What is Pulled Elbow?

Pulled Elbow or “Nursemaids Elbow” is common in young children between 1 and 4 years of age.It is rare beyond the age of 6 years. It is due to the annular ligament of the radial head becoming stretched and entrapped. There is usually a history of a pull on the affected arm, such as when a child tries to run off in a different direction when walking with the hand held by a parent.Sometimes the incident is unobserved or thought to be too trivial to have caused any injury. The child typically allows the arm to hang loosely by their side in a pronated position. They are usually undistressed unless the arm is moved.

Clinical Features

• The parents come with complaint of the child not using the affected limb
• here is usually a history of a pull on the affected arm, such as when a child tries to run off in a different direction when walking with the hand held by a parent. Although there may not be history of pull in half the cases
• Inspection: The child keeps the elbow in extension and the forearm in pronation and is distressed only on elbow movement. Usually there is no swelling, deformity or bruising of the elbow or wrist
• Palpation:  tenderness is usually absent
• Movements: marked resistance and pain with supination of the forearm.

Diagnosis

• Clinically established with a classic history and examination.
• X rays are unnecessary if there is a typical history and no visible swelling or deformity. If the child has a pulled elbow the X ray is normal. The child may have normal use of the arm on return from radiology since positioning by the radiographer may solve the problem.
• Plain radiographs are indicated when a differential diagnosis is suspected:
  • significant tenderness, swelling, bruising or deformity
  • reduction fails

Treatment

The treatment consists of reducing the ligament back to its original position

1. Have your child sit in a chair facing you or stand facing you. Ask an older sibling or adult to distract the child as that there is slight temporary pain when you treat a pulled elbow, and it will be easier to slip the ligament back into place if the child is relaxed.
2. You should support the elbow with one of your hands, placing your thumb over the radial head with some gentle pressure. Hold
   the child’s hand in your other hand as if you are shaking hands.
3. Fully supinate the forearm and then fully flex the elbow. A click is usually felt over the radial head either when the elbow is fully supinated or fully flexed. This is known as supination/flexion manoeuvre. Alternatively one can also try full pronation followed by flexion (pronation flexion manoeuvre).
   

   

   

   

4. A click is felt as the ligament moves back into the correct position. You may not always hear this happen.
5. Offer the child a toy to see if he or she will once again use his or her arm.  A good test for successful reduction is whether the child will actively reach for a toy at arms reach. Most children will use the arm normally within 5 minutes of the reduction. There may be residual pain, but overall, the child should feel much better.
6. Failure may be due to not putting the elbow through the complete range of motion. Repeat the reduction if the ligament is still out of place. This process should cure and treat your child’s pulled elbow in a few seconds, and they should be ready to play once again.
7. If the reduction has been delayed for 12 hours or longer the child may not use the arm normally for a longer period of time.  A sling ± backslab can be used for comfort, with review of whether the child will use the arm 24 hours late

Recurrant Pulled Elbow

Recurrances with pulled elbow are common till 3-4 years age. The repeat injuries are treated in the similar manner. Repeated subluxations do not produce long term problems. The problem generally disappears by 5 year age. Very rarely, in child with multiple recurrances the doctor may advice cast for 3 weeks

Updates in the management of pulled elbow

Obscure pathology of pulled elbow: dynamic high-resolution
ultrasound-assisted classificationHossam S. Diab • Manal M. S. Hamed •Yasser Allam

J Child Orthop (2010) 4:539–543

Of the 50 included children, 39 (78%) had intact,yet interposed annular ligament (classified as type I) and 11
(22%) had torn annular ligament (classified as type II). The latter underwent splinting for 7 days. Three out of the 50
children had recurrent subluxation and constituted falsenegative cases for the detection of torn ligament and represented
the reoccurrence rate of 6%.

Dr Taral V Nagda

Institute of Paediatric Orthopaedic Disorders
 www.ipodindia.org
taralnagda@gmail.com

E plate hemiepiphysiodesis is a modern method to correct the deformities of long bones in a growing child. It works on the principle that controlling the growth on one side of growth plate results in angulation on the opposite side.

In presence of deformity the growth modulation on the convex side/ apical side can result in slow controlled correction of the deformity. The advantages of such a procedure will be

• No need of immobilisation or plaster as the bone is not cut
• Earlier mobilisation and return to activities
• Slow and safe correction
• The growth resumes normally after plate removal hence can be done even at younger age
• Timing of surgery not important as long as atleast 1 year available for corection before the growth stops.
  

Indications

• Correcting angular deformity in a growing child with open physis

Prerequisites

 
• 1 year of growth remaining
• One plane deformity frontal sagital oblique
• Growth potential on opposite side
  

Contraindications

• Closed Physis
• Skeletal Maturity
• Physio logical Deformities

Case Study

8 yr old girl with renal osteodystrophy with genu valgum shows excellent correction in 1 year

Equipments needed

• C ARM
• Radiolucent table
• 1mm and 1.5 mm guide wires
• E plate
• 4.5mm self tapping cannulated screws (15-30mm)
• Stop Drill

Surgical steps

Step 1 : LOCALIZATION OF PHYSIS

• Under image intensifier 1.5 mm guide wire is passed at the center of physis
• Confirmed in both AP & Lat views

Step 2: SKIN INCISION

• About 1.5 cm centered over guide wire
• The incision is deepened till perichomdrium
• E plate is positioned with its central hole sliding over the guide wire over the perichondrium
• The plate should be along the midline of the bone axis on lateral view

Step 3 GUIDE WIRES

• 2 guide wires are passed  through the holes on either sides of the physis
• They  need not be parallel but  care should be taken is not to violate the physis

Step 4 SELF TAPPING CANNULATED SCREWS

• Screw length is measured
• Should not be too short
• Generally 15-30 mm screws are sufficient
• Cortex is drilled
• Self tapping screws are passed

Step 5 Closure and Dressing

The closure is done in layers and compression dressing is applied.

No cast or immobilization is needed

Full weight bearing supported walking and knee mobilization are started the next day

Post op Protocol

• Day care surgery
• No immobilisation
• Immediate mobilisation
• Xrays once in 3 months
• Implant removal once the deformity is corrected

Advantages of E plate over staples

• Flexi bility
• Unconstrained implant
• Load sharing
• One plate per physis
• Fully threaded cannulated screws resist pull-out forces
• Diverging screws function like a hinge to gently guide natural growth
• Easy to remove

preoperative picture the child has varus and inernal rotation

3 year old child with tibia vara  The child has varus and internal rotation deformity not correcting on serial follow up.

Proximal  Block is made with 2 K wires inserted parallel to knee joint and perpendicular to the tibia.

Distal block is made with 2 K wires inserted inserted parallel to ankle and perpendicular to distal tibia.

In the transverse plane the proximal wires are in axis of the knee joint ( inter epicondylar axis) and the distal wires 15 degrees internal to bimalleolar axis

The osteotomy is made at CORA with multiple drill holes made in transverse plane and completed with 5 mm osteotome

When the wires are braught parallel the varus and the rotational deformities are corrected

The wires are connected  with miniexternal fixation clamps

An antero posterior anti toggle wire is added to proximal and distal blocks

The fixator is removed once the osteotomy heals generally 6 weeks post op

Step 1

Step 2

Indications for Tenotomy

Cases of CTEV on treatment with serial plasters by Ponseti method where forefoot is corrected but there is inability to get the ankle dorsiflexion beyond 20º.

Prerequisites

1. Pirani midfoot score 0
2. Forefoot abduction of approximately 60º should be achieved
3. Lateral border should be straight
4. Heel should be neutral or slight valgus

This abduction allows the foot to be safely dorsiflexed without crushing the talus between the calcaneus and tibia If the adequacy of abduction is uncertain, apply another cast or two to be certain. Abduction of approximately 60 degree in relation­ship to the frontal plane of the tibia is possible. Neutral or slight valgus of os calcis is present. This is determined by palpating the posterior os calcis.

Preparing the family-

Parents should be properly informed about the nature of the procedure proper consent should be taken. Post operative elevation, possibility of red discolouration due to blood ooze should also be explained

Anasthesia-

Tendoachilis tenotomy is done under local anesthesia. Before taking the patient on table lignocaine sensitivity test must be done.

Position-

Prone position is given to patient with proper padding for the trunk. An OT assistant

Preparation –

Procedure should be done in operation theatre to maintain the sterility and prepared for any complication though very rare.

Limbs are prepared with antiseptic solution distal to knee joint. Draping is done to isolate the field but care should be taken not to suffocate the child.

Surgeon should always wear the operating gown and sterile gloves.

Inj lignocaine 4%

without adrenaline is infilterated near and just above the tendoachilis insertion

Procedure-

Assistant dorsiflexes the ankle making the tendon tight and prominent keeping knee in extension. Tendon should be palpated at the insertion. 15 no blade (always with the handle for better control) is inserted with the single prick like incision (3-4 mm) just above the tendoachilis insertion medial to lateral side of the tendon with the bevel facing laterallt. The blade is now turned by 90 degrees to remain horizontal on anterior surface of the tendon. Tenotomy is done from inside out fashion from anterior to posterior surface of the tendon. Care should be taken not to damage the calcaneal cartilage.As assistant continues the dorsiflexion sudden “pop” is felt with achieving the full dorsiflexion. Dorsiflexion should be checked both in knee flexed and extended. There is no need to take sutures. Small dressing is applied and child

should immediatetely handed over to mother for feeding.

After 10 minutes once the bleeding is controlled and the child is relaxed an above knee pop is applied with knee in 90 flexion and feet externally rotated 60 and 20 dorsiflexion

Advantages of the prone position-

1. It is very easy to hold the child in the prone position.
2. Child is very comfortable in this position and does not kick while doing the procedure making the surgeon comfortable and in better control to carry out the procedure.
3. Tendoachilis is posterior structure and prominent in this position and therefore only tight tendon fibres are cut and avoid damage to peritendinous soft tissues.
4. Chances of damaging the neurovascular structures are very less.