – you can hear me prattle on about ultrasound in ED. Chris Nickson has given me the title: “No Xray, No Problem!” to talk on… and I cannot wait.  The real reason I enjoy working after hours – I can practice the way I like – using US in place of Xray.  To me that is a heap of fun and very satisfying!

So onto today’s case.

3 year old girl is brought into the ED one Sunday morning.  She was playing with her older cousins at aunty’s house last night when there was a scream and then silence from the bedroom.  Her aunt went into the room and found her crying and holding her leg.  She was carried out and put to bed.

Fast forward to the next morning – and she is still not wanting to walk.  Refuses to put her foot onto the ground, insisting on being carried.

She is well, afebrile, no other symptoms.  She isn’t really yet developmentally able to localise her exact site of pain – but is clearly upset when I touch her lower leg.  There is no lesion, wound or puncture to the sole of the foot and her hip, knee and ankle all move well without much discomfort.

So – being me and it being a Sunday… ultrasound is indicated.

Now be warned – this is outside the realm of “current practice” although there are a handful of case studies looking at long bone fractures in kids with ultrasound.  Most show it is useful.  However toddler’s fractures are subtle – very subtle.  Even with a solid history and a good Xray it can be hard to see those spiral cracks.

So what did our patient’s tibia look like?

tibia fract

Well it is subtle.  This image is the result of a few minutes searching.  It is very easy to miss subtle fracture on ultrasound.  One really needs to be slow and methodical

 

Here is the plain film for comparison:

tib fract toddler The US image here is profiling the anterior surface of the tibia, the fracture was not detectable on lateral views.

  1. So my learning points from this case:
  2. (1)  that one needs to be careful and methodical
  3. (2) Use the contralateral limb for comparison – there are a heap of growth plates etc
  4. (3) Call any subtle anomaly if you see it – confirm on Xray if uncertain

Casey

Clinical Case 110: Sepsis, Scans and Surgeons

Here is a case that may keep you guessing.  One for the US nerds.  Here we go:

25 year old tourist – visiting the town, she has been backpacking for 6 months and the history is a little vague… but basically she thinks she may have had a miscarriage about 5 months ago.

She had a positive pregnancy test and two weeks later developed pain and PV bleeding.  Didn’t see a doctor as she had no travel insurance…  the pain settled and she thinks she may have passed some large clots  – anyway the symptoms settled and she carried on her travels.  No imaging was done.

Fast forward to now – 5 months later.

The history is of 24 hours of lower ado pain. The pain started in the left iliac fossa.  Was well localised but has since become more generalised – on examination she is guarding and has clear peritonism across the lower belly.  Certainly she is more tender on the left.  She is febrile (39.8 C = 103.6 F), tachycardia 110 and has a BP of 90/60.  She denies any recent PV loss, discharge or urinary symptoms.  Her bowels were OK until yesterday – no motion since the pain started.  A VBG shows a mild, compensated metabolic acidosis, normal lactate.

He UA shows some pyuria but no nitrites.  And the B-hCG is…..   [drum roll] .. negative.

So in summary – a 25 yo lady who may have had a spontaneous miscarriage 5 months ago now presents with a sepsis picture, left iliac fossa pain and peritonism.  We need a scan!  So I will show you a series of 6 TV US images now and let you interpret them…  here we go.   [I have added captions to orient you if you are not familiar with TV scan which can look a bit weird to the uninitiated ]

I think I will let this case linger here for a few days.  Would really love to hear your thoughts on these images, the possible diagnoses and where to next!

Of course I will tell you what the final outcome and diagnosis was – but first lets see what you think of these images in this scenario.

Comments please.  Are you a super sleuth with a scanner?

Casey

Right ovary on TV

Right ovary on TV

Longitudinal pelvis view

Longitudinal pelvis view

Left pelvis adnexa

Left pelvis / adnexa

Left ovary

Left ovary

Left pelvis mass long.

Another look at the left pelvic mass

Being A Doctor’s Doctor – Penny Wilson and Geoff Riley

Have you ever treated a fellow doctor?  How did it feel?  Did you feel confident or intimidated?

Consulting and treating our colleagues can be really tricky.  The dynamics seem a little alien, there is a huge risk of assumption leading to errors and of course there is always the nagging doubt that you may need to go against their wishes in some circumstances.

Dr Penny Wilson @nomadicgp – a regular in the O&G corner of Broome Docs and now the co-creator of the Bit & Bumps podcast has chipped in this week.  She has interviewed Prof. Geoff Riley – former rural GP and Psychiatrist – who was until recently my boss at the Rural Clinical School in Western Australia.  Geoff has developed a practice over the years as a doctor’s doctor.  He has treated many fellow doctors including some with significant impairment.

So sit back and relax, grab a cuppa and listen to this fascinating discussion about how we ought to approach being a GP to another doctor – and also how we can be better patients when we go along to see our own family doctor.

Yes – we should all have a GP.  Do you see one? If not – I would love to hear why – hit me on the comments below.

Onto the podcast DOWNLOAD HERE

Casey

SMACC Chicago – it’s heating up

Greetings readers

I have been on a bit of R&R on the run into Xmas and trying to avoid the Internet for a few weeks!

Today though I have come out of hibernation to remind you that the biggest and brightest conference is coming soon… in June 2015.

That may seem like a long way into the future – but the competition for tickets, workshops and hotels is getting tight.

I know that you will seriously regret leaving your planning too late – so get on over to the smacc.net.au website now and register for the conference. Check out ht awesome line up of speakers, workshops and social program.

I have just received a prompt from the organising committee to help me sharpen up my act and together we will make SMACC Chicago to most entertaining and engaging medical event that the world has ever seen!

Most importantly – my favourite part of this awesome event is the chance to meet you all, its so much fun to chat live after all your contributions to the comments and Tweets.  So come on aver and say “Hi”

Casey

SMACC PROMO