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Three Part Question

In a [child presenting with pulled elbow] does [manipulation followed by immobilisation] prevent [recurrent episodes]?

Clinical Scenario

A 3 year old child accompanied by his mother presents to the emergency department with symptoms of pulled elbow following a minor slip on the stairs where he grabbed the bannister. Mum is quite annoyed when you examine the child as you reduced the same elbow 5 days previously. Happy that the elbow was in full use before the initial discharge you wonder if splinting the elbow in some way would have prevented recurrence.

Search Strategy

Medline(R) Ovid interface 1950- date
EMBASE 1974-date
Google Scholar
[(pulled adj elbow) OR (nursemaids adj elbow) OR (nurse adj elbow) OR(ligament, annular) OR (radial head subluxation)] AND [(exp.splints) OR (plastercast.mp) OR (casts,surgical) OR (plaster of paris.mp) OR (immobilisation) OR (immobilization)] AND [(exp.recurrence) OR (recur$)]
Limited to humans and English

Search Outcome

75 articles found
1 paper relevant to clinical scenario

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Assad M Taha 2000 Lebanon	64 consecutive children diagnosed with pulled elbow who all had manipulative reduction. Those with first names starting A-M had POP with elbow flexed and suppinated for 2 days. Names N-Z control group. All assessed by author at 2,5 and 10 days,	Randomised Control Trial	Recurrence or persistence of pulled elbow when examined at 2,5 or 10 days.	Children A-M no recurrence/persistence N-Z 1 on day2, 3 on day5, 0 day 10	Small numbers in study. Randomisation by name could lead to inclusion bias. Researcher not blinded at recruitment into trial. No record of reduction technique or clinician(s) carrying out reduction.

Comment(s)

Only one study with a small population of children diagnosed with pulled elbow. Over the study period of 3 years recurrence was seen in only 4 children. If all children were splinted with a POP then it would seem there would be a financial burden and also the distress to the child from having a cast and requiring follow up, that would not benefit the majority.

Clinical Bottom Line

The evidence is not strong enough to start splinting all pulled elbows following manipulation. The number of children suffering recurrence in the available study over a fairly long period of time would not suggest treatment other than manipulative reduction should be carried out at present.

References

1. Assad M Taha The treatment of pulled elbow: a prospective randomised study. Archives of Orthopaedic and Trauma Surgery (2000) 120: 336-337