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 Best practice and Fifteen-minute consultationsFifteen-minute consultation: Assessing the child with an elbow injury Edwards1,2, Roland3,4 Author affiliationsAbstractThis article aims to provide a concise summary of the key considerations when assessing a child with an elbow injury. Elbow injuries are common with acute elbow trauma, accounting for 2%–3% of all visits to the emergency department. This article will cover history, examination and key X-ray findings, along with a brief guide to management. It is hoped this article will help healthcare professionals who assess children with elbow injuries. Our work is applicable to those both in the hospital and community setting. is estimated that upper limb fractures (ULF) account for over 80% of all paediatric fractures presenting to the emergency department.1 2 Acute elbow trauma accounts for an estimated 2%–3% of all visits to the emergency department,3 with elbow injuries making up an estimated 25% of all paediatric sport-related injuries.1 4 5 Most ULFs are secondary to falls and injuries during sporting activities, with an increase in recent years of trampoline-related injuries.5 Elbow injuries can be exceptionally painful and cause a lot of distress. An appropriate examination is vital due to the neurovascular bundles that run around the elbow. It is estimated that 10% of fractures around the elbow may have neurovascular compromise.6 Therefore, being able to examine for these injuries is important. Another difficult aspect of paediatric elbow injury is interpreting plain radiographs. This is complicated due to the numerous ossification centres. This Fifteen-minute consultation will aim to help understanding around elbow injuries and provide tips and tricks during examination and interpretation of radiographs. HistoryLike all fractures, elbow injuries can be very distressing for children, so prior to the consultation pain should be assessed and appropriate analgesia given. As with any history, think about when and how the injury occurred. Importantly are there any other injuries that will need to take precedence? Although the grossly swollen elbow may be the focus of everyone’s attention, traumatic brain injury which also occurred during the fall may be the actual cause of the child’s agitation. Understanding how a child feels can help identify where an injury may be.7 Always document the hand dominance of the child. Boxes 1 and 2 and discuss some important points when taking a history from the patient. Box 1 Important considerations for the historyContact trauma. Which area of the body or limb was involved?Was there any valgus force applied with the hand planted? Consider if the medial components of the elbow joint are damaged.7 Was it a fall on an outstretched hand? Consider the proximal forearm or the distal humerus.7 Was there any acute pain while throwing? This depends on the patient’s skeletal maturity, medial epicondyle apophysitis, medial epicondyle avulsion fracture or ulnar collateral ligament injury.7 18 Any hyperextension? Injury could include damage to the distal humerus and proximal ulna from a posterior dislocation or impingement of the elbow.7 Axial traction on the arm with the elbow in full extension with the forearm pronated (eg, forcefully pulling on the wrist of a young child)—could suggest radial head subluxation (nursemaid’s elbow or pulled elbow).7 Is there any joint instability? Were there any pops, cracks or any feeling of instability? This could suggest ligament damage around the joint. Are there any neurovascular complaints? Are there any distal neurovascular complaints? For example, consider burning, prickling, tingling (may suggest paraesthesia), hot, cold or numb (may suggest vascular compromise) feelings. Any significant medical history? For example, haemophilia, sickle cell disease or other coagulopathies that may complicate the injury. No history of trauma, but a red, swollen, painful joint? Consider a septic arthritis or osteomylitis. Box 3 reflects on a real life case and box 4 shares some consideration for a septic joint. Box 2 SafeguardingSafeguarding is crucial when taking a history of any child with an injury. Does the injury match the presentation? Is the injury or supervision appropriate to the age of the child? Is the story you are getting from the child the same as the story from the parents or guardians with them? Is the story consistent or is the story changing? It is always worth noting how many previous presentations to the emergency department the child has had. However, clearly each case must be assessed on its own individual merits.19If something does not sound right, or you have a concern, raise and escalate it as per your local policy.Box 3 The septic jointIf a patient presents with a red elbow or any joint for that matter and there is no significant history of trauma, consider if this could be osteomyelitis or a septic joint, especially if there is fever or the pain is out of proportion with the injury presented.What can be deemed a minor injury can sometimes have a significant diagnosis behind it.Signs and symptoms suggestive of a septic joint include the following:Pain out of proportion, but very minor or no trauma to the joint.Decreased movement of the joint.Erythema.Swelling.Hot joint.Fever.Box 4 A case to make you thinkA paediatric registrar was asked to review a 7-year-old child in the paediatric emergency department following a small graze to an elbow after a trivial fall a few days ago. The parents were not concerned initially as the child was able to still use his elbow. But in the last 24 hours, the child had been less reluctant to use it. The child had an unremarkable medical and birth history and was on no medications. He was well, saying the elbow was sore and paracetamol and ibuprofen were not helping. He had no other symptoms. Of note the elbow was red on the area of the fall and with some extension of the redness around the joint. The joint was sore to touch. The rest of his examination was unremarkable. The child had a temperature of 38.0°C, with otherwise normal observations. A review of the X-ray with the paediatric consultant suggested there was a possible line around the radial head, and this was a likely fracture. The temperature was felt to be an intercurrent illness. The child was sent home.The following day the child re-presented to the paediatric emergency department. The parents stated he was more unwell, and he had a higher temperature of 39.5°C. The child still could not use his elbow and it was still red and very sore. A review of the patient could only find this red, sore, hot elbow, which he is unable to move. Another elbow X-ray was ordered, and the possible line that was seen the day before now looked less like a line. The X-ray showed some periosteal reaction, with swelling around the joint in the fat planes. This could be consistent with osteomyelitis. The patient was referred to the orthopaedic team and treated with surgical drainage of the elbow and antibiotics.Pain managementOptions for pain management for children with elbow injuries can include the following:Simple analgesia, such as paracetamol and ibuprofen.Intranasal diamorphine or fentanyl for greater pain.While awaiting imaging, a soft plaster cast can help with pain.Remember to reassess the pain.ExaminationAnalgesia is crucial and should be given to help aid examination. It may not be possible to adequately examine the joint until analgesia has been provided and the child is calmer and more familiar with the environment they are in. When examining an acute elbow injury, remember to examine the joint above (the shoulder) and the joint below (wrist). In children, pain in the elbow can be a red herring for pain in other joints.7 It is crucial, and before X-ray, to assess the neurovascular status of the upper limb. If there is neurovascular compromise, this will likely change the management as this will need urgent intervention. Neurovascular examinationVascular status should be checked: is there a peripheral radial pulse, and are the distal digits warm, well perfused and with good capillary refill?In children with elbow injuries, it is crucial that the neurovascular status of the limb is documented clearly, as it has been estimated that 10% of elbow injuries can have neurovascular compromise.6 The BOAST (British Orthopaedic Association Standards for Trauma) 2015 guideline states, specifically for supracondylar fractures, that each individual needs to be documented. The four nerves that require documentation are the radial, ulna, median and anterior interosseous nerves. However, it would probably be good practice to document these nerves in any upper limb injury.8 Litigation cases to the National Health Service in the last 15 years have found supracondylar fracture misdiagnosis as one of the most common claims.9 10 For neurological deficit that has been missed in supracondylar fractures, payouts range from ?27 000 to ?251 000.9 10 Assessing nerve supply in children with sore elbow can be difficult, especially when they are in pain. A simple way to assess the neurological status of the upper limb in both children and adults can be the Rock, Paper, Scissors, OK? method.2 8 11 12 Matched like the children’s game, this can help to examine neurology and document the specific nerves. Rock tests the median nerve, Paper tests the radial nerve, Scissors tests the ulna nerve, and the OK sign tests the anterior interosseous nerve.2 8 11 12 An infographic summing this up is shown in figure 1. Download figureOpen in new tabDownload powerpointFigure 1Rock, Paper, Scissors, OK? infographic.2 6 20LookLook at the joint; is there any bruising, bleeding, evidence of an obvious open fracture or any neurological deficit such as a wrist drop (suggesting a radial nerve injury)? If there is any obvious open fracture or obvious significant deformity, think about prompt neurovascular assessment. If in doubt, compare with the opposite elbow.FeelIt is important to palpate the following areas around the elbow7:Anterior elbow.Posterior elbow.Medial elbow.Lateral elbow.MoveWhat is the range of motion of the elbow? Can the patient fully flex and extend the joint? Around 50% of patients, both adults and children, who cannot fully extend their elbow will have a fracture.3ImagingMost often these injuries will require a radiograph to help assist in the diagnosis. What makes interpreting the paediatric elbow radiograph challenging is all the ossification centres (figure 2).Figure 2Age-matched elbow X-rays showing ossification centres.When reviewing the paediatric elbow radiograph, there are four questions that need to be answered13 14:Are the fat pads normal?Check the fat pads on the lateral projection.A displaced anterior fat pad (sail sign) is abnormal.A visible posterior fat pad is always abnormal.Not all joint effusions are associated with fractures.An effusion often suggests that a significant injury has occurred. This is irrespective of whether a fracture can be seen or not (figure 3).Figure 3Normal and abnormal elbow fat pads.Is the anterior humeral line normal?Check the anterior humeral line on the lateral projection.A line traced along the anterior cortex of the humerus should have at least one-third of the capitellum anterior to it.If less than one-third of the capitellum lies anterior to this line, there is a strong probability of a supracondylar fracture with the distal fragment (including the capitellum) displaced posteriorly (figure 4).Figure 4Anterior humeral line.Is the radiocapitellar line normal?Check the radiocapitellar line on the lateral projection.The normal radius frequently shows a bend or slight angulation in the region of its tuberosity. Draw the radiocapitellar line along the long axis of the proximal 2–3 cm of the radius, not along the long central axis of the shaft of the radius.A line drawn along the longitudinal axis of the radial head and neck should pass through the capitellum. If it does not pass through the capitellum, a radial head dislocation is likely. Clinicians should check for radial head dislocation as this is an indication for an urgent orthopaedic referral (figure 5).Figure 5Radiocapitellar line.Are the ossification centres normal? (figure 6).7 14Remembering the order of when the ossification centres appear can be challenging 7 14 . Understanding when these appear is important to help reviewing x-rays of the elbow (figure 6) Figure 6Elbow ossification centres by age.Differential diagnosisIn the following sections, some of the most common elbow injuries and fractures are discussed. Where surgical management is mentioned, this implies an orthopaedic intervention. This will often involve a referral to orthopaedics for urgent consideration.Radial head subluxation or nursemaid’s elbow or pulled elbowIt is estimated that there are 50 000 presentations of pulled elbow to UK emergency departments every year.6 The child will usually present not using one arm. Radial head subluxation (RHS) usually occurs when a pull motion occurs. This sudden pull on an arm in a young child pulls the radius through the annular ligament. This may partially tear the ligament, allowing the radius to become trapped within the radial head and the capitellum.15 If the elbow is swollen, or the child is in significant distress because of this, it is less likely to be a pulled elbow. Therefore, other managementmay need to be considered (figure 7). Figure 7Pulled elbow mechanism.Hyperpronation and supination-flexion techniques are known methods of reducing RHS. The hyperpronation technique involves the examiner supporting the child’s arm at the elbow while applying moderate pressure on the radial head using one finger, and gripping the distal forearm with the other hand and quickly hyperpronating the arm.15 The supination-flexion technique involves the examiner supporting the child’s arm at the elbow while exerting pressure over the radial head, usually using a thumb or a finger. With the other hand, the examiner holds the distal portion of the forearm and pulls with gentle traction.15 Maintaining the traction, the examiner fully supinates the child’s arm. Whichever technique is chosen, remember the following:Give analgesia to the child.Warn parents that the child may cry during the procedure. Crying may occur due to the child not being able to understand the procedure or due to a very small discomfort during the procedure.Perform the procedure. You should feel a click. A click is an important confirmatory sign of a successful reduction and should be documented on the notes. If you did not feel a click, this may mean the procedure has not been successful.Whether successful or not, leave the child to go and play with some toys for 10–15 min and see if they start using the arm.If after reassessment the child starts using the arm, discharge the child. If the child has not restarted using the arm, consider a second attempt of relocation.If this fails, it is worth considering performing an X-ray of the arm and reconsidering the diagnosis.Most common elbow fracturesSupracondylar fracturesThese account for up to 60% of fractures around the elbow.7 Of these fractures, 5%–10% will have a neurovascular deficit.6 16 The most common affected nerve is the anterior interosseous nerve, which is estimated to affect 4.6% of supracondylar fractures. The second most common nerve affected is the radial nerve at 4.1%. Management can be both conservative and surgical. This will depend on the degree of displacement of the fracture, if there is any neurovascular compromise and on local policies (figure 8). Figure 8Supracondylar fracture.Fracture of the lateral epicondyleThis accounts for up to 15% of paediatric elbow fractures in children.1 Management for these fractures is often surgical (figure 9). Figure 9Lateral epicondyle fracture.Medial epicondyle avulsion fracturesThese often occur following throwing injuries and are included in ‘the little league’ injuries. These are where the medial epicondyle apophysis is separated. These fractures can be managed both conservatively and surgically (figure 10).Figure 10Medial epicondyle avulsion fracture.Radial head or neck fractureWith this type of injury remember to assess the distal radius as this can also be injured. Management will be dependent on the degree of displacement. This fracture can be managed both conservatively and surgically (figure 11).Figure 11Radial head fracture.Other elbow injuriesElbow dislocationsThese account for an estimated 5% of all elbow injuries in children.15 They carry a high risk of neurovascular injury. A prompt neurovascular assessment is crucial. Often these are caused by a direct fall on the elbow. These need urgent reduction either in the emergency department using ketamine sedation or in theatre (figure 12). Figure 12Elbow dislocation.Discharging patients: ‘safety netting’The following advice should be given to parents when discharging a patient:Analgesia is important, such as simple paracetamol and ibuprofen.If the patient develops any new numbness, tingling or paraesthesia in the arm, this may suggest the plaster is too tight. Therefore, the patient should return for review.If simple analgesia is not controlling the pain, or the pain is escalating, a review is needed. Consider if there is a problem with the cast. Did we miss another injury? Or could this be compartment syndrome or an underlying osteomyelitis? Compartment syndrome is uncommon, but possible in elbow fractures.16 17Figure 13 shows a summary infographic of the radiological considerations for the paediatric elbow. Download figureOpen in new tabDownload powerpointFigure 13Paediatric elbow injuries infographic. AP, anterior-posterior; RC, radiocapitellar.Figure 14Anterior-posterior X-ray of the elbow.Figure 15Lateral X-ray of the elbow.Figure 16Anterior-posterior X-ray of the elbow.Figure 17Lateral X-ray of the elbow.Test your knowledgeWhich nerve is most commonly affected in supracondylar fractures?Median nerve.Ulna nerve.Anterior interosseous nerve.Radial nerve.Posterior interosseous nerve.Which of the following ossification centres would you not expect to see on an X-ray of the elbow in child aged 9?Lateral epicondyle.Capitellum.Radial head.Internal (medial) epicondyle.Trochlear.Testing the anterior interosseous nerve can be achieved by making which of the following shape?Rock.Paper.Scissor.OK.High five.A child presents with a sore elbow following a fall on a playground. What do the following X-rays suggest (figures 14 and 15)?Supracondylar fracture.Radial head fracture.Radial neck fracture.Olecranon fracture.Elbow dislocation.A child presents with a sore elbow following a fall on a playground. What do the following X-rays suggest (figures 16 and 17)?Supracondylar fracture.Radial head fracture.Radial neck fracture.Olecranon fracture.Elbow dislocation.Answers to the multiple choice questionsC.A.D.A.B.References?Rennie L, Court-Brown CM, Mok JYQ, et al. The epidemiology of fractures in children. Injury 2007;38:913–22.doi:10.1016/j.injury.2007.01.036pmid: of ScienceGoogle Scholar?Marsh AG, Robertson JS, Godman A, et al. Introduction of a simple guideline to improve neurological assessment in paediatric patients presenting with upper limb fractures. Emerg Med J 2016;33:273–7.doi:10.1136/emermed-2014-204414pmid: Full TextGoogle Scholar?Appelboam A, Reuben AD, Benger JR, et al. 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BMJ 2008;337:a1518.doi:10.1136/bmj.a1518pmid: Full TextGoogle Scholar?Davidson AW. Rock-paper-scissors. Injury 2003;34:61–3.CrossRefPubMedGoogle ScholarView AbstractFootnotesTwitter @drsarahedwards, @damian_roland Contributors SE developed and wrote the article. DR reviewed and edited the article. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Patient consent for publication Not required. Provenance and peer review Commissioned; externally peer reviewed. Request PermissionsIf you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.Request permissionsCopyright information: ? Author(s) (or their employer(s)) 2020. No commercial re-use. 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