Late Arrival at the Hospital with Pulled Elbow: an Issue Missed by Parents
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Original Article Acta Medica Anatolia Volume 2 Issue 4 2014 Late Arrival at the Hospital with Pulled Elbow: An Issue Missed by Parents 1 2 3 3 Mustafa Uslu , Murat Kezer , Hakan Sarman , Cengiz Isik 1 Department of Orthopedics and Traumatology, Duzce University School of Medicine, Duzce, Turkey. 2 Department of Orthopedics and Traumatology, Special Siirt Hayat Hospital, Siirt, Turkey. 3 Department of Orthopedics and Traumatology, Abant Izzet Baysal University School of Medicine, Bolu, Turkey. Abstract Objectives: Pulled elbow is a traction trauma. The interval between trauma and visiting a doctor is too long. Methods: This was a 1-year retrospective review of 69 children who presented at the emergency department with a discharge diagnosis of pulled elbow. Results: The median time from trauma to reduction was 7 hour (h), with 37 patients waiting up to 6 h, 10 waiting 6–12 h, six waiting 12–18 h, and 12 waiting 18–30 h. Conclusions: Parents lose much time not understanding the problem. Parental education to promote recognizing the problem and seeking prompt attention and reduction is important. Keywords: Pulled elbow, children, diagnose, treatment, parents Received: 03.06.2014 Accepted: 16.06.2014 doi: 10.15824/actamedica.10592 Acta Medica Anatolia Introduction Pulled elbow is typically diagnosed in emergency pulled elbow between 2010 and 2011. In total, 69 departments in children younger than 5 years of age children with pulled elbow were evaluated (1,2). The injury mechanism is a forceful traction retrospectively. Data on age, sex, patient history, applied to an extended and pronated arm (2,3). The injured side, recurrence rate, injury pattern, and incidence of this injury is 3.0% in children younger doctor presentation time were extracted from the than 8 years of age (4). Boys are affected more often records. We assessed injury pattern and the time than are girls, and the injury is usually present on the from trauma to reduction. Pulled elbows were left side (5). Parents may have pulled the child’s reduced with hyperpronation or supination-flexion forearm while the child was walking or falling down maneuvers according to emergency physicians’ or may have lifted the child from the ground by the experience. After the child started to use the affected hands (6). Additionally, the child can cause this injury arm again, the reduction was deemed successful. No by pulling, falling, or clinging to a swing (7). Some immobilization was applied to the injured arm after cases are idiopathic simply because the children are reduction. too young to provide a comprehensible history. An inability to use the affected arm, pain upon moving the elbow and, rarely, a noticeable click at the time of injury are the main complaints that lead the parents 40 37 to bring the child to the emergency room (8). 30 Active and passive supination of the forearm is 20 restricted and resisted by child. After reduction, the n 10 12 pain is relieved and joint movements return. A major 10 6 4 problem is delay in seeking medical attention. Most parents simply do not recognize pulled elbow as the 0 problem. 0-6 6- 12- 18- 24- 12 18 24 30 hours Materials and Methods The Institutional Non-invasive Ethics Committee of Figure 1. Distribution of patients according to time to Düzce University Medical Center approved this seek medical attention (n, number of patients). retrospective study. We scanned the Emergency Department records of children with a diagnosis of Correspondence: Hakan Sarman MD, Department of Orthopedics and Traumatology, Bolu, Turkey. 119 [email protected] Original Article Uslu M et al. Table 1. Summary of results. trauma to reduction was 7 h, with 37 (53.6%) patients Sex n waiting up to 6 h, 10 (14.4%) waiting 6–12 h, six male 34 (8.6%) waiting 12–18 h, four (5.7%) waiting 18–24 h, and 12 (17.3%) waiting 24–30 h (Fig. 1). Sixteen of the female 35 42 pull cases went to the Emergency Department Age (years) within the first 6 h, six within 6–12 h, four within 12– 0-1 4 16 h, four within 16–24 h, and 12 within 24–30 h. 1-2 28 Seventeen of the 19 fall cases went within 6 h and 2-3 17 only two went within 6–12 h. All four swing cases 3-4 9 went within 6 h. Finally, two of the idiopathic cases 4-5 4 went within 6–12 h, and two went within 12–18 h. All of the pulled elbows were reduced in the emergency 5-6 2 room: 39 with pronation and 30 with supination 6-7 2 maneuvers. At the 1 year follow-up, 11 had two and 7-8 1 two had three subluxations on the same side. 8-9 1 Injury side Discussion right 27 left 42 Pulled elbow is a common injury among children aged between 1 and 3 years (1,2). Boys are more commonly Reduction maneuver affected than are girls, and left-side injury is seen pronation 33 more than is right-side injury (5). Whereas the supination 36 incidence of this injury has been reported as 3.0% (4), Redislocation the exact incidence is not known. In our study, the none 0 male to female ratio was nearly equal and left-sided injury was most common. The age range of affected only one 11 children was 8–108 months. two times 2 three times 0 Although the mechanism of injury has been clearly four times 0 stated in reports (8, 9), the injury patterns that lead to Injury pattern this mechanism have received little attention to date. pulling 42 A sudden traction trauma by pulling an extended pronated arm is the major responsible factor. Most falling 19 parents do not know that this trauma pattern can lead clinging to swing 4 to a pulled elbow in this way. As picking up children by idiopathic 4 their forearms or hands and lifting are not considered Doctor application time (hours) as trauma by parents, they simply do not realize what 0-6 37 can happen to their child. A delay in suspected diagnosis is the main reason for the late presentation 6-12 10 at the hospital; this delay is due to parents’ lack of 12-18 6 knowledge about the disorder. Indeed, only 37 of the 18-24 4 69 cases in our study went to the hospital within the 24-30 12 first 6 h. The absence of trauma signs does not alert parents to take children for treatment. Most of the children were too young to give a comprehensible Results history. Other trauma patterns are falling down, clinging to swings, and idiopathic. In total, 69 children diagnosed with pulled elbow for the first time were evaluated (Table 1). The sample Recurrence after treatment is seen rarely. Recurrences consisted of 35 females and 34 males. The mean age typically appear early (within the first week) after was 29 (range, 8–108) months. Forty-two had left- treatment, and sometimes multiple recurrences are sided and 27 had right-sided injuries. Injury was seen in the same patient (10). Early recurrences may caused by a pull in 42 (61%) cases, a fall in 19 (27.5%) indicate insufficient reduction (11) or repeated cases, and clinging to a swing in 4 (5.5%); it was trauma. Late recurrence of a pulled elbow is rare and idiopathic in four (5.5%) cases. The median time from should raise at least a suspicion of child abuse (11). Acta Med Anatol 2014;2(4):119-121 120 Original Article Uslu M et al. We identified 13 recurrences after treatment in our study. Eleven had two and two had three subluxations on the same side. The major reason for recurrences seemed to be repeated trauma attributable to parents. Conclusion It is important to advise parents not to pull or lift children by their forearms or hands. Indeed, it would be interesting to see whether an educational intervention with the parents upon their first visit could decrease the number of recurrences. References 1. Jongschaap HC, Youngson GG, Beattie TF. The 7. 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