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What is the utility of point-of-care ultrasound for suspected pulled elbow? A single-centre case series
David J McCreary1, Nikhil Tambe1, Niall Mullen1
1Paediatric Emergency Department, Sunderland Royal Hospital, Sunderland, United Kingdom.
Insights
Point-of-care ultrasound (POCUS) reliably confirms pulled elbow in children, reducing unnecessary X-rays and emergency department wait times. This diagnostic tool aids clinicians in accurately identifying this common pediatric injury.
Area of Science:
- Pediatric Emergency Medicine
- Diagnostic Imaging
- Musculoskeletal Ultrasound
Background:
- Radial head subluxation, or pulled elbow, is a frequent pediatric emergency department presentation.
- Diagnosis can be challenging due to atypical histories and difficulty examining distressed children.
- Unnecessary imaging and misdiagnosis (e.g., treating fractures as pulled elbows) are common issues.
Purpose of the Study:
- To assess the accuracy of point-of-care ultrasound (POCUS) in diagnosing suspected pulled elbow in children.
- To determine POCUS's effectiveness in differentiating pulled elbow from other elbow injuries.
Main Methods:
- Retrospective review of pediatric patients (0-5 years) with elbow injuries from November 2020 to November 2022.
- Exclusion of major trauma cases and patients with obvious deformity or significant swelling.
- Application of POCUS by trained clinicians following established protocols.
Main Results:
- POCUS correctly identified pulled elbow in all 32 patients with positive sonographic findings (100% specificity).
- The study achieved 100% sensitivity in diagnosing pulled elbow.
- POCUS helped identify soft tissue injuries in cases with atypical histories and negative findings.
Conclusions:
- POCUS is a reliable diagnostic tool for confirming pulled elbow in pediatric emergency settings.
- Appropriately trained clinicians can effectively use POCUS as an extension of the physical examination.
- Implementing POCUS can decrease radiation exposure and reduce emergency department length of stay for children and their families.
Abstract:
Radial head subluxation, known as pulled elbow or nursemaid's elbow, is a common presentation to the Paediatric Emergency Department (PED). Fifty per cent of children present following an unwitnessed injury or with an atypical history. Furthermore, examination can be difficult in an upset or frightened child meaning the precise location of the injury is not always easily identifiable. Many children receive upper limb x-rays unnecessarily and others undergo attempted reduction for suspected pulled elbow when a fracture is the cause of their pain.
Objective:
To evaluate the ability of point-of-care ultrasound (POCUS) to correctly identify cases of suspected pulled elbow.
Methods:
A retrospective review of patients aged 0-5 years presenting to the PED of our large District General Hospital from November 2020 to November 2022. We reviewed the electronic medical records of all patients presenting with a triage category of 'elbow Injury'. We excluded patients presenting with obvious deformity, significant swelling and history of road traffic collision or other major trauma mechanism such as a fall from a height. POCUS was carried out by the authors according to pre-existing clinical protocols.
Results:
Thirty-seven patients underwent POCUS. Twenty-nine had a typical history and all had a positive POCUS for pulled elbow. Of the remaining eight patients with an atypical history, three were found to have a positive POCUS compared to unaffected elbow. Five patients with an atypical history had negative POCUS findings and were diagnosed as soft tissue injuries after further assessment. All 32 with positive sonographic signs had a final diagnosis of pulled elbow, meaning the specificity was 100% (47.8-100) (P = 0.00003). The sensitivity was 100%.
Conclusion:
Use of POCUS by appropriately trained clinicians, as an extension of a clinical examination, in this retrospective study reliably confirmed pulled elbow. This has the potential to reduce both unnecessary radiation as well as the time in the emergency department for the child and their carers.
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