Thursday, 21 July 2016

Do something for you today - reduce a pulled elbow

At least once a day, I like to think I have just simply fixed something.  Since I am not very good at DIY, that means finding some other way to scratch the itch.  Reducing a pulled elbow is hugely satisfying and anyone can do it if they know when and how to do so.

Pulled elbow (also called nursemaid's elbow) is not a true dislocation of the elbow but rather a subluxation of the radial head within the annular ligament of the elbow.

Based on empirical evidence, a pulled elbow hurts.  Additionally, there is often a second victim: the person who was involved in causing the pulled elbow (although there isn't always another person involved).  In fact, I was once hugged by a grateful relative after I reduced a child's pulled elbow.  What they don't know is that I already wanted to hug them for bringing me the elbow to fix.

Whatever specialty you work in, there are times when too much of what you do is intangible.  Sometimes I can see patient after patient and despite pouring my heart and soul into what I do, I don't get the feeling that I have really made anyone better.  These days are when I need a pulled elbow to shake that feeling off.  If you ever get the chance, I highly recommend doing it.  It is a fairly easy thing to do and, as I discovered recently, there are so many ways to do it.

When to attempt reduction of a pulled elbow

Before discussing technique, knowing how to do it isn't nearly as important as knowing when to do it.  There are some things that need to be considered before attempting a reduction.  Anyone can fix a pulled elbow, as long as they ask the right questions beforehand.

Is the child the right age?  There is bound to be a bell shaped curve for the age at which a child can get a pulled elbow. I would be sceptical about that diagnosis from the age of five up.

Does the mechanism fit with a pulled elbow?  Typical mechanisms include toddlers being swung around by fun uncles, toddlers being grabbed to keep them from running into the road etc.  A fall from a height is not likely to be a pulled elbow.

Are there signs that are inconsistent with a pulled elbow?  With distraction (not the anatomical kind), have a gentle feel of the elbow.  There shouldn't be any swelling.  There may be tenderness at the radial head but not in the distal humerus.  Feel all of the limb from the clavicle to the hand.  The two places that you are most likely to find point tenderness are the clavicle or the distal radius.

Often, children have had a previous episode.  If everything points towards a pulled elbow, there is no need to do an X-ray before attempting reduction.

How to reduce a pulled elbow

When I first did paediatric emergency medicine, I was taught to extend and supinate the elbow to reduce it.  That seemed to work most of the time.

Then, when I returned to work in a paediatric emergency department, I was told that flexing and pronating was better.  I have been doing it that way since then and it feels like it works more often.

 Of course the scientist in me is sceptical about the change.  Maybe something else affected  my success rate.  So what does the evidence say?  I was intrigued to find studies including other methods that I had not heard of, such as flexion with supination. (1)  I even found a Cochrane Review (2) which looked at the question.  It dodged the flexion vs extension question but concluded that pronation was probably successful more often than supination and possibly less painful.

So, I asked people on twitface which method they tend to use.

While finding it reassuring that two thirds of my colleagues were doing it 'my way', I was also interested to see that many will use a different method and that every possibility of twist and bend/ straighten is felt to be valid. 
I was pleased that nobody said anything about having to put firm pressure on the radial head.  I believe that all recommendations to do this are based in myth.  There is no logical reason why the radial head needs any guidance and I certainly don't press on the painful bit while applying my swift twist and bend.

I was also pleased that someone pointed out that if necessary, these can be left alone to resolve.  They always do, although it might take a day or two to finally slip back into place, during which time there will be discomfort.  I would still advocate reduction as success means that the resolution of pain is pretty much immediate.

Which brings me back to my original point.  How you do it is very much secondary to when you do it.  So, instead of worrying about technique, when the time is right, do something for you and fix a pulled elbow.

Edward Snelson

Disclaimer - I say that there are lots of methods, but my way is the right way.

For general principles of assessing children's injuries, follow this link.

  1. Macias CG et al, A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations, Pediatrics. 1998 Jul;102(1):e10
  2. Krul M et Al, Manipulative interventions for reducing pulled elbow in young children, Cochrane Library

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