Ortho on the go
Ortho on the go
Pediatric patient with elbow pain
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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Hello everybody and welcome back to the podcast. Another interesting case that we had in the ortho urgent care this week, which I thought would be fun to share for another episode. We had a two-year-old come in complaining of andor the parents uh brought the patient in complaining of uh lack of use of the left arm. Uh the mother states that the night before she was playing with her brother, who was her older brother. They were holding each other's hands and swinging each other around, and then immediately she started to kind of complain andor uh not use her left arm. They tried to treat this conservatively uh with anti-inflammatory medications and rest. She didn't sleep well that night. They brought her to our orthopedic urgent care the next day uh for evaluation regarding this. According to the mom, there was no previous injuries noted to the left elbow. She's otherwise a healthy two-year-old. Um, in our urgent care, uh, because sometimes we're busy, our medical assistants do an evaluation of the patient and then discuss and or uh decide if x-rays needed to be ordered for this patient because she was a two-year-old complaining of elbow pain. X-rays were ordered. I did see her after the x-rays. Interestingly enough, upon me entering the room, I noticed that she was using her left arm uh quite well. Uh, she was actually using it to hold on to her mother. Uh, she pushed herself up in her mother's lap a few times while using it. I examined the elbow. According to the mom, prior to the x-rays, the patient would not use the arm at all. She would not bend or straighten the arm, didn't want anybody to touch it, actually cried quite a bit during the x-rays. I examined the elbow. She didn't react to any tenderness andor palpation throughout the elbow. In a two-year-old, sometimes it's hard for them to verbalize pain. So oftentimes I'll examine while I'm watching their face to see if there's any reaction or grimace on their face, or a lot of times they'll retract to palpation uh within the area of tenderness. So usually in kids younger than two or three, I'll oftentimes not rely on verbal communication uh to let me know if there's any tenderness or the area of pain, but I'll look at their face while palpating and see if they retract uh the arm andor the extremity while palpating to any specific area, which is usually a sign of this is the area that's painful for them. So for her, when I was examining her, she didn't retract to any palpation uh throughout the elbow area. Based upon the mechanism of injury uh that the mom was telling me, I thought possibly she had a nursemaid's elbow, so made sure to really palpate throughout the lateral elbow area quite significantly. I then tested her range of motion gently at first because um, according to the mom, she did not want to use the arm at all. So initially I just had her hold the arm at 90 degrees of elbow flexion, and then I tried to uh pronate and supinate the hand and wrist to the maximums. She was able to tolerate this without pain or grimacing or retraction. I then flexed her elbow up to full flexion, full extension. And again, she tolerated this quite well without any significant symptoms. The mom was quite surprised. Uh, she states that prior to the x-rays and prior to me coming in the room for the examination, she would not use the arm at all, would not let anybody touch the arm. And then as we talked, and I talked with the mom over the next five or ten minutes, I could see that she was using the arm more. Uh, she walked out without any concerns, holding her mom's hand with the left arm, again, without any concerns. So I think what happened in this case is, you know, in her age range with the attraction injury and the immediate pain uh and lack of fall, and mom states this was witnessed, so there is no concern about unwitnessed fall. Um, that would make you think of a differential as in a fracture of the elbow. Uh, she likely had a nursemaid's elbow because we obtained x-rays, and one of the positions of the x-rays is to get her into a hyper supinated position uh for evaluation of the AP of the forearm. Um, she likely with I heard her crying during the x-rays during this time, so likely this hyperpronated position with her kind of crying or being fussy reduced the nursemaid's elbow for the patient. So this was reduced prior to me coming into the room. I thought an interesting case, I do see this not unfrequently that these nursemaids' elbows are reduced prior to me entering the room. If we do get x-rays uh beforehand, oftentimes if I see the patient or hear the history, I'll hold off on the x-rays because they're often not needed for these nursemaids' elbows. And um, I'll just do a clinical examination and during the examination I'll try the reduction techniques and see if I can feel uh the pop or click. These are definitely one of the more satisfying pediatric elbow injuries to have because it's um quite um relieving to the parents and the patient that you're able to manipulate the arm, and after the manipulation, they use the arm without any concerns. So, just a review if we remember, these nursemaids' elbows typically happen uh commonly in children from one to four years of age. Some of the literature shows that the average age is about 28 months. It's pretty rare after five years of age for these to happen. There's a slightly more andor increased predominance for these to happen in females compared to males. Usually the mechanism of injury is a longitudinal traction. Um they can happen from a fall on an outstretched arm as well, but again, typically a longitudinal traction type injury that frequently causes them. There's a few different uh theories as to why these nursemaids' elbows uh happen and are um uh frequently happen. Again, we don't know, but some people think that it's the smaller size of the radial head in relation to the shaft and the fact that the annual ligament is thinner in children, especially under the age of five, is why this more frequently happens. There is some predisposition to children that are slightly above and are elevated weight for their age, possibly again, relating to the traction and the uh aggressiveness of the pull or the weight of the pull potentially causing these. Originally they were described as radial head supplexations or dislocations, but again, the more anatomical or appropriate terminology would be uh aneurigament um injury. So the aneurigament becomes interposed between the radial head and the capitalum, uh, and oftentimes this is what causes it to happen. Sometimes in the history they can hear a click, but frequently when I've seen these in the past, it's often a child who just refuses to use the limb, holds it in a slightly flexed position. A lot of the times the form will be slightly pronated, and they'll react andor grimace to a palpation uh diffusely throughout the lateral aspect of the elbow. Uh again, radiology is not necessary to confirm the diagnosis. Um they do andor have shown that 25% of the time the radiocapitellar line will uh be slightly lateral to the center of the capitellum. Ultrasounds can be used quite frequently. Um, they do have a pretty good specificity and sensitivity regarding these nursemaids' elbows, but again, these are often reserved for patients where you try these reduction maneuvers or techniques and potentially they don't work. And then you can get the imaging to ensure that there's no evidence of fracture and/or the ultrasound to see if there's interposition of these annul ligaments, and potentially that's not being reduced by these reduction maneuvers. Differential diagnosis, as we talked about, there's no trauma associated with these oftentimes. If it's an unwitnessed fall and the patient comes in with limited range of motion, uh I may be less prone to manipulate the elbow prior to getting x-rays because, again, not sure if the patient had a fall and has some type of suprachondylar fracture causing the limited mobility of the elbow. If it's a witnessed kind of traction type injury to the elbow, then oftentimes we can hold off on these x-rays. Radial head dislocations, forearm synostosis are always possible. Radial neck fractures, lateral condyle fractures, alecranon fractures, and supracondylar fractures again are always possible, but these would be more consistent if the patient had a fall to cause the potential onset of symptoms. So for reduction maneuvers, um, oftentimes there's two types of maneuvers you can use. Um the supination technique, I think, is the probably more common one. You hold um andor the provider holds the uh elbow at a 90-degree flex position. Uh, you try to put your thumb over that radial head area. You hypersupinate uh the hand andor wrist at this 90-degree uh flex position, and then you you move the arm into maximal flexion. And oftentimes you'll feel a palpable click or hear a palpable click when the reduction of the radial head is noted. You can also try hyperpronation technique and involves again taking the elbow flex at this 90-degree position and pronating the arm into the extremes of pronation, again, with the one hand palpating the elbow and the lateral aspect of the elbow, again, oftentimes feeling a reduction and/or click. Um, I would try both next techniques. In my experience, typically the supination technique works the best. Um, and so I usually try that first. And oftentimes I can do this when just checking range of motion of the patient. If I think the history is consistent with concerns for a nurse maid's elbow, um, if this doesn't work, then I may try this hyperpronation technique. From a follow-up perspective, ideally you keep the patient there for five or ten minutes. Typically, within five or ten minutes, they should go back to completely normal use of the elbow, using that arm to push themselves up with full motion of the arm. Oftentimes the patient or the baby will be less fussy, um, and that typically shows you that the elbow is reduced back into position. You can consider possible immobilization, but often unnecessary if it's the first episode. Typically reserve this if they have multiple episodes that could potentially, andor multiple episodes that have happened. Uh these uh episodes uh can occur more often, especially in children at the age of three, and the initial treatment with multiple episodes of this can be cast application in a flexed and neutral or stupinated position of the elbow to provide that elbow in a more stable position. If the elbow is unreducible, um, you can put this patient into a posterior mold splint, have them follow up with your children's orthopedic specialist. Uh sometimes this will require uh open reduction in the OR. Again, imaging could be provided at that time, including uh ultrasounds if you do have a good musculoskeletal ultrasound available to you that can help to see if there's interposition of this aneurigament. So I think this is really an interesting case. Again, I've seen these in the past quite often. Will they be reduced prior to me seeing the patient? They are um good ones to reduce in clinic because, again, uh the patient does feel satisfaction and symptom relief quite um soon after the reduction is performed. And so it is definitely a satisfying one to do. I think pediatric elbow injuries are often very hard to treat and they have a large differential diagnosis and the onset of symptoms and or the history behind the symptoms is often important in indicating if there is a concern for underlying fracture or the severity of the injury. Again, if this was an unwitnessed um injury, the child just came into the room, was playing with her brother in the other room, and complained of pain within the elbow and/or disuse of the elbow because they couldn't potentially vocalize the pain within the elbow. I would possibly consider uh radiographs prior to uh trying some manipulation techniques on the patient because, again, it could have been secondary to a fall. Uh, again, these are possible with a fall in the arm in a fully extended position, but also possible for fractures to happen within the elbow area. So you definitely want to look to see if there's any effusion within the elbow with these. Uh try these uh hypersupination and pronation uh reduction techniques um prior to andor if the history is consistent with um a nursemaid's elbow with a traction type injury prior to getting any imaging, because oftentimes this will resolve their symptoms. So, again, thanks again for listening to the episode. I thought this was a fun and interesting case to review regarding pediatric elbow pain in a two-year-old female. Uh, this was her left arm. Some of the literature does show that left arms can be more common uh for these uh types of injuries, possibly because oftentimes they happen due to traction injuries from the parent pulling on the child's arm. And the the, you know, most of us are right-handed, so we we hold on to the left arm of the child. Please again follow us on social media, uh, Ortho uh on the go podcast on both Facebook and Instagram for updates on when new episodes are published. Please don't hesitate to communicate or reach out uh if there's interesting cases andor topics you would like to discuss or with any feedback regarding these podcasts. Uh, thanks again for listening.