Procedures

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 )

Procedurette: Bug Plug

If you've ever had a patient with a live insect stuck in their ear (or had one yourself) you know that the associated discomfort is enormous. Add to that an overlay of well-warranted patient anxiety and overall yuck-factor, and you've got a minor procedure with a big challenge.

What's the best way to get that pesky bug out and save the day?

Enter Whit Fisher, MD, and his most recent Procedurette video, "Bug Plug"

(Check out the rest of Dr. Fisher's Procedurettes series for more short, fun problem-solving videos on EM procedures!)

For medical professionals only. This Procedurette describes ways to identify, kill, and remove insects that have become stuck in a patient's ear.

POCUS: Shoulder Dislocation

Case:

An 18-year male with a history of a left shoulder dislocation presents with a chief complaint of “my shoulder is out of place.” Prior to arrival, the patient fell during a soccer game and felt his shoulder dislocate. He is neurovascularly intact.

Introduction:

The glenohumeral joint is the most commonly dislocated major joint in the body. The glenoid is shallow, with only a small portion of the humeral head articulating with it. While this allows for a wide range of motion, this makes the shoulder an unstable joint. Anterior dislocations account for 95 to 97% of all glenohumeral dislocations. Posterior dislocations account for most of the remainder, whereas inferior and superior dislocations are rare [i]. It is important that the dislocation is reduced as soon as safely possible since neurovascular complications increase with time.

A common practice is to obtain radiographs before reduction of a shoulder dislocation to confirm the diagnosis and exclude fractures. Recent literature has demonstrated the advantage of point-of-care-ultrasound (POCUS) in detecting both anterior and posterior shoulder dislocations. However, further investigation is necessary to assess the ability of ultrasonography in detecting fractures associated with dislocation [ii]. Factors associated with fractures include age over 40, first-time dislocation, and traumatic mechanism. When all three factors were absent, the negative predictive value for the presence of a fracture was 96.6 percent (95% CI 88.3-99.6) [iii]. If none of the aforementioned criteria are met and the clinician feels that this is an uncomplicated anterior shoulder dislocation, pre-reduction radiographs are unnecessary.  

X-rays are often taken following a reduction to confirm successful reduction and exclude any fracture caused by the procedure. Post reduction films are time consuming and need to occur after any sedating medications have worn off. Imagine discovering that the reduction was unsuccessful? This patient may need to undergo sedation again, the length of stay is dramatically increased, and your patient is probably not thrilled!

Don’t worry, there is another option! Ultrasound is a cost-effective, portable, safe, and real-time tool that can be used in this situation. POCUS allows for a dynamic evaluation of the glenohumeral joint, immediately informing you of a successful reduction or the need for additional shoulder manipulation. Additionally, ultrasound can also be used to guide intra-articular local anesthetic. As good as this sounds, there are some limitations to using POCUS. Ultrasound is highly operator-dependent, it is not sensitive for a labral or rotator cuff tears, and fractures can be difficult to assess.

Let’s Scan

Figure 1: Getting set up

Figure 1: Getting set up

Grab a high-frequency, linear-array probe or the curvilinear probe. Depending on patient habitus and personal preference, either probe is a fine choice. Position the probe in the transverse orientation, behind the shoulder and over the scapular spine. Move the probe laterally until you can visualize the glenoid. Continue to move laterally until you have a good view of the humeral head.

Normal Shoulder:

Figure 2: Normal Shoulder Anatomy on POCUS

Figure 2: Normal Shoulder Anatomy on POCUS

Figure 3: Normal Shoulder Anatomy on POCUS.&nbsp; Photo Source:  https://sonostuff.com/2016/08/23/msk-pocus-2nd-installment-muscles-tendons-and-bones-oh-my-foamed-foamus-meded-ultrasound/

Figure 3: Normal Shoulder Anatomy on POCUS. 
Photo Source: https://sonostuff.com/2016/08/23/msk-pocus-2nd-installment-muscles-tendons-and-bones-oh-my-foamed-foamus-meded-ultrasound/

Figure 4: Normal Shoulder Anatomy on POCUS Photo Source:  http://www.foamem.com/2014/06/05/shoulder-ultrasound-intra-articular-injection-and-reduction-2/

Figure 4: Normal Shoulder Anatomy on POCUS
Photo Source: http://www.foamem.com/2014/06/05/shoulder-ultrasound-intra-articular-injection-and-reduction-2/

If the shoulder is in appropriate anatomical position, the shoulder joint should be immediately adjacent to the glenoid. If the shoulder is not dislocated, the patient should be able to internally and externally rotate the shoulder while adducted, and the rotational articulation between the humeral head and glenoid fossa will be seen clearly on the ultrasound screen.

Abnormal Shoulder:

With an anterior dislocation, the humeral head will be deep on the screen, while with a posterior dislocation, the humeral head will be more superficial on the screen (closer to the probe).  A hyperechoic hemarthrosis is often seen in the joint when shoulder is dislocated.

Figure 5: Anterior Shoulder Dislocation&nbsp;

Figure 5: Anterior Shoulder Dislocation 

Figure 6: Posterior Dislocation [iv]

Figure 6: Posterior Dislocation [iv]

Figure 7:&nbsp;Comparing Anterior Dislocations to Posterior Dislocations. Photo Source:&nbsp; http://www.emdocs.net/wp-content/uploads/2014/06/shoulderDislocation.png

Figure 7: Comparing Anterior Dislocations to Posterior Dislocations. Photo Source: http://www.emdocs.net/wp-content/uploads/2014/06/shoulderDislocation.png

Pain Control:

Another advantage to ultrasound is that it can be used to guide an intra-articular lidocaine injection. Systematic review articles have found that complication rate, length of stay, and cost were significantly lower in patients who received intra-articular lidocaine when compared with those who received intravenous sedation [i],[ii],[iii]. Sterilize the skin over the shoulder and place local anesthetic with a small bore needle. Use the ultrasound transducer to locate the glenoid and humeral head. Using a long axis or in-plane technique guide a 20-gauge spinal needle into the joint and inject 20 mL of 1% lidocaine into the joint space [iv]. Give the medication 10-20 minutes to kick in and proceed with your reduction.

Figure 8: Representation of intra-articular lidocaine injection

Figure 8: Representation of intra-articular lidocaine injection

Video source: Dr. Shirley Wu

Take Home Points:

  • Position the probe in the transverse orientation, behind the shoulder and over the scapular spine. Move the probe laterally until you can visualize the glenoid and the humeral head.
  • With an anterior dislocation, the humeral head will be deep on the screen, while with a posterior dislocation, the humeral head will be more superficial on the screen (closer to the probe). 
  • Complication rate, length of stay, and costs were significantly less in the intra-articular lidocaine group when compared with the intravenous sedation group

If you want to see more, here is a helpful 6 min video by Mike Stone on ultrasound for dislocation and tips on intraarticular lidocaine injections using US guidance.

Resident Reviewer: Dr. TJ Ye

Faculty reviewers: Dr. Otto Liebmann

References:

[i] Marx, John A, Robert S. Hockberger, Ron M. Walls, Michelle H. Biros, Daniel F. Danzl, Marianne Gausche-Hill, Andy Jagoda, Louis Ling, Edward Newton, Brian J. Zink, and Peter Rosen. Rosen's Emergency Medicine: Concepts and Clinical Practice. , 2014. Chapter 53, 618-642.e2

[ii] Abbasi S, Molaie H, Hafezimoghadam P, Zare MA, Abbasi M, Rezai M, Farsi D. Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department. Ann Emerg Med. 2013 Aug;62(2):170-5. doi:10.1016/j.annemergmed.2013.01.022. Epub 2013 Mar 13.

[iii] Emond M, Le Sage N, Lavoie A, Rochette L. Clinical factors predicting fractures associated with an anterior shoulder dislocation. Acad Emerg Med. 2004Aug;11(8):853-8.

[iv] Mackenzie DC, Liebmann O. Point-of-care ultrasound facilitates diagnosing a posterior shoulder dislocation. J Emerg Med. 2013 May;44(5):976-8. doi: 10.1016/j.jemermed.2012.11.080. Epub 2013 Mar 13.

[v] Waterbrook AL, Paul S. Intra-articular Lidocaine Injection for Shoulder Reductions: A Clinical Review. Sports Health. 2011;3(6):556-559. doi:10.1177/1941738111416777.

[vi] Hunter, B, Wilbur, L MD.  Can Intra-articular Lidocaine Supplant the Need for Procedural Sedation for Reduction of Acute Anterior Shoulder Dislocation?  Ann Emerg Med 59(6): 513-4; 2012.

[vii] Ng VK, Hames H, and Millard WM: Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature. Can J Rural Med 2009; 14: pp. 145-149

[viii] Custalow, Catherine B, James R. Roberts, Todd W. Thomsen, and Jerris R. Hedges.Roberts and Hedges' Clinical Procedures in Emergency Medicine. Philadelphia, PA: Elsevier/Saunders, 2013. Internet resource.