painfree flexion/extension of elbow but pain on supination/pronation
absence of clinical elbow effusion
if fall unlikely, and findings suggest pulled elbow, attempt reduction and if successful or pulled elbow highly likely, then Xray not usually required. Delayed presentations more than a few hours may not be able to be reduced - these can generally be allowed home with expectant spontaneous reduction within a few days once inflammation subsides.
specifically check for other sites commonly injured with that mechanism:
eg. fall onto outstretched hands:
wrist, elbow, supracondylar and surgical neck humerus
a third of paediatric fractures involve the growth plate
familiarise yourself with the Salter-Harris classification (I - V)
if growth plate is displaced or angulated, manipulation must be done within the first week otherwise delayed reduction substantially increases the risk of growth problems.
parents should be warned of risk of delayed growth plate problems (usually pain in 6-12 months), although the incidence is quite small and tends to increase with the number of the S-H classification (ie. SH V is more likely to result in growth arrest).
some important ossification dates:
radial head and medial epicondyle of humerus do not ossify until age 5-6 years.
This has two useful applications:
if a radial head is visible, but not the medial epicondyle on XR, then this raises the possibility of an avulsed medial epicondyle, esp. if elbow is dislocated.
radial head may be damaged without evidence on XR, so follow up XR’s should be done if elbow effusion present to assess injury adequately.
the scaphoid bone does not ossify until age 6 -7 years.
scaphoid fractures under age 7 years are exceedingly rare and thus scaphoid x-rays, are not usually indicated in this age group.
remodeling
Certain angular deformities will remodel over time to produce a limb without any detectable deformity. However, one cannot always rely on remodeling to occur, and one should attempt to achieve as near as possible anatomical reduction.
The remodeling capacity in these circumstances is determined by four factors:
age of child (younger the better).
distance of the fracture from end of the bone:
closer to the end, the better chance for remodeling.
amount of angulation.
plane of angulation.
Remodeling will not usually correct the following deformities:
angular deformity of diaphyseal fractures.
angular deformity not in plane of movement of contiguous joint.