Emergency Department Visits for Nursemaid's Elbow in the United States, 2005–2006

Current Approach to the Management of Forearm and Elbow Dislocations in Children

Pediatric orthopedic injuries are a common reason for presentation to the emergency department. This article sequentially discusses 2 important upper extremity injuries that require prompt management in the emergency department. Radial head subluxations are discussed with a focus on current evidence for imaging, reduction techniques, and follow-up. Elbow dislocations, although less common than radial head subluxations, are also addressed, highlighting imaging, reduction, immobilization, and follow-up recommendations.

Reconsidering the "Classic" Clinical History Associated with Subluxations of the Radial Head

Introduction

The national burden of radial head subluxations in the United States (U.S.) population is poorly defined, and non-classical injury mechanisms have been increasingly reported in recent years. The purpose of this study is to report historical national estimates and demographic characteristics of patients presenting to U.S. emergency departments (ED) with subluxations of the radial head.

Methods

This cross-sectional, retrospective study analyzes the National Electronic Injury Surveillance System (NEISS) database (2001–2017) to identify patients ≤ 7 years of age presenting to U.S. EDs with subluxations of the radial head.

Results

Linear regression (R2 = 0.65; P < 0.01) demonstrated that the annual number of patients presenting to U.S. EDs with subluxations of the radial head increased significantly (P < 0.001) between 2001 (N=13,247; confidence interval [CI], 9,492–17,001) and 2010 (N=21,723; CI, 18,762–24,685), but did not change significantly between 2010 and 2017 (R2 < 0.01; P = 0.85). It also demonstrated that 51.0% (CI, 45.3%–56.6%) of injuries were either self-induced or spontaneous, whereas 36.8% (CI, 31.6%–42.0%) and 9.4% (CI, 8.0%–10.7%) were associated with parents/guardians or siblings, respectively. The majority of injuries occurred in patients who were the age of one (33.5%; CI, 32.1%–35.0%) and two (35.1%; CI, 33.7%–36.6%); females (57.8%; CI, 56.8%–58.9%) were more commonly injured than males.

Conclusion

Although the national burden of radial head subluxations may be less than previously reported, it still results in over 20,000 ED visits annually in the U.S. Given that over half of such injuries are actually self-induced or spontaneous, caretakers should be taught to recognize the clinical presentation of radial head subluxation, since the classically described history of a patient being lifted or pulled by the arm may simply have never occurred.

Radial Head Subluxation: Possible Effective Factors on Time to Re-use the Affected Limb

Introduction

Radial head subluxation (RHS) is a common disorder in children. Although it is not accompanied by any important short- or long-term sequel, it could make the parents worried about.

Objective

The purpose of this study was to determine the possible effective factors that may influence time to use the affected limb.

Methods

This cross-sectional study was conducted prospectively during the years 2014 to 2016. All children under the age of 6 years who visited the emergency department (ED) and were diagnosed as having RHS were eligible. The patients' baseline information was recorded. After the reduction, the time until the affected arm use returned was recorded. The possible relationship between the baseline data and time to re-use the affected limb was assessed.

Results

During the study period, 112 children with a mean age of 30.18 ± 18.18 months were evaluated (53% male). Among the children who visited the ED during the first 4 hours and thereafter, 84% and 60%, respectively, re-used their limb in less than 10 minutes after reduction (p = 0.004). Also, 55% of children less than or equal to 24 months and 89% over the age of 24 months re-used the arm in 10 minutes (p < 0.001). The success rate of the first reduction maneuver was significantly lower in children with a recurrent dislocation (p = 0.001).

Conclusion

It is likely that age less than or equal to 24 months and ED visit after 4 hours of the event lead to a longer duration for re-using the affected arm following reduction.

Manipulative interventions for reducing pulled elbow in young children

BACKGROUND

Pulled elbow (nursemaid's elbow) is a common injury in young children. It often results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial dislocation) of the radial head. It can also be caused by a fall or twist. The child experiences sudden acute pain and loss of function in the affected arm. Pulled elbow is usually treated by manual reduction of the subluxed radial head. Various manoeuvres can be applied; most commonly, supination of the forearm, often combined with flexion, and (hyper-)pronation. It is unclear which is most successful. This is an update of a Cochrane review first published in 2009 and last updated in 2011.

OBJECTIVES

To compare the effects (benefits and harms) of the different methods used to manipulate pulled elbow in young children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, LILACS, PEDro, clinical trial registers and reference lists of articles. Date of last search: September 2016.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical trials evaluating manipulative interventions for pulled elbow were included. Our primary outcome was failure at the first attempt, necessitating further treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated trials for inclusion, assessed risk of bias, and extracted data. We pooled data using a fixed-effect model.

MAIN RESULTS

Overall, nine trials with 906 children (all younger than seven years old and 58% of whom were female) were included, of which five trials were newly identified in this update. Eight trials were performed in emergency departments or ambulatory care centres, and one was performed in a tertiary paediatric orthopaedic unit. Four trials were conducted in the USA, three in Turkey, one in Iran, and one in Spain. Five trials were at high risk of selection bias because allocation was not concealed and all trials were at high risk of detection bias due to the lack of assessor blinding. Eight trials compared hyperpronation with supination-flexion. We found low-quality evidence that hyperpronation resulted in less failure at first attempt than supination-flexion (9.2% versus 26.4%, risk ratio (RR) 0.35; 95% confidence interval (CI) 0.25 to 0.50; 811 participants, 8 studies). Based on an illustrative risk of 268 failures at first attempt per 1000 children treated using supination-flexion, this amounted to 174 fewer failures per 1000 children treated using hyperpronation (95% CI 134 to 201 fewer). Based on risk differences data, we also estimated a number needed to treat of 6 (95% CI 5 to 8); this means that six children would need to be treated with the hyperpronation method rather than the supination-flexion method to avoid one additional failure at the first attempt.The very low-quality evidence (from four studies) for pain during or after manipulation means that it is uncertain whether there is or is not a difference between pronation and supination-flexion. There was very low-quality evidence from six studies that repeat pronation may be more effective than repeat supination-flexion for the second attempt after initial failure. The remaining outcomes were either not reported (adverse effects, recurrence) or unsuitable for pooling (ultimate failure). Ultimate failure, reported for the overall population only because of the differences in the study protocols with respect to what to do after the first attempt failed, ranged from no ultimate failures in two studies to six failures (4.1% of 148 episodes) in one study.One trial compared supination-extension versus supination-flexion. It provided very low-quality evidence (downgraded three levels for very serious risk of bias and serious imprecision) of no clear difference in failure at first attempt between the two methods.

AUTHORS' CONCLUSIONS

There was low-quality evidence from eight small trials that the pronation method may be more effective at first attempt than the supination method for manipulating pulled elbow in young children. For other outcomes, no conclusions could be drawn either because of very low-quality evidence or the outcomes not being reported. We suggest that a high-quality randomised clinical trial comparing hyperpronation and supination-flexion is required to provide definitive evidence. We recommend that this is preceded by a survey among clinicians to establish the extent of clinical equipoise and to optimise the study design and recruitment.

Radial Head Subluxation Among Young Children in the United States Associated With Consumer Products and Recreational Activities

This study investigated the epidemiology of children treated in US emergency departments for radial head subluxation (RHS) associated with consumer products and recreational activities using data from the National Electronic Injury Surveillance System. An estimated 430 766 (95% confidence interval: 341 194-520 339) children ≤5 years of age were treated for RHS in US emergency departments from 1990 to 2011. The mean patient age was 2.1 years, and 56.5% of patients were girls. The most common mechanism of injury was a fall (43.2%), followed by arm pull (39.4%). The annual rate of RHS increased significantly by 190.1% during the 22-year study period. This is the largest study of RHS to date and the first to use a nationally representative sample to investigate secular trends and mechanisms of injury for RHS associated with consumer products and recreational activities. Events associated with consumer products and recreational activities are an important increasing source of RHS.

Transbrachialis Buttonholing of the Radial Head as a Cause for Irreducible Radiocapitellar Dislocation: A Case Report

BACKGROUND

Isolated dislocation of the radial head is an uncommon injury among pediatric patients. Although closed reduction may be successful, some patients require open reduction with or without soft-tissue repair or reconstruction. If the radiocapitellar joint is not properly reduced, the long-term complications of pain, stiffness, neuropathy, and dysplasia can result from chronic radial head dislocation.

METHODS

While performing a cartwheel, a 13-year-old gymnast sustained a radiocapitellar dislocation that was unable to be reduced by closed means and failed 2 attempts at open reduction. Ultimately, the radial head was determined to have translated anterior to the brachialis muscle during the dislocation and subsequently buttonholed through the muscle as the elbow was flexed and rotated. It remained suspended by the brachialis tendon, preventing anatomic reduction. Once the radial head was delivered from this tendinous sling, anatomic restoration of the radiocapitellar joint was obtained.

RESULTS

Ultimately, the patient was able to return to full, unrestricted activity. At 9 months following surgery, she denied pain, and the elbow was stable upon examination. Elbow range of motion was 5 to 130 degrees with 80 and 90 degrees of pronation and supination respectively.

CONCLUSIONS

This represents the first reported case of suspension transbrachialis buttonholing of the radial head in the brachialis tendon as a cause of initially irreducible radiocapitellar dislocation. When evaluating patients with persistent anterior subluxation or dislocation of the radial head, this etiology should be considered.

At-risk children of at-risk parents: assessing common injuries to the children of teenage parents

OBJECTIVE

To examine the common injuries in the children of teenage parents seen in the emergency department (ED) of a large level I trauma center.

STUDY DESIGN

We used admission records for guarantor age to assess common injuries.

RESULTS

The majority of the patients were white, in the care of the mother, and suffered accidental injuries, with bruising and skin marks the most common. Although children born to teenage parents are at an increased risk for child abuse, the rate of abuse in this study sample remained low. Falls and ingested objects were the leading mechanisms of injury in these patients, who were generally evaluated and discharged from the ED.

CONCLUSION

This study highlights the common injuries and mechanisms to better understand how injuries are sustained in this unique population. The results of this study can be used for educational purposes both in the ED and in classroom-based parenting classes. Prevention efforts for teenage parents should be geared toward teaching better supervision and improving home safety.

Incidence of elbow dislocations in the United States population

BACKGROUND

There is minimal published information regarding the epidemiology of simple elbow dislocations. The purpose of this study was to report the estimated incidence of elbow dislocations in the United States, with use of the National Electronic Injury Surveillance System (NEISS) database.

METHODS

The NEISS database includes 102 hospitals representing a random sampling of all patients presenting to U.S. emergency departments. The database was queried for elbow dislocation events. NEISS data for 2002 through 2006 were used for raw data and weighted injury counts. Incidence rates with 95% confidence intervals (95% CI) were calculated by age group and sex, with use of U.S. census data.

RESULTS

One thousand and sixty-six elbow dislocations were identified, representing a weighted estimate of 36,751 acute dislocations nationwide. A calculated incidence of 5.21 dislocations per 100,000 person-years (95% CI, 4.74 to 5.68) was noted. The highest incidence of elbow dislocations (43.5%) occurred in those who were ten to nineteen years old (6.87 per 100,000 person-years; 95% CI, 5.97 to 7.76). The incidence rate ratio for the comparison of dislocations in males with those in females was 1.02 (5.26 per 100,000 for males and 5.16 per 100,000 for females). In patients ten years or older, 474 injuries (44.5% of total dislocations) were sustained in sports. Males dislocated elbows in football, wrestling, and basketball. Females sustained elbow dislocations most frequently in gymnastics and skating activities.

CONCLUSIONS

The estimated incidence of elbow dislocations in the U.S. population is 5.21 per 100,000 person-years, with use of a national database. Adolescent males are at highest risk for dislocation. Nearly half of acute elbow dislocations occurred in sports, with males at highest risk with football, and females at risk with gymnastics and skating activities.

Manipulative interventions for reducing pulled elbow in young children

BACKGROUND

Pulled elbow (nursemaid's elbow) is a common injury in young children. It results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial dislocation) of the radial head. The child experiences sudden acute pain and loss of function in the affected arm. Pulled elbow is usually treated by manual reduction of the subluxed radial head. Various manoeuvres can be applied. Most textbooks recommend supination of the forearm, as opposed to pronation and other approaches. It is unclear which manoeuvre is most successful. This is an update of a Cochrane review first published in 2009.

OBJECTIVES

The objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, LILACS, PEDro, clinical trial registers and reference lists of articles. Date of last search: July 2011.

SELECTION CRITERIA

Any randomised or quasi-randomised controlled clinical trials evaluating manipulative interventions for pulled elbow were included. Our primary outcome was failure at the first attempt, necessitating further treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data.

MAIN RESULTS

One trial with 66 children was newly included in this update. Overall, four trials with 379 children, all younger than seven years old, were included. All four trials compared pronation versus supination. One trial was at high risk of selection bias because allocation was not concealed and all four trials were at high risk of detection bias due to the lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (21/177 versus 47/181, risk ratio 0.45; 95% confidence interval 0.28 to 0.73). Pain perception was reported by two trials but data were unavailable for pooling. Both studies concluded that the pronation technique was less painful than the supination technique.

AUTHORS' CONCLUSIONS

There is limited evidence from four small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. We recommend that a high quality randomised trial be performed to strengthen the evidence.