Missed cases of ‘pulled elbow’– A retrospective study of 28 cases managed at a tertiary care centre in Uttarakhand

Introduction: The ‘pulled elbow’ is fairly common injury seen at primary care level. This injury has characteristic history, clinical presentation and imaging features. Many often the injury is missed and neglected for days and picked up later at further consultation. The missing of these injuries might be a result of gaps in our core knowledge and clinic-radiological assessment. Method : We hereby evaluate a data of 28 cases with missed pulled elbow injuries that were treated in our institute. Various aspects of first opinions and reason for delay are described for comprehensive knowledge of gaps in the treatment. Result: The strengthening of practical knowledge regarding this simple injury is recommended in order to diagnose and treat them in first place and avoid agony of child and parents. Lack of knowledge regarding proper assessment of elbow by clinical and radiological methods has been found to be a major cause for missed injuries. Conclusion : The knowledge of factors responsible for delayed or missed diagnosis at initial consultation is necessary for remedial measures for its appropriate management at primary level and decrease healthcare burden at tertiary level care.


Introduction
Pulled elbow syndrome is a common elbow injury in Available online at: www.surgicalreview.in 18 | P a g e epidemiological and demographic data is available from various studies pertaining to the injury [2,3]. The injury occurs from two month of age to seven years with peak at 2-3 years and presentation after seven years of age is rare. Female sex and left side of elbow are more commonly affected [4].
The strengthening of attachments of annular ligament and subannular membrane by the age of five years relates to decrease incidence in older children and anatomic studies have validated slippage of annular ligament following a longitudinal traction over extended elbow [5].
The positive factors related to the injury are relative absence of concomitant injuries and favorable outcome following spontaneous or attempted closed reduction and rarity of reported negative sequelae. Early diagnosis and reduction therefore is necessary to relieve the discomfort and avoid irreducible, neglected and symptomatic cases.

Materials and Methods
A retrospective data of consecutive cases in an annual audit of outpatient cases was evaluated for pediatric elbow injuries with diagnosis of pulled elbow confirmed clinically or by radiological assessment from July 2013 to February 2015 in our tertiary care hospital.
The inclusion criteria was any referred case of suspected pulled elbow for evaluation from immediate to late presentation.

Results
A total of 30 cases were identified that met inclusion criteria as described and their data was analysed. Two cases were excluded later as one with congenital dislocation of bilateral radial head and the other had radial head dislocation as part of hereditary multiple exostoses. The rest 28 cases were part of the study. The most cases were in 2-3 year age bracket (24 cases, 85.71%) while two cases were more than 3 year old. This is in accordance with usual age of presentation described in other studies as well. The males dominated our studies as 16 cases (57.14%) and left side as the commoner side involved in 22 cases (78.57%). As the left side has been a commoner presentation, males in our studies have remarkable higher incidence and it might have social reason as male child is more likely to be consulted more and to better places.   The various patterns of provisional diagnosis was given (Diagram 1) and the list includes soft tissue injury as most common first diagnosis in 21(75%) cases, probable physeal injury and probable infection in 2 cases each (07.14%) and nerve injury in 3 cases (10.71%).
All the cases were managed successfully with closed reduction technique except one case which reduced spontaneously.
No recurrence of deformity was seen in follow of at least four months (range 4 months to 18 months).

Discussion
The pulled elbow syndrome has been specifically linked to classic history of longitudinal traction injury to pediatric elbow.
Many studies have reported failure of getting classical history in sizeable number of cases. 33 to 49% cases were linked to no clear history about mechanism of injury in certain literature [6,7]. underlying fracture is suspected [1,5,8,9].
The concept of 'radiocapitellar line' a line drawn along the axis of proximal radial shaft bisects the centre of ossification of capitellum in a normal elbow in every position, is critical and easy method to delineate subtle deviation from normal anatomy.
A radiocapitellar line off the centre of capitellum is commonly found in pulled elbow cases [10,11].
There is however a possibility of self reduction of the subluxation during positioning for elbow radiographs.
Ultrasonography has been another option [12] for the diagnosis but in good hands and our centre has limited human resources for musculoskeletal ultrasonography.
The closed reduction was done by passive supination of the forearm as described method in previous studies [1,3,6,8,13]. The procedure used by us was found to be easy and effective method of reduction.
Recently hyperpronation methods of reduction have been studied as an equally good alternative method of reduction [14,15].
The workers believe this method of reduction useful in cases of failed attempt of supination method. We used a short period of protective sling and arm pouch. Studies recommend that it helps in healing and checks occurrence of second injury [5,16].
Almost all of these cases require no further intervention in reported literature and the need for surgery is limited.
We experienced no surgical requirement as each case had uneventful reduction and there was no recurrence or other complication in the follow up period.