Episode 61 – The Elbow

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We review a podcast from Dr. Tim Horeczko’s Pediatric Emergency Playbook on elbow injuries.

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Core Content

We delve into core content on other elbow adjacent injuries using Rosen’s Emergency Medicine (8th edition) Chapter  and Tintinalli’s Emergency Medicine (8th edition) Chapter  as a guide.

Elbow Trauma

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 Rosh Review Emergency Board Review Questions

A 63-year-old man presents with left arm pain after a fall. His X-ray is shown below. What structure is commonly injured with this fracture?

A. Axillary nerve

B. Median nerve

C. Radial nerve

D. Ulnar nerve

Answer

C. Radial nerve injury is the most common nerve injury seen after humeral shaft fractures. These fractures usually occur from a direct blow to the arm and can be seen in falls and motor vehicle collisions. Patients present with severe pain, arm swelling and decreased range of motion. The arm can be shortened or rotated in a complete fracture depending on the location of the fracture. A complete neurovascular exam should be performed as with all fractures and dislocations. The radial nerve may be injured during humeral fracture in up to 20% of patients. The injury is usually a neuropraxia and resolves spontaneously in most patients. However, this recovery can take months. Humeral fractures rarely need specific reduction maneuvers for treatment. They should be placed in a sugar tong splint and placed in a sling. Gravity alone is typically successful in fracture reduction. The axillary nerve (A) may be injured during glenohumeral dislocations. The median nerve (B) may be injured during posterior elbow dislocations. Anterior elbow dislocations can be associated with ulnar nerve injury (D).

 

A 3-year-old girl was walking on the sidewalk with her mom when she fell onto the street. In a panicked state, her mom picked up the little girl by her arm. Immediately after, the little girl refused to move her right arm complaining that it hurt. In the emergency room, the girl is holding her right arm in a flexed, pronated, and adducted position. There is no crepitus, swelling or point tenderness along the entire right arm or clavicle. Which of the following is the next step in management of this patient?

A. Actively supinate and flex the elbow while applying pressure over the radial head

B. Consult orthopedics for casting

C. Obtain an ultrasound

D. Perform a skeletal survey

Answer

A. This child has “nursemaid’s elbow” that is due to subluxation of the annular ligament rather than dislocation of the radial head. The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. It occurs in toddlers due to traction via pulling on a pronated and extended arm. The child immediately refuses to the move the arm and often cradles the affected arm. Parents often give a history of a young child with no history of trauma who suddenly refuses to use an arm. The diagnosis is clinical and imaging studies are generally not needed. If reduction is unsuccessful after 2–3 attempts then imaging studies may be warranted. Treatment is manual reduction via supination and flexion or hyperpronation. A palpable click may be felt and the child usually regains immediate movement of the arm and relief of discomfort. A skeletal survey (D) should be obtained in all cases of suspected child abuse to assess for fractures in multiple stages of healing. Child abuse should be on the differential in all pediatric orthopedic cases. Consulting orthopedics for casting (B) is not necessary as this is a dislocation injury. Ultrasonography (C) has been used as a noninvasive modality to assess for annular ligamentous injury and displacement of the radial head from the capitellum. It has also been used to assess progress of treatment for patients with recurrent subluxations, however it is not the first-line diagnostic nor treatment option.

Episode 49 – The AAP BRUE (formerly ALTE) Guidelines

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The Free Open Access Medical Education (FOAM)

We review the American Academy of Pediatrics guideline on Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants.

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Note: Some have voiced concerns that these guidelines potentially downplay the event. The concern is that the yield of these workups and admissions may be low, but possibly worthwhile.  At FOAMcast, we are not qualified to critique these guidelines but there are helpful tables and charts in them to realize that these recommendations really are only for specific events and children AFTER thorough history and physical.

Generously Donated Rosh Review Question

A 6-week-old boy is brought to the emergency room because of cyanosis. He was sleeping comfortably in a supine position right after a feeding when he suddenly choked, became limp and lips turned blue. The mother witnessed the event and blew to the face of the boy. The whole episode lasted for about two minutes. EMS was called and upon arrival at the house, the boy was back to his usual self. At the ER, he boy has normal vital signs with normal physical examination findings.

A. Admit for cardiorespiratory monitoring

B. Discharge after reassuring the parents

C. Observe for four hours in the ER

D. Request for complete blood count

Answer

A. Admit for cardiorespiratory monitoring. The boy in the vignette had an apparent life-threatening event (ALTE) which is not a specific diagnosis but a description of an acute, unexpected episode that is frightening to the caretaker. ALTE includes one or more of the following features: apnea, color change (may be cyanotic, pallid, erythematous or plethoric), marked change in muscle tone (limpness or rigidity) and choking or gagging. A specific cause for ALTE can be identified in over one-half of patients after a careful history, physical examination, and appropriate laboratory evaluation. The remaining cases are considered idiopathic if no cause can be identified after a thorough assessment. Common etiologies for ALTE include gastroesophageal reflux, neurologic problems (such as seizures), and respiratory infection. The history of an ALTE must be taken seriously, even if the infant appears entirely well by the time he or she is evaluated. In-hospital observation with cardiorespiratory monitoring is indicated for infants whose initial evaluation suggests physiologic compromise. Hospital admission may provide important clinical information where additional episodes may be witnessed by medical personnel during the observation period. In addition, serious underlying medical conditions may become apparent.  Discharging the patient after reassuring the parents (B) and observing the patient for four hours in the ER (C) are not appropriate management strategies for the infant in the vignette who needs admission for cardiorespiratory monitoring. Requesting for complete blood count (D) is not routinely done in the evaluation of an ALTE and would not aid in the management for the infant in the vignette.

References:

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B et al. Subcommittee on Apparent Life Threatening Events. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.  Pediatrics. In Press

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