Nurse Reduction of Pulled Elbow

• Time to normal usage (minutes) [ Time Frame: End of enrollment- 2 years ] [ Designated as safety issue: No ]
• Time to discharge from ED (minutes) [ Time Frame: End of enrollment- 2 years ] [ Designated as safety issue: No ]
• Proportion of patients with presentation compatible with RHS, have reduction attempted, who are subsequently diagnosed with fracture. [ Time Frame: Every 3 months during enrollment ] [ Designated as safety issue: Yes ]
• Proportion of patients with RHS not identified by nurse pathway. [ Time Frame: End of enrollment- 2 years ] [ Designated as safety issue: No ]

Radial head subluxation (RHS), or pulled elbow, is the most common upper extremity injury in young children, accounting for up to 60% of upper extremity emergency department (ED) visits. At CHEO alone there are about 250 cases per year. Children with this injury suffer discomfort and an inability to use their arm. The injury is most commonly caused by a pull on the arm in the course of normal parenting such as dressing or lifting children. The vast majority of these injuries are quickly and easily treated by a simple reduction maneuver which restores normal arm usage within a few minutes with minimal discomfort. However these children often wait several hours in an ED to see a physician. During this time the patient is in pain. Parents, who often have caused the injury, suffer needless concern over having inflicted a serious injury to their child.

This study seeks to reduce time to treatment, by having this injury identified and treated by the triage nurse on arrival. The investigators primary objective is to show that nurses are equivalent to physicians at successfully reducing RHS. Secondarily, the investigators hope to show a reduction in time to normal arm usage of at least 30 minutes. The investigators will also track the accuracy of nurse identification of RHS.

Several centres in Canada and Australia have already implemented such protocols. However there are no studies of their treatment effectiveness or impact on wait times. During the study period, patients will be assigned to either nurse treatment or traditional physician treatment on the basis of their day of presentation. Prior to treatment the nurse will explain the injury, the new protocol and the risks and benefits of the procedure. The family will be informed that they are able to wait for a physician assessment if they prefer. Verbal consent for the procedure will be obtained. As no information will be collected, outside of that needed for any emergency department visit, and no follow-up is planned written consent for participation in the study will not be obtained.

The investigators intend to show this new protocol will decrease the time children are in pain, decrease time of parental stress and help to alleviate emergency wait times. If successful as a study intervention the investigators aim will be to have a standing medical directive in the emergency for the nurse initiated reduction of radial head subluxation.

• Experimental: Nurse Reduction
  Patients randomized to reduction by nurse.
  Intervention: Procedure: Reduction of Radial Head Subluxation
• Active Comparator: Physician Reduction
  Patients randomized to treatment by Emergency Department Physician in traditional ED manner
  Intervention: Procedure: Reduction of Radial Head Subluxation

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Inclusion Criteria:

• Age up to 6 years
• Physical exam consistent with RHS which includes not using the affected limb, holding the elbow in extension or slight flexion, forearm in pronation, and patient is distressed only on elbow movement
• Injury within preceding 12 hours

Exclusion Criteria:

• Deformity of clavicle or arm
• Swelling of elbow or wrist
• Significant tenderness on palpation of arm
• Metabolic bone disease (i.e. osteogenesis imperfecta)
• Neuromuscular disorder that excludes adequate assessment (i.e. severe cerebral palsy)