Pulled elbow: A case of an atypical presentation in an infant

Abstract

Pulled elbow is more common between the ages of 1 and 4 years. A few cases have been reported in the literature under the age of 1 year. The usual mechanism of injury is forced pronation of an extended arm. We present a case of pulled elbow in an 8 months old infant with an atypical mechanism. The child rolled over to her side and stopped moving her left elbow. After excluding fracture with plain radiographs, pulled elbow was suspected on clinical assessment. Supination-flexion reduction method was used under analgesia. The child was observed until started mobilising the arm fully. A high index of suspicion for pulled elbow should be kept in infants despite the absence of the usual presentation. Careful clinical assessment and prompt reduction method result in regaining the normal function.

Full text

Forte Journal Of Orthopedics & Sports Medicine Volume 1 Issue 1 2019
Case Report
Citation: Haroon Majeed., et al. “Pulled elbow: A case of an atypical presentation in an infant”. Forte Journal
Of Orthopedics & Sports Medicine 1.1 (2019): 1-5
Page | 1
Pulled elbow: A case of an atypical presentation in an infant
Sahar Mohammed Al Blooshi11, Dr Ali Nawaz2, Mr Haroon Majeed*3
1Resident Emergency Medicine, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates.
2Consultant Emergency Medicine, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates.
3Consultant Trauma and Orthopaedic Surgeon, Manchester University NHS Foundation Trust, Oxford Road,
Manchester, England, United Kingdom.
*Corresponding Author: Haroon Majeed, MBBS; MRCS; MSc; FEBOT; FRCS (Tr & Orth), Consultant Trauma and
Orthopaedic Surgeon, Manchester University NHS Foundation Trust, Oxford Road, Manchester, England, United
Kingdom. Email ID: haroon.majeed@nhs.net
Received: March 27, 2019; Accepted: March 28, 2019; Published: May 05, 2019
Pulled elbow is more common between the ages of
1 and 4 years. A few cases have been reported in
the literature under the age of 1 year. The usual
mechanism of injury is forced pronation of an
extended arm. We present a case of pulled elbow
in an 8 months old infant with an atypical
mechanism. The child rolled over to her side and
stopped moving her left elbow. After excluding
fracture with plain radiographs, pulled elbow was
suspected on clinical assessment. Supination-
flexion reduction method was used under
analgesia. The child was observed until started
mobilising the arm fully. A high index of suspicion
for pulled elbow should be kept in infants despite
the absence of the usual presentation. Careful
clinical assessment and prompt reduction method
result in regaining the normal function.
Nursemaid’s elbow, commonly known as pulled
elbow, is defined as subluxation of the radial head
caused by axial traction or a sudden pull of an
extended and pronated forearm [1]. Radial head
subluxation accounts for two-thirds of the upper
extremity injuries in pre-school children and is the
most common cause of sudden inability to
mobilise the elbow [2]. The radial head slips out of
the annular ligament in to the supinator muscle [3].
Pulled elbow has been reported to be more
common in children between the ages of 1 and 4
years with a peak incidence between 2 and 3 years
[3, 4]. Some epidemiological studies have reported
a slightly higher incidence in girls, however a
Introduction
Abstract

Forte Journal Of Orthopedics & Sports Medicine Volume 1 Issue 1 2019
Case Report
Citation: Haroon Majeed., et al. “Pulled elbow: A case of an atypical presentation in an infant”. Forte Journal
Of Orthopedics & Sports Medicine 1.1 (2019): 1-5
Page | 2
recent large study reported no significant gender
difference in its incidence [3]. Fewer cases have
been reported under the age of 1 year [4, 5].
Typical history of a pulled elbow includes forced
pulling the child along by the hand or the child
tossing and turning with his or her arm under the
body [3, 4]. The presentation usually includes
sudden acute pain with the child seen not to
mobilise the affected arm and holding it close to
his or her body. Plain radiographs are
recommended to exclude fractures [2]. Treatment
typically includes flexion-supination manoeuvre
however, hyperpronation method is also used, with
some studies reporting this to be less painful [6, 7].
Successful reduction leads to return of full
function and favourable prognosis [4]. A large
series of 2331 cases of pulled elbow during a 10-
years study period, reported that 3.9% of pulled
elbows occurred in children under the age of 1
year [4]. We report a case of pulled elbow in an
eight-month old child with atypical history and
presentation.
Her mother brought an eight-month old girl to the
emergency department as she noticed the child had
stopped moving her left arm. There was no
reported history of trauma, fall or forced-pulling
the child with hands. However, her mother noticed
that the child rolled over to her side while
crawling, followed by crying and inability to move
her left arm. There was no delay in presentation
and the child was brought within an hour of this
occurrence. There were no other reported health
problems or similar history in the past. The
suspicion of non-accidental injury was sufficiently
excluded on history. On examination the child was
sitting comfortably in her mother’s lap. Her left
arm was noticed to be held in extension and
pronation with no visible bruising or deformity.
On closer look there was a subtle swelling around
the left elbow compared to the opposite side. The
child was hesitant for her affected elbow to be
palpated or attempted to be mobilised. Plain
radiographs of the elbow and the rest of the arm
were obtained and the possibility of a fracture was
excluded (Figure 1). Despite the very young age of
the child (< 1 year) and the lack of usual history of
presentation, the diagnosis of a pulled elbow was
suspected.
After administration of sufficient analgesia and
explanation to the child’s mother, an attempt of
supination and flexion manoeuvre was performed
holding the child’s elbow at 90° with one hand
while supinating the wrist and flexing the elbow
with the other. Although there was no audible click
during this manoeuvre but the child was noticed to
be more comfortable and started mobilising her
elbow actively within 10 to 15 minutes. She was
observed for a period of 30 minutes and
subsequently discharged from the emergency
department with appropriate advice to her mother
with regards to analgesia and mobilisation. A
telephonic follow-up was performed at 8 weeks
Case History

Forte Journal Of Orthopedics & Sports Medicine Volume 1 Issue 1 2019
Case Report
Citation: Haroon Majeed., et al. “Pulled elbow: A case of an atypical presentation in an infant”. Forte Journal
Of Orthopedics & Sports Medicine 1.1 (2019): 1-5
Page | 3
after the injury and no issues were reported by the
child’s mother with regards to the elbow.
Figure 1: Anteroposterior and lateral plain
radiographs prior to reduction manoeuvre to exclude
fracture
Young children are prone to sustain pulled elbow
largely because of the anatomical features
including the shallow, concave radial head,
relative plasticity of the cartilage and the immature
annular ligament [8]. The usual mechanism of
forced-pulling on an extended forearm, commonly
seen in the usual age of presentation (1 to 4 years),
may not be seen in children under the age of 1
year. This may be due to the fact that generally, a
child starts standing and walking at about 1 year of
age, so the 1-year-old or older children have a
higher physical activity level than the under-1-
year-old infants [4]. Rolling over during sleep
begins at about 5 months of age. Pulled elbow may
occur when the child rolls over without co-
ordination, thereby trapping the arm underneath
the body [4].
The incidence of pulled elbow is far less common
in this age group (under 1-year) and the
presentation may be atypical [4]. This leads to
difficulty in establishing the diagnosis and the
dilemma of performing the reduction manoeuvre
in the absence of the typical presentation. The
child with this injury may be sitting calm or even
be seen playing holding the affected arm with the
body. In the usual age group (1 to 4-years), the
history of presentation and the findings of clinical
examination are considered sufficient for making
the diagnosis. Plain radiographs, although not
considered necessary, but are important primarily
to exclude fractures prior to performing the
reduction manoeuvre, in particular in cases of
atypical presentation [5, 8]. Obtaining plain
radiographs is also important in view of the fact
that there have been a few reports of such cases of
fractures which were initially misdiagnosed as
pulled elbow and the patients were unnecessarily
exposed to reduction manoeuvres [4, 9]. On plain
radiographs an increased radio-coronoid distance
is considered to be the most frequently visible and
Discussion

Forte Journal Of Orthopedics & Sports Medicine Volume 1 Issue 1 2019
Case Report
Citation: Haroon Majeed., et al. “Pulled elbow: A case of an atypical presentation in an infant”. Forte Journal
Of Orthopedics & Sports Medicine 1.1 (2019): 1-5
Page | 4
confirmatory sign of pulled elbow, however, this
may be difficult to appreciate in a very young child
(< 1 year) [5]. Studies have also reported a
valuable role of ultrasonography for establishing
the diagnosis of pulled elbow if the presentation
and diagnosis remains unclear [7, 8].
When a child is brought with a painful or swollen
elbow with lack of movements, with or without a
history of an injury, the differential diagnosis,
other than pulled elbow, includes supracondylar
fracture, olecranon fracture, radial neck fracture,
lateral condyle fracture, soft tissue contusion and
septic arthritis [3].
Various reduction manoeuvres have been
described, of which, two are most commonly
practiced. These include supination-flexion, as
described above, and hyperpronation, which is
performed by holding the child’s elbow at 90° with
one hand while firmly pronating the wrist with the
other [4, 6, 7]. A debate regarding the choice of
reduction method is ongoing in the literature. In a
recent Cochrane review of 9 studies (906 patients),
Krul et al. found that the hyperpronation method
was slightly more effective at first attempt and less
painful [7], however overall the studies were found
to be of low quality with limited evidence. The
failure rate of hyperpronation method ranged from
4.4% to 20.9% (mean 9.2%), and of supination-
flexion method ranged from 16.2% to 34.2%
(mean 26.4%). Bexkens et al., in another
systematic review and meta-analysis with 7
randomized trials from 1998 to 2016 (701
patients), also revealed similar results after
reduction of primary and recurrent pulled elbows
[10]. Bek et al., in a randomised controlled trial
(66 patients), compared the two methods of
reduction and found similar rates of final reduction
[6].
Successful reduction is indicated by the child’s
ability to commence mobilisation of the elbow
soon after reduction, regardless of the either
method used by the treating physician [3].
However a satisfying ‘click’ is not always heard
and is reported in 70% cases [4]. Children with
pulled elbow usually respond dramatically to the
reduction with a complete resolution of pain and
are seen to recover to full function [8]. Temporary
immobilisation with a sling for 2 days has been
shown to reduce the risk of recurrence, however,
the sling may be difficult to tolerate by the
younger children [3, 11]. The literature reports an
estimated incidence of recurrent pulled elbow of
27% to 39%, mostly among children in first 2
years of life [3]. If neglected, it might, in rare
cases, result in a long-term functional disability [3,
8] and might be one of the rare causes of
osteochondritis dissecans of the radial head [12].
Pulled elbow is less common in children under the
age of 1 year. A high index of suspicion should be
kept in this age group in case of a young child
presenting with inability to mobilise the elbow,
Conclusion

Forte Journal Of Orthopedics & Sports Medicine Volume 1 Issue 1 2019
Case Report
Citation: Haroon Majeed., et al. “Pulled elbow: A case of an atypical presentation in an infant”. Forte Journal
Of Orthopedics & Sports Medicine 1.1 (2019): 1-5
Page | 5
despite the absence of the usual history of a pulled
elbow. After exclusion of a fracture with plain
radiographs and administration of sufficient
analgesia, the appropriate reduction manoeuvre
results in complete resolution of pain and return of
full function.
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