The Painful Elbow
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To review common presentations of the painful elbow in pediatric population.
An 8-year-old presents with acute right elbow injury and pain. What is your initial approach?
- DO NOT MISS emergencies: Any open wound, dislocation, pain out of proportion or exam with neuro-vascular compromise suggests severe injury or compartment syndrome.
- Palpable tenderness with effusion, and/or swelling suggests fracture and warrants imaging.
If you suspect compartment syndrome and the patient is in clinic, what should you do next?
- Call 911 for transport to the ED—compartment syndrome can quickly lead to loss of limb.
- Classically, there are 6 "P's" associated with compartment syndrome:
- Pain out of proportion
- Pulselessness (very late finding)
- Poikilothermia (the inability to regulate body temperature)
A 2-year-old acutely is not moving her elbow and parents give a good story for a nursemaid elbow. What is the best way to reduce a nursemaid elbow?
- Calm the patient and have the patient sit on the caregiver’s lap while you evaluate for swelling and tenderness. If there is no swelling and you cannot palpate any deformities, bony step offs or point tenderness, and you suspect nursemaids elbow, proceed to attempt the reduction.
- Two ways to reduce a nursemaid elbow:
What are the typical ages for nursemaid elbow?
- 6 months to 4 years old.
- After 5-6 years old, the annular ligament becomes fibrous and less likely to slip over the radial head.
If nursemaid elbow reduction does not work, exam is reassuring, and x-rays are negative, what are your next steps?
- Consider a contusion or occult fracture.
- Splint the patient in a long arm splint with the wrist immobilized in a neutral position (either supinated or pronated) and the elbow at 90 degrees.
- Repeat physical exam and x-rays in one week.
What are helpful hints for examining young children?
- Sit down so as to make yourself look smaller, use distractions such as lights and toys, and examine other parts of the body first, such as heart and lungs.
- Develop trust and rapport with the patient prior to the exam.
- Watch the patient’s face for any clues of tender areas by looking for a change in expression or an increase in crying from baseline.
What should a pediatrician be looking for on an x-ray of the lateral elbow?
- There are two important lines which help in the diagnosis of dislocation and fracture . These are the Anterior humeral line and the Radiocapitellar line.
- Anterior humeral line: A line drawn (on the lateral view X ray) along the anterior surface of the humerus should pass through the middle third of the capitellum. If it does not bisect the capitellum, that is concerning for a supracondylar fracture—especially if a posterior fat pad is present.
- Radial capitellar line: A line drawn through the center of the radial neck should pass through and bisect the capitellum. This is regardless of the positioning of the patient (any view on Xray) since the radius articulates with the capitellum. If it does not bisect the capitellum, that is concerning for a fracture or other occult injury.
What are three typical findings concerning for occult fracture on lateral elbow x-ray?
- An anterior humeral line that does not bisect the capitellum implies supracondylar fracture.
- A radial capitellar line that does not bisect the capitellum implies radial head dislocation or radial neck fracture.
- A posterior fat pad implies traumatic effusion, possible occult supracondylar fracture.
What do fat pad signs on elbow x-ray signify?
- A posterior fat pad sign is sensitive for joint effusions and is concerning for occult fracture.
- The anterior fat pad sign (a.k.a. anterior sail sign), can be normal and does not necessarily signify an occult fracture, but in the clinical setting of tenderness or swelling of the elbow, splinting and repeat x-rays in 7-14 days should be performed to look for callus formation indicative of a healing fracture.
- If there is no posterior fat pad sign and no obvious break in the bone, you can be pretty confident that there is no fracture or occult fracture.
When should you sling versus splint a radial head fracture?
- Sling if the radial head fracture is non-displaced, subtle, and non-comminuted.
- Splint and immobilize if
- the fracture angle is greater than 30 degrees
- there is > 2 mm displacement
- a comminuted fracture.
What other elbow injuries are important for general pediatricians to be familiar with?
- Overuse injury is a growing phenomenon in the past 5-10 years due to increased sports activities in youth.
- Pediatricians should evaluate for apophysitis or apophyseal avulsion.
- There are two types of growth plates—physis and apophysitis.
- Physis is a growth plate along the long bones of the body that makes the child longer and taller.
- Apophysis is a growth plate to which muscle tendons attach and give shape to the bone. In children, this is a weak link, which can be prone to bony injuries called apophysitis.
What is a classic history for an apophysitis versus an apophyseal avulsion?
- Classic history of an apophysitis is a baseball pitcher who throws several times a week, plays several times per week, has increasing pain with medial throw, and has been losing velocity on his throw.
- Classic history of an apophyseal avulsion is a baseball pitcher who is doing okay but has gradually increasing pain, hears a pop on one pitch and suddenly cannot throw anymore.
- Obtain x-rays to help distinguish between the two. On x-rays, look for growth centers and a widened or displaced apophysis. Bilateral x-rays are helpful to compare the opposite arm.
What about little league elbow?
- For little league elbow, pay attention to the medial epicondyle.
- Can be common with baseball players during wind-up since the abducted externally rotated (ABER position) pulls on the medial epicondyle.
- Any tenderness or effusion there are good indications for imaging to evaluate for any bony injuries.
Are there lateral epicondyle injuries in kids?
- Yes, the abduction and external rotation (ABER) position pulls on the medial epicondyle and compresses the lateral aspect of the elbow.
- You don’t typically see fractures and avulsions on the lateral side, but you can see osteochondritis dissecans.
What is osteochondritis dissecans?
- Segmental avascular necrosis of articular subchondral bone (Staheli’s Pediatric Orthopedics 3rd edition).
- Most common at the end of growth (during early adult life) and in joints subject to repetitive microtrauma.
Is tapping the joint the only definitive way of distinguishing septic bursitis versus simple overuse injury?
- Yes, but use the patient’s history to help.
- You may not need to tap the joint if the patient has minimal swelling over the bursa, no fevers, has no pain with range of motion, is healthy, is not immunocompromised and you overall have a very low clinical gestalt of septic bursitis.
When can you send overuse injuries back to play and what should you advise in regards to rehab?
- Get the child to rest. Advise families that return to play too early can make the injury worse.
- For the little league elbow with reassuring x-rays, advise families about 4 to 6 weeks of rest with a goal of return to play without pain.
- During this time, physical therapy can work with children to improve the biomechanics of their throw by using core muscles, shoulder, and the whole body instead of just the arm.
There has been a lot of talk about non-steroidal anti-inflammatory drugs (NSAIDs) and not administering them while bones and cartilage are healing—is it okay to give NSAIDs?
- Much of the talk about avoiding NSAIDS while bone and cartilage are healing was extrapolated from animal studies.
- For the most part, it is considered acceptable to use NSAIDs, so long as they are not used for a prolonged period of time.
- ED evaluation for open fractures, dislocations, compartment syndromes, and severe supra-condylar fractures are warranted and should be done via EMS transport to the closest ED.
- Watch out for epicondyle fractures and osteochondritis dessicans.
- Reduce nursemaid elbows in clinic and send them home.