The Child With a Painful Arm: A POCUS Screening Protocol to Identify Fracture in Children With Upper Extremity Injury

BACKGROUND: Young children present frequently to the emergency department with an immobile, painful arm. It is often difficult to discern a point of tenderness in a frightened, injured child. Common approaches included sending the child for x-ray studies of the extremity or empirically attempting reduction of radial head subluxation. We created a step-by-step point-of-care ultrasound screening protocol of the upper extremity to increase or decrease the probability of fracture before x-ray study or reduction.

CASE REPORT: We present the cases of 6 children younger than 4 years without a clear history of pulled elbow and without swelling or deformity on examination, for whom this protocol revealed fracture or lowered the probability of fracture, thereby increasing the safety of radial head reduction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In most cases, identification of a single fracture on ultrasound allows for focused x-ray study on the area of fracture. Children with a normal ultrasound screen can undergo reduction of radial head subluxation safely.