Irreducible pulled elbow followed with supervised neglect and ultrasonography: Two case reports

Pulled elbow (PE) is one of the most common upper limb injuries in children. The success rate of manipulation for PE ranges from 74 to 99%, with a favorable prognosis. However, the diagnosis of PE is often determined by the typical injury pattern, and there is a lack of diagnostic certainty. In recent years, ultrasonography has been used for the diagnosis of PE; however, it is still not a commonly used modality for the diagnosis. Moreover, manual reduction of PE is often difficult, and there is no consensus on the management of the elbow when the reduction maneuver fails. Further, it is unclear whether surgery or external immobilization is necessary. We followed two cases of irreducible PE with ultrasonography without aggressive treatment such as surgery or external immobilization. Both cases were initially irreducible, but spontaneous reduction was confirmed by ultrasonography seven days after injury in one case and nine days after injury in the other case. To the best of our knowledge, this is the first report of cases of irreducible PE in which the patients were carefully followed by ultrasonography without external immobilization or other intervention, and spontaneous resolution was confirmed. Although careful follow-up is necessary as ultrasonography may show no normalization in the radiocapitellar joint immediately after reduction, supervised neglect without external immobilization could be an optional treatment for irreducible PE and reduce unnecessary surgery.