MINUTIAE AND SOURCE CONTROL

A couple of weeks ago in our virtual study group - a key component of the fellowshipexam.com course - we had a great question.

What is the best (or definitive way) to reduce a pulled elbow?

As a question, it highlights two very important issues when studying for the fellowship exam.

When you’re studying for the fellowship exam in particular:

1. Don’t overdo the minutiae
2. Be careful of conflicting sources

"If you lined up 10 FACEMs and asked them....they'd each give slightly different answers."

Firstly to answer the question about the pulled elbow itself from the perspective of a practicing FACEM:
  I have absolutely no idea! Personally I have both extended/supinated and flexed/pronated pulled elbows. I can tell you I find that for each method that 60% of the time it works every time.

Feel free to quote me on that, and use the same statistic for reduction of dislocated shoulders!

To make a comments about the nature of the question itself:

I suspect if you lined up 10 FACEMs and asked them how to reduce a pulled elbow they would each give slightly different answers. It’s not a subject that is readily prone to research in terms of a superior treatment, and so I doubt there will every be definitive literature on the subject. (Which is not to say there shouldn’t be!)

So candidates need to be careful.

DON'T OVERDO THE MINUTIAE.

I would be prepared to guarantee that there will not be an SAQ asking you to describe the evidence behind different reduction methods of a pulled elbow. At most, it is likely to be 1 MCQ, and thus represents a minuscule proportion of the total exam marks. There are lots of subjects where the minutiae is important (resus, controversial treatments such as stroke lysis) so be careful of exhausting yourself reading endlessly on subjects where there is:

1. likely to be no good answer
2. not a great deal of effect on the exam outcome.

One of the problems facing people preparing for the fellowship exam is that emergency medicine covers so many topics that it is very easy to be immersed in each of them. Unfortunately that way madness lies!

You will never know as much about orthopaedics as an orthopaedic surgeon, or cardiology as a cardiologist. It’s important to learn to identify the really important topics and study them hard (stuff marked “expert” in the curriculum is a good place to start) and make sure you don’t get stranded in the minutiae that’s less important.

BE CAREFUL OF SOURCE CONFLICTS.

Particularly where a subject is unlikely to have definitive answers, it’s easy to get confused by multiple sources, especially by hospital based clinical guidelines. The source of the confusion about a pulled elbow was one such hospital guideline. 

As an example of source conflict on the subject:

Cameron Paediatric Emergency Medicine says:

“these children should be held firmly by a parent while the forearm is firmly and fully supinated in extension. It is helpful for the doctor to cradle the elbow in the outer hand with the thumb over the radial head while their inner arm rotates….If the procedure is not successful hyper-pronation should be attempted with the same setup. This combination of techniques should elicit success in >90% of children”.

Up to Date, on the other hand says:

"Supination/flexion and hyperpronation are two techniques for reduction of [pulled]. Both techniques are effective. Supination/flexion is the method that has been used most commonly. However, meta-analysis of four randomized trials found that successful reduction was more likely with hyperpronation (RR 0.45, 95% CI 0.28-0.73) although the quality of the evidence was felt to be low. Based on this analysis, nine children would require treatment by the hyperpronation method rather than supination/flexion to avoid one failed reduction on first attempt.

Hyperpronation method — In the hyperpronation method, the examiner supports the child's arm at the elbow and places moderate pressure with a finger on the radial head. The examiner grips the child's distal forearm with the other hand and hyperpronates the forearm….

Supination/flexion method — In the supination/flexion method, the examiner supports the child's arm at the elbow and exerts moderate pressure on the radial head with one finger. With the other hand, the examiner holds the child's distal forearm, and then pulls with gentle traction. While maintaining traction, the examiner fully supinates the child's forearm and then fully flexes the elbow in one smooth motion."

Again, this comes back to the issue of a lack of a definitive answer.

When sources are conflicting for a “low yield” issue we suggest our candidates go with what’s written in the textbook that the most examiners contribute to (ie Cameron) and not worry too much more about it. We're not saying don’t be curious, or advocating disinterest in learning.

Just make sure you keep your powder dry for the important stuff.