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  6. Pulled elbow, emergency medicine, paediatrics (187) (1)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Pulled elbow, emergency medicine, paediatrics (187)

Objectives

This guideline describes how to assess and manipulate a pulled elbow in children.

Scope

Children presenting to the Emergency Department with a pulled elbow.

Audience

Emergency department staff at RHC.

Pulled elbow is a common childhood injury in under fives. Emergency Departments treat on average five cases per week.1 There is predominance in girls and the left side. Longitudinal traction of the child’s forearm results in a pulled elbow. This pulls the radial head through the annular ligament causing traumatic subluxation of the radial head.

History and Examination

Pulled elbow is usually caused by an adult pulling on the child’s arm or pulling on the forearm of a resisting child. However in 50% there may be no history of a pull on the child’s arm.2 This is often because the event was unwitnessed. The child may find localising the pain difficult and even complain of wrist pain.

There should be a sudden loss of function in the affected arm. The child holds the forearm in slight flexion with pronation. During examination the child often allows flexion and extension but will find supination and pronation painful. On examination there should be no joint swelling, bruising, warmth or erythema. 

Investigation

This should be a diagnosis concluded from history, presentation and subsequent successful manipulation. An elbow x-ray is not routinely required and is usually normal. 

Manipulation

After simple analgesia the pulled elbow should be manipulated. The majority will only need a single manipulation.3

There are two common manipulation techniques.

  1. One hand should be placed over the radial head in order to palpate a click, sometimes felt on successful reduction. The technique involves extending the child’s forearm and pronating (child’s palm downwards). See image below.
  2. The alternative technique involves the child’s forearm being supinated (child’s palm upwards) followed by flexion. See image below.

The pronation technique is more successful and less painful.4,5

The child should be reviewed 15 minutes after attempted reduction, they will often be happily using the arm and can be safely discharged with parental advice to avoid lifting or pulling the child by the arm.

Parents should also be advised a pulled elbow can be recurrent in 5% of cases; this risk lessens as the child gets older and the annular ligament tightens.Given the low recurrence rate there is no benefit in splinting pulled elbows post manipulation.6

If the child is still not using the arm, manipulation should be repeated using the alternative technique. X-ray should be requested if the child will not use the affected arm 15 minutes after repeat attempt at manipulation.

Occasionally the child may not be using the arm on review but the reduction felt successful. In cases where the injury is greater than 12 hours old the child may take 1-2 days to use the arm again.7 In this case the child can be discharged, with a broad arm sling and Emergency Department review in 48 hours.

photograph demonstrating hand position for the pronation technique

1. Pronation technique

photograph demonstrating hand position for the supination technique

2. Supination technique

* X-ray of radial head subluxation may be normal or may show increased radio-coronoid distance on the lateral x-ray.  The radiocapitellar line may be displaced by more than 3mm.  The radiographer may have reduced the pulled elbow when supinating the elbow for the AP film.

Pulled elbow management flowchart

pulled elbow management algorithm

* X-ray of radial head subluxation may be normal or may show increased radio-coronoid distance on the lateral x-ray. 8 The radiocapitellar line may be displaced by more than 3mm. 9 The radiographer may have reduced the pulled elbow when supinating the elbow for the AP film.

Editorial Information

Last reviewed: 28/11/2017

Next review date: 31/10/2025

Author(s): Steve Foster.

Version: 4

Approved By: Paediatric Clinical Risk & Effectiveness Committee

Document Id: 187

References
  1. Jongschaap HC, Youngson GG, Beattie TF. The epidemiology of radial head subluxation ("pulled elbow") in the Aberdeen city area. Health Bull 1990;48:58-1.

  2. Staheli LT. Trauma/management in primary care. In: Fundamentals of pediatric orthopedics. Philadelphia: Lippincott, Williams and Wilkins; 2008.

  3. von Laer L. Elbow injuries. In: Pediatric fractures and dislocations. New York: Thieme; 2004;p. 122–210.

  4. Krul M, van der Wouden JC, van Suijlekom-Smit LWA et al. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD007759.

  5. Lewis, D. Reduction of pulled elbows. BestBets Best Evidence Topics, 2003.

  6. Ellis, G. Treatment of recurrent pulled elbows. BestBets Best Evidence Topics, 2008.

  7. Smith BS, Crelin D. Paediatric elbow injuries: Part 1: Assessing the elbow, identifying and managing a pulled elbow. AENJ 2011; 14:115-119.

  8. Scapinelli R, Borgo A. Pulled elbow in infancy: diagnostic role of imaging. Radiol Med 2005; 10:655–664.

  9. Snyder HS. Radiographic changes with radial head subluxation in children. J Emerg Med 1990; 8(3):265.