Paedsy Procedures

Authors: Franklyn Osian / Editor: Liz Herrieven / Reviewer: Charlotte Davies / Codes: / Published: 19/04/2021 / Reviewed: 11/02/2025

Here is a brief overview of three of our favourite and most satisfying PEM procedures. They epitomise Emergency Department (ED) practice but can seem tricky to the PEM naive practitioner. Once youve identified and managed these once, we practically guarantee you will feel on top of the world! But youve got to be in the game to win the game so, get yourself into paeds!

Hair Tourniquets

Hair tourniquets sound easy to remove, but can be very tricky.¹ The hair wraps itself round and round a finger, compromising blood flow. Its much more common in infants (at around 3months old when maternal postpartum hair loss kicks in), and is a potential cause for them being unsettled and crying. The hair tightening around the digit or penis causes oedema so, even seeing the hair can be difficult.

Prompt removal is easiest hopefully you can see the offending hair, get underneath it with scissors and snip. You may be able to get a blunt instrument underneath the hair, and then cut down.

Depilatory cream works in about 71% of cases.² A cutting suture needle may help to cut the thread.³ Good magnification and lighting will be essential!

If all else fails, you may need assistance from your local friendly plastic surgeon theyve got fantastic operating skills, and some magnifying loupes.

Pulled Elbow 

In young children, the annular ligament which holds the radial head (the end of the radius near the elbow) is more funnel shaped than in adults which means its really easy for the radial head to pop out and sublux. Its common in 1-4 year olds, often with a history of being lifted up by the hand which gives it its third name of nursemaids elbow.

The child normally presents with a vague history of trauma or lifting. They are often happily playing, but not using the affected arm. If theyre miserable, consider a supra-condylar fracture in your differentials, as the mechanisms are similar.

To reduce, there are two main methods. 

• Pronation
  Put your finger on the radial head.
  Excessively pronate (show me your nail varnish)
• Flexion-supination
  Apply pressure over the radial head
  Supinate the arm (show me your palms)
  Then flex (bend) the elbow

Theres an excellent video explaining this on DFTB.⁴

Which works better, pronation or supination? There are many research papers on this, including one reviewed by RCEMLearning,⁵ and the answer changes regularly. Pick one – try it, and if it doesnt work, try again.

If these methods dont help, my standard practice is to give the child some analgesia (no, I probably havent given it already), send for an x-ray (in case Ive missed a fracture) and then re-try. If that fails again, pop them in a broad arm sling, home with analgesia and review either in paeds ED review clinic or fracture clinic.

For more information, look at DFTB.⁶

Patella dislocation

A young adult male got tackled whilst playing football and heard a snap on his left knee. His knee was flexed fully and he noticed his kneecap was dislocated upwards. On examining of the left knee, the patella was superiorly dislocated 3cm above the knee, with the knee held in flexion. He was hesitant to straighten his knee and had a limited range of motion with inability to straight-leg raise. There was no significant swelling, warmth or redness. Sensation and peripheral pulses were present.

The patella dislocation was successfully reduced, and plain film radiographs obtained. Because the patient was unable to straight leg raise and the patella remained high riding, he was referred to orthopaedics for review.

Patella Dislocation Reduction

• Provide short acting analgesia -e.g. analgesic gas or penthrox.
• The patella should relocate in about 30-45secs.
• Provide longer acting analgesia
• Splint knee
• Obtain plain film radiographs
• Re-examine, particularly for ability to straight leg raise.
• Discharge + crutches, analgesia and follow up plan

The Technique:

Standing on the lateral side of the left leg with the left hip flexed, extend the knee and guide the patella into anatomical position with the index finger and thumb cupped over the patella.

In a superior dislocation: Hyperextend knees

Two digits should be used under the medial and lateral borders of patella to lift it away from the surface of the femur.

Use medial and lateral rocking movements of the patella, while keeping it lifted, to help to relocate the patella onto the trochlear groove.

The Patella

The patella (the largest sesamoid bone) assists in coordinating the forces of the quadriceps and patellar tendons. It functions both a lever (where it magnifies the force exerted by the quadriceps during knee extension) and a pulley (the patella redirects the quadriceps force as it undergoes normal lateral tracking during flexion).

When patellofemoral injuries occur amongst athletes, they are more common in men. In the general population and amongst non-athletes however, women present more commonly with patellar disorders.

Patellar dislocations are uncommon and superior dislocations are a lot more rare. Injury may be due to direct trauma to the patella or to a valgus (twisting) stress combined with flexion and external rotation.

The most common type of patellar dislocation is a lateral dislocation. Patellar dislocations for ease are classified based on the following:

i) location of patella as it relates to its anatomical space;
ii) rotation about its horizontal or vertical axis; and
iii) the directionality of the articular surface.

An extra-articular patella dislocation is one in which the patella is no longer in its anatomical space anterior to the femoral condyles, but instead is found either medially, laterally, superiorly (as our index patient) or inferiorly.

Intra-articular dislocations are:

• Horizontal A rare occurrence, in which the patella has rotated on its horizontal axis with the articular surfaces facing either proximally or distally
• Vertical Also a very uncommon event, in which the patella rotates around its vertical axis with impaction of one of the lateral surfaces in the intercondylar notch of the femur.

Symptoms of a dislocated patella

When a kneecap dislocates, it will usually look out of place or at an odd angle. But in many cases, it will pop back into place soon. Typical symptoms would include.

• A popping sound/sensation
• Significant knee pain/tenderness
• Inability to straighten the knee affected
• Swelling of the knee
• Inability to walk/bear weight

Summary

Some cases of patellar dislocation may require surgical intervention. These are mostly cases of recurrent patella dislocation which is also more common in women. Many dislocations, however, are reduced at the bedside successfully. Spontaneous reductions are also fairly common.

It is essential to establish presence or absence of other complicating events such as an associated patella tendon rupture which may very well also be managed conservatively, involving immobilization, supportive braces and physical therapy, or surgical repair for complete tendon rupture.

These injuries can usually be recognised relatively easily, and swift expert action in the form of reduction and immobilisation can not only ensure reduction in pain and anxiety for the patient but can also be quite satisfying for the clinician.

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References

1. Andrew Tagg. Hair tourniquets, Don’t Forget the Bubbles, 2017.
2. Knapp S. Hair Tourniquet Syndrome. #EM3, 2024.
3. Lin M. Trick of the Trade: Hair tourniquet release. Academic Life in Emergency Medicine (ALiEM), 2012.
4. Don’t Forget The Bubbles. How to reduce a pulled elbow (nursemaids elbow reduction)? [Internet]. YouTube. 2020 [cited 2025 Feb 10].
5. Laing S, Abela N, Davidson C. December 2016 New in EM. RCEMLearning, 2017.
6. Tessa Davis. Pulled elbows, Don’t Forget the Bubbles, 2021.
7. Bassi RS, Kumar BA, Superior dislocation of the patella; a case report and review of the literature. Emergency Medicine Journal 2003;20:97-98.
8. Johnson AE. Patellar Injury and Dislocation. Medscape, 2024.
9. Udogwu UN, Sabatini CS. Vertical patellar dislocation: A pediatric case report and review of the literature. Orthop Rev (Pavia). 2018 Sep 5;10(3):7688.
10. Jahangir N, Umar M. Spontaneous superior patellar dislocation in young age: case report and reduction technique. J Surg Case Rep. 2017 Mar 9;2017(3):rjx036.
11. Guthrie K, Patellar dislocation. Life in the Fast Lane (LITFL), 2023.
12. Physiopedia – Patellar dislocation.