Newport: Nursemaids Elbow

Cases:

Patient #1: 18 month old boy who had been riding in the basket of a shopping cart. His older brother grabbed and pulled on his arm from inside the main part of the cart. He cried immediately and afterwards would not move the arm. Exam showed a crying, well-developed toddler holding his arm splinted to his body. The arm appeared normal with no swelling and was mildly tender to palpation diffusely. Reduction was attempted, child was left alone with family and after 10 minutes was happily eating a popsicle and using his arm. Magical. Re-exam showed no swelling and normal ROM. Pt was discharged within 20 minutes of arrival. The parents were profusely thankful. You leave the room feeling like a total rock star.

Patient #2: 2.5 year old girl who presented about 2 hours after a fall from a low stool. She was roughhousing with siblings and toppled onto the ground on her outstretched arm. She cried afterwards and then wouldn't move the arm. Mom was a military spouse and had 4 other children, 3 of whom had sustained nursemaid's elbows. She had learned the reduction maneuver and attempted to reduce it at home. The patient cried more and still wouldn't use the arm, so mom brought her to the ER. Exam showed a young girl holding her arm close to her body. The arm had very slight swelling at the distal humerus and was focally tender to palpation at the distal humerus only. Reduction was attempted but after 10 minutes she was still not using her arm. X rays were obtained and showed a non-displaced supracondylar fracture. You leave the room kicking yourself and wondering “why didn’t I just get x-rays.” Pt was sent to the local children’s hospital, casted, followed conservatively and had cast removed in 4 weeks.

Could this unfortunate situation been avoided? The good news is, probably yes.

Commonly referred to as nursemaid’s or pulled elbow, radial head subluxation is a common injury in toddlers. It occurs when longitudinal traction is placed on an extended and pronated arm. This position allows the annular ligament to catch between the radial head and the capitellum. It occurs slightly more often in girls and on the left side. It is usually a pulling mechanism (50%), but can be seen with falls, direct blow or twisting. In <6 months, MOI is usually rolling over. The most common scenario is an adult pulling abruptly up on the arm, such as tolift the child onto a sidewalk or step, or when the child abruptly falls/throws themselves to the ground while an adult is holding their arm (i.e. tantrum injury).

Nuresemaid’s is a clinical diagnosis. Children with suspected nursemaid’s generally hold the arm close to their bodies, with elbow extended or flexed/pronated. The arm should not be painful unless moved. The radial head may be tender, but the distal humerus should not be. Swelling is rare. Exam should palpate the entire extremity from clavicle to fingers if possible.

How to reduce? There are two methods: extension/supination and “forced” or hyperpronation.

Hyperpronation: Support elbow with finger at radial head giving mild pressure. Hold distal forearm and hyperpronate. 

Extension/supination: Support arm at elbow with finger at radial head. Pull traction on forearm, fully supinate then fully flex in a single movement.

Both methods are widely used and both work. Multiple studies have been done comparing the two methods.  The evidence is not overwhelming, but it appears pronation MAY have a slightly increased success rate and decreased perception of pain. So… Pronation may have the edge.

Nursemaid's Elbow Pearls:

  • Entrapment or partial tearing of annular ligament
  • 20-25% of elbow injuries in children
  • 50% from pulling mechanism
  • Most common ages 1-3
  • Will not use arm
  • Holding arm extended or slight flexion. Distal humerus is NOT tender but radial head may be.
  • No swelling
  • X-rays if: Swelling, unusual mechanism, tenderness to palpation over distal humerus, focal tenderness
  • Differential: Supracondylar or buckle fracture
  • Reduction maneuvers: Supination/flexion versus hyperpronation
  • Hyperpronation may be less painful and have a slightly higher success rate

Faculty Reviewer:

Dr. Kristina McAteer 

References:

i. McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med. 1999;6(7):715. 

ii. Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998;102(1):e10. 

iii. Krul M, van der Wouden JC, van Suijlekom-Smit W, Koes BW. Manipulative interventions for reducing pulled elbows in young children. Cochrane Database Systematic Review. 2012 Jan 18;1.

iv. Coleman R, Reiland A. Chapter 28. Orthopedic Emergencies. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment Emergency Medicine, 7e.New York, NY: McGraw-Hill; 2011. 

v. Green DA, Linares MY, Garcia Peña BM, et al. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatr Emerg Care 2006; 22:235.

vi. Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom MP, Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: a systematic review and meta-analysis. Am J Emerg Med. 2016 Nov 2 (epublished ahead of print )

52 Articles: Head CT in Minor Trauma

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:

Haydel et al., NEJM 2000.  Indications for Computed Tomography in Patients with Minor Head Injury.

Main Points:

1. This two-phase prospective trial sought to “derive and validate a set of clinical criteria that could be used to identify patients with minor head trauma in whom a head CT (HCT) could be foregone.”

2. “Minor head trauma” was defined as: loss of consciousness in a patient presenting with GCS 15, intact cranial nerves, and normal strength and sensation in all extremities.

3.  The presence of at least one of the following: Headache, vomiting, age >60 years old, drug/alcohol intoxication, short-term memory deficit, evidence of trauma above the clavicles, or post-traumatic seizure, was found to be 100% sensitive for subsequently positive HCT (presence of cerebral contusion, subdural or epidural hematoma, depressed skull fracture, or subarachnoid or intraparenchymal hemorrhage).

Background:

Since the advent of CT in the 1970s, many studies have sought to determine the most efficient and best use of this powerful tool for minor head trauma.  Early studies of HCT on patients with GCS 13-15 showed 17-20% incidence of positive findings and recommended HCT for all, but subsequent studies have shown positive HCT findings in GCS 15 patients to be as low as 6-9%.  Historically in the USA, ~66% of annual head trauma is “minor,” ~10% of this group will have positive HCTs, and ~1% will require neurosurgery.  This begs the question: is there a subset of minor head trauma patients for whom HCT adds little or no value?  Could we save time, money, and risk of complications for all participants if we could identify these patients based on clinical presentation? 

Method:

The study occurred at a large urban Level 1 trauma center from 1997 to 1999, and was split into two phases.  Phase 1 enrolled 520 consecutive patients with minor head trauma who were over 3 years old, presenting <24 hours since the trauma, getting a HCT already, and had “minor head trauma,” defined as a loss of consciousness in a patient with a GCS of 15, normal cranial nerves, and normal strength and sensation in all extremities.  No patients who did not lose consciousness or who declined HCT were included, and the CT scan was considered “positive” if it showed a cerebral contusion, subdural or epidural hematoma, subarachnoid, depressed skull fracture, or intraparenchymal hemorrhage.

Seven clinical variables from Phase 1 were found to correlate with positive HCT findings, and their predictive value was prospectively assessed in Phase 2, which enrolled 909 patients with the same inclusion criteria as Phase 1.  Importantly, the Phase 2 patients still received normal trauma care, with HCTs ordered at the discretion of the providers whether or not any of the Phase 1 variables were present; the researchers were simply validating the Phase 1 criteria again.

Results:

●        Phase 1 (520 patients)

○        36 patients (6.9%) had positive HCTs

○        Predictive Variables: Headache, vomiting, age >60, post-traumatic seizure, short-term memory deficit, drug/alcohol intoxication, and evidence of trauma above the clavicles. Of note, "short-term memory deficit + drug/alcohol intoxication + evidence of trauma above the clavicles” were the strongest predictors: If they had scanned ONLY the patients who had all 3 of these combined, the number of scans would have decreased 31%, and sensitivity would still have been 94%

●        Phase 2 (909 patients)

○        57 patients (6.3%) had positive HCTs

○        All patients with positive findings had at least 1 of the seven Phase 1 variables (sensitivity 100% [95% CI 95-100], specificity 25%, NPV 100%)

○        All 212 patients (23.3%) with ZERO Phase 1 variables had negative HCTs (20-26%, 95% CI; NPV 100%)

●        Of 93 patients from both Phases who had positive HCTs (total % → % obs, % surgery):

○        Cerebral Contusion: 47% →  100%, 0% 

○        SDH: 38% → 94%, 6%

○        SAH: 14% → 100%, 0%

○        Epidural: 10% → 78%, 22%

○        Depressed Skull Fracture: 11% → 80%, 20%

Discussion:

●        Historically, lots of head trauma (66%) is minor, with few (~10%) of these patients having positive HCTs, and even fewer (~1%) requiring neurosurgery.  So there is fat to trim.

●        In this study alone, if the criteria derived in Phase 1 had been applied to the Phase 2 patients (ie, “do not scan if zero variables are present”), the number of HCTs would have decreased by 22% with no additional missed findings. This certainly has broader implications when considering the trajectory of our healthcare spending as a percentage of GDP…. which is essentially like the SpaceX Falcon 9 rocket, which has 9 liquid oxygen engines and can generate 1.5 million pounds of thrust at sea level.

○        The study quotes one estimate that a 10% reduction in the number of HCTs in minor head trauma patients would save >$20,000,000 per year

●        This was the first study to derive predictors that were 100% sensitive for positive HCTs, but it is important to note a few caveats:

○        The 95% Confidence Interval of “95-100%” for the sensitivity of their variables indicates that when generalized to the great big world, there is a chance that these predictors will no longer be perfect

○        “Positive CT findings” obviously does not necessarily equate with morbidity or mortality.  Whether we should try to find CT findings or those lesions that require intervention is a broader, and more controversial, topic.  This study simply sought to attain 100% sensitivity for HCT findings with a high degree of confidence.  They provide no information on the clinical significance of these findings as far as mortality or functional outcome.

●        Bottom line: Holding the clinical significance of lesions and a discussion on the sensitivity of HCT aside, discharging patients home after minor head trauma with a negative HCT and a normal neurological exam is generally supported in the literature.  If the variables these investigators are promoting help to identify patients who are exceedingly unlikely to benefit from receiving a HCT, and it saves everyone money, time and some risk of complications, then let’s consider it the next time someone comes in after being struck in the face by a feather.

Level of Evidence:

Based on the ACEP grading system for therapeutic questions this study was graded a level I.

Reviewers:

Resident Reviewer: Dr. Anatoly Kazakin
Faculty Reviewer: Dr. Matt Siket

Source Article:

Haydel et al. Indications for Computed Tomography in Patients with Minor Head Injury. N Engl J Med.  2000 July;343(2);100-105.

A Fast Diagnosis

CASE:

HPI: Johnny is a 5 year-old boy, previously healthy, who presents with fever, emesis, and abdominal pain for one week. Eight days ago, he had fevers as high as 102F, but was otherwise feeling well. Four days prior to admission his fevers resolved, but he developed emesis and abdominal pain, which continued daily until presentation.

Vitals:  Temp 37.4°F | Pulse 106 | Resp 20 | SpO2 98% | BP 139/96

Exam: Appears fatigued. Abdomen distended with increased bowel sounds, tympany to percussion, and diffuse tenderness. No hepatosplenomegaly. No respiratory distress or increased work of breathing.

You decide to take an ultrasonographic look at his abdomen, thinking this could be appendicitis or intussusception. You throw the probe on the patient’s right and left upper quadrants, and see the following:

How do you interpret these clips?

These images demonstrate bilateral pleural effusions and B-lines (see Figure 1):

Figure 1: Right and left upper quadrant views of abdomen, respectively, demonstrating bilateral pleural effusions (green arrows) and B-lines (blue arrows).

Figure 1: Right and left upper quadrant views of abdomen, respectively, demonstrating bilateral pleural effusions (green arrows) and B-lines (blue arrows).

What would be your next step?

After obtaining these images, it was decided to obtain dedicated images of the lung, leading to the procurement of the following clips:

How do you interpret these clips?

Both sets of images demonstrate diffuse B-lines bilaterally, as well as pleural effusions (Figure 2):

Figure 2: Right and left posterior lung fields, respectively, with diffuse B-lines bilaterally (blue arrows), as well as pleural effusions (green arrows).

Figure 2: Right and left posterior lung fields, respectively, with diffuse B-lines bilaterally (blue arrows), as well as pleural effusions (green arrows).

What are B-lines?

B-lines are vertical, hyperechoic lines originating from pleura, which obliterate normal horizontal A-lines in their wake.

  • Isolated B-lines may be a normal finding in healthy lungs, but if there are three or more of them in one interspace they are considered pathologic.
  • They are caused by a decreased difference in density or acoustic impedance between the pleura and parenchyma, and represent fluid in the alveolar or interstitial spaces.
  • Several potential physiologic causes of this artifact include: (1)

o   Intra- or interlobular septal thickening
o   An increase in lung parenchymal water content
o   An increase in lung parenchymal density
o   Decreased lung ventilation.  

  • If diffuse, they can signify:

o   Pulmonary edema
o   Acute Respiratory Distress Syndrome (ARDS)
o   Congestive Heart Failure (CHF)
o   Interstitial fibrosis.

  • If local, they can represent:

o   Pneumonia
o   Pulmonary contusion
o   Infarct 

How do pleural effusions appear on ultrasound?

  • FAST View: Anechoic triangle above the diaphragm in RUQ and LUQ views.
  • Lung may be seen as a triangular structure superior to the diaphragm that exhibits a wave-like movement as if floating in the fluid.

    o   In our case, the lung has fluid in the interstitial spaces, and is therefore appreciated as B-lines as is described above.

Did you know that ultrasound is more sensitive than chest radiograph for pleural fluid?

Ultrasound can detect physiologic amounts of pleural fluid (5mL), but becomes more reliable with increasing volumes, and is 100% sensitive for detecting effusions >100mL. (3)

Contrast this with chest radiography, in which blunting of the costophrenic recesses are seen only after >200mL of pleural fluid has accumulated.

What could cause these findings in the setting of this patient’s signs and symptoms?

The patient’s B-lines are bilateral and diffuse, thus the team has concern for pulmonary edema. Given his lack of respiratory distress, normal oxygen saturations, and hemodynamic stability, it would be unlikely for him to have ARDS, CHF, or interstitial fibrosis. This is further supported by a cardiac ultrasound that reveals normal global systolic function.

You get more information from mom, who states that Johnny’s face has appeared puffy and his abdomen has been distended for the past several days. 

Putting together Johnny’s fever, emesis, abdominal pain and distension, puffiness,  and hypertension, along with his ultrasound findings of pulmonary edema and pleural effusions, the team suspects nephrotic syndrome. A urinalysis is sent, which confirms the team’s suspicion by demonstrating the following:

  • 100 protein
  • 17 WBC
  • 129 RBC
  • Urine protein:creatinine ratio 1.41 (normal 0.00 – 0.17)

What is the final diagnosis?

Acute post-infectious glomerulonephritis

This is characterized by inflammation and/or cellular proliferation of the glomeruli, and may manifest as an acute nephritic or nephrotic syndrome.

  • Nephritic syndrome consists of hematuria, proteinuria, and evidence of volume overload
  • Nephrotic syndrome consists of severe proteinuria, hypoalbuminemia, and edema.

o The most common cause of acute glomerulonephritis is poststreptococcal glomerulonephritis, but other infectious agents can also cause it.
o The classic triad of glomerulonephritis is hematuria, edema, and hypertension.
o The edema of glomerulonephritis is caused by excessive renal fluid and sodium retention. (2)

  • Manifests initially in areas of low tissue resistance including periorbital, scrotal, and labial regions. Ultimately it becomes generalized.
  • Symptoms include anorexia, fatigue, abdominal discomfort, and diarrhea.
  • Fluid overload can also occur in the lungs as pulmonary edema or pleural effusions, but this is usually clinically asymptomatic, as in our patient. Both of these findings can be observed by ultrasound, as seen in our patient and explained above.

CASE CONCLUSION:

The patient was admitted to the hospital. He received Lasix, isradipine, and hydralazine for his volume overload and hypertension. At his one month follow up visit at nephrology clinic, he no longer had proteinuria, and his hypertension had resolved. It was felt that his glomerulonephritis was resolving.

PEARLS:

  1. Bedside ultrasound can be a quick, inexpensive, and useful tool in parsing out undifferentiated abdominal pain, in conjunction with history and physical exam.
  2. B-lines on ultrasound signify interstitial syndrome, which may represent pulmonary edema in the appropriate clinical setting.
  3. Acute glomerulonephritis can cause fluid overload, which leads to generalized edema. This can cause abdominal pain and distension. It can also in some cases lead to pulmonary edema and pleural effusions.

FACULTY REVIEWERS:

Erika Constantine, MD

Max Rubinstein, MD

Robyn Wing, MD, MPH

References:

1. Smargiassi A, Inchingolo R, Soldati G, Copetti R, Marchetti G, Zanforlin A, et al. The role of chest ultrasonography in the management of respiratory diseases: document II. Multidisciplinary respiratory medicine. 2013;8(1):55.

2. VanDeVoorde 3, René G. Acute poststreptococcal glomerulonephritis: the most common acute glomerulonephritis. Pediatrics in review / American Academy of Pediatrics. 2015 Jan;36(1):3-13.

3. Soni NJ, Franco R, Velez MI, Schnobrich D, Dancel R, Restrepo MI, et al. Ultrasound in the diagnosis and management of pleural effusions. Journal of Hospital Medicine. 2015 Dec;10(12):811-6.

4. Karen S. Cosby and John Kendall MD, M D. Practical Guide to Emergency Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.

5. “Lung Ultrasound Part 1.” http://www.ultrasoundpodcast.com/2013/02/lung-ultrasound-part-1/ Accessed Dec 2 2016.