Urgent Care Evaluation and Management of Pediatric Elbow and Forearm Pain, Part II (Trauma CME)

Table of Contents

 

About This Issue

Understanding the unique anatomy of the pediatric elbow and forearm and growth plate development are crucial to ensuring optimal patient care. Appropriate management of elbow and forearm pain in children can help prevent nonessential imaging in growing bodies and future functional limitations. In this issue, you will learn:

The anatomy of the pediatric elbow and common mechanisms of injury in children;

Traumatic and nontraumatic causes of pediatric elbow and forearm pain, including various types of overuse and chronic conditions, fractures, dislocation, and other serious presentations;

The urgent care management for chronic causes of pain, dislocation, and fracture, including those that require emergency department or orthopedic referral for further evaluation and treatment.

CODING & CHARTING: Documentation of elbow and forearm pain in children in the urgent care setting can be problematic depending on the level of complication. Learn more in our monthly coding column.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Anatomy
6. Differential Diagnosis
7. Urgent Care Evaluation
   1. History
      1. Key Elements of the History
         1. Mechanism of Injury
         2. Pain Characteristics
      2. Systemic Symptoms
      3. Nonaccidental Trauma Considerations
8. Physical Examination
9. Diagnostic Studies
   1. Radiographic Studies
      1. Pediatric Radiation Safety
      2. Minimizing Movement During Imaging
   2. Ultrasound
   3. Magnetic Resonance Imaging
10. Treatment
    1. Nontraumatic Injuries and Overuse Conditions
       1. Radial Head Subluxation (Nursemaid’s Elbow)
       2. Medial Epicondylar Apophysitis (Little League Elbow)
       3. Lateral Epicondylitis (Tennis Elbow) and Medial Epicondylitis (Golfer’s Elbow)
       4. Juvenile Idiopathic Arthritis (JIA)
       5. Ulnar Neuropathy
    2. Traumatic Elbow Injuries
       1. Supracondylar and Lateral Condylar Fractures
       2. Torus Fractures of the Distal Radius and Ulna
       3. Greenstick and Complete Forearm Fractures
       4. Physeal (Growth Plate) Fractures
       5. Open Fractures
       6. Monteggia Fracture
11. Special Populations
    1. Neonates and Infants
    2. Immunosuppressed Children
    3. Children with Neuromuscular or Connective Tissue Disorders
12. Controversies and Cutting-Edge
    1. Minimal Intervention for Torus Fractures
    2. Nonoperative Treatment of Certain Open Fractures
    3. Sedation and Reduction in Urgent Care
    4. Ultrasound Use
    5. Prevention and Education in Sports Activities
13. Summary
14. 5 Things That Will Change Your Practice
15. Risk Management Pitfalls in the Urgent Care Management of Elbow and Forearm Pain in Children
16. Time- and Cost-Effective Strategies
17. Critical Appraisal of the Literature
18. Case Conclusions
19. Coding & Charting: What You Need to Know
    1. Determining the Level of Service
       1. Problems Addressed
       2. Complexity of Data
       3. Risk of Patient Management
    2. Documentation Tips
20. Coding Challenge: Pediatric Elbow and Forearm Pain in Urgent Care
21. Clinical Pathways
    1. Clinical Pathway for Urgent Care Evaluation and Management of Nontraumatic Pediatric Elbow and Forearm Pain
    2. Clinical Pathway for the Urgent Care Management of Traumatic Pediatric Elbow and Forearm Pain
22. References

Abstract

Elbow and forearm pain in children is a common presentation in urgent care. The possible causes of the pain include trauma, overuse, or underlying conditions. While many of these causes are minor and self limiting, some can lead to serious complications if missed. The unique anatomy of growing children, along with challenges in obtaining a reliable history and performing an examination, can make diagnosis difficult. This article reviews both traumatic and nontraumatic causes of elbow and forearm pain in children, including fractures, dislocations, overuse injuries, and inflammatory conditions. It outlines a systematic approach to evaluation, highlights high-risk injuries, and provides practical management strategies.

Case Presentations

A 2-year-old girl presents to urgent care refusing to move her right arm…

• The mother says she was playing with the child in the park and swung her around by the wrists, which she seemed to enjoy.
• The mother then heard a pop, after which the child stopped using the right arm. The mother denies any swelling or bruising of the wrist or elbow.
• The child appears comfortable, and the right arm is held close to the body in a slightly flexed and pronated position.
• The mother tearfully asks you if she broke her child’s arm...

A 7-year-old boy is brought into urgent care, screaming in pain and protecting his left forearm with his right hand…

• He fell from the monkey bars on the playground 30 minutes ago.
• A distal forearm deformity is visible from a distance, and no open wound is appreciated.
• You consider whether this patient needs radiographic images and an orthopedic consultation...

A 13-year-old baseball player presents to urgent care complaining of right elbow pain…

• He states that his pain has become progressively worse over the last 4 weeks. He ices at home and takes acetaminophen, but it has not gotten any better. He denies recent trauma or swelling to his elbow joint.
• The patient is an avid pitcher and plays baseball 5 to 6 times a week and has had 2 to 3 games every weekend for the last month.
• His father asks if he can just get a brace and some pain medication so he can play in the state tournament this weekend.
• You are pretty sure this is an overuse injury, but you wonder if there is more going on...

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

8. * DeFroda SF, Hansen H, Gil JA, et al. Radiographic evaluation of common pediatric elbow injuries. Orthop Rev (Pavia). 2017;9(1):7030. (Review) DOI: 10.4081/or.2017.7030

9. * Kellogg ND, American Academy of Pediatrics Committee on Child A, Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-1241. (Review) DOI: 10.1542/peds.2007-0883

15. * Sansone L, Gentile C, Grasso EA, et al. Pain evaluation and treatment in children: a practical approach. Children (Basel). 2023;10(7). (Review) DOI: 10.3390/children10071212

16. * American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793-797. (Guideline) DOI: 10.1542/peds.108.3.793

19. * Raissaki MT. Pediatric radiation protection. European Radiology Supplements. 2004;14(S1):74-83. (Guideline) DOI: 10.1007/s10406-004-0011-7

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Keywords: pediatric, elbow, humerus, ulna, radius, FOOSH, sports-related injury, fat pad, overuse injury, radial head subluxation, nursemaid’s elbow, radial head fracture, supracondylar fracture, lateral condylar fracture, ulnar fracture, olecranon fracture, Monteggia fracture, Torus fracture, x-ray, buckle fracture, greenstick fracture, Salter-Harris classification system, growth plate fracture, septic arthritis, juvenile idiopathic arthritis, osteomyelitis, Little League elbow, lateral epicondylar apophysitis, medial epicondylitis, ulnar neuropathy, cubital tunnel syndrome, osteochondritis dissecans, CRITOE, growth plates, ossification centers, nonaccidental trauma, osteosarcoma, Ewing sarcoma, long arm splint, splinting, radiocapitellar line, anterior humeral line, ALARA