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Nursemaid's Elbow

Topic updated on 01/21/15 11:49am
Introduction
  • Also known as subluxation of radial head 
  • Epidemiology
    • most common in children from 2 to 5 years of age.
  • Pathophysiology
    • mechanism
      • caused by longitudinal traction applied to an extended arm
    • pathoanatomy
      • caused by subluxation of the radial head and interposition of the annular (orbicular)  ligament into the radiocapitellar joint. 
Presentation
  • Symptoms
    • a child with radial head subluxation tends to hold the elbow in slight flexion and the forearm pronated.
  • Physical Exam
    • pain and tenderness localized to the lateral aspect of the elbow.
Imaging
  • Radiographs
    • recommended views
      • not routinely indicated in presence of classic history and physical examination
    • findings
      • radiographs are normal
Differential
 

Pediatric Elbow Injury Frequency & Treatment

Fracture Type % elbow injuries Peak Age Requires OR
Supracondylar fractures 41% 7  majority
Radial Head subluxation 28% 3  rare
Lateral condylar physeal fractures 11% 6 majority 
Medial epicondylar apophyseal fracture 8% 11 minority 
Radial Head and Neck fractures 5% 10 minority 
Elbow dislocations 5% 13 rare 
Medial condylar physeal fractures 1% 10 rare 
 
Treatment
  • Nonoperative
    • closed reduction 
      • indications
        • acute cases
  • Operative
    • open reduction
      • indications
        • chronic injuries 
Techniques
  • Closed reduction of radial head subluxation 
    • reduction techniques
      • reduction is performed by manually supinating the forearm and flexing the elbow past 90 degrees of flexion.   
      • while holding the arm supinated the elbow is then maximally flexed 
      • during this maneuver the physician’s thumb applies pressure over the radial head and a palpable click is often heard with reduction of the radial head.
      • alternative technique includes hyperpronation of the forearm while in the flexed position. 
    • followup
      • immobilization is not necessary and the child may immediately resume use of the arm.
      • follow up is only needed if the child does not resume normal use of his arm in the following weeks.
Complications
  • Recurrence
    • occurs in 5% to 39% of cases, but generally ceases after 5 years of age.

 

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Qbank (2 Questions)

TAG
(OBQ11.97) A 3-year-old male has decreased use of his left elbow after his mother grabbed his arm and attempted to lead him across the street. Physical exam demonstrates guarding of the extremity with a slightly flexed and pronated arm, elbow swelling, and focal tenderness. A lateral radiograph is shown in Figure A. What is the most appropriate first step in management? Topic Review Topic
FIGURES: A          

1. MRI
2. Aspiration of the elbow joint with blood cultures
3. Closed reduction via supination and flexion
4. Closed reduction via longitudinal traction
5. Placement into long arm splint with no reduction required

PREFERRED RESPONSE ▶
TAG
(OBQ07.69) A 2-year-old is brought to the emergency room with reports of acute elbow pain and limited use of the left upper extremity. The patient is neurovascularly intact and is afebrile. Examination reveals that the elbow is in slight flexion and the forearm pronated but further examination is limited secondary to pain. AP and lateral radiographs are shown in Figures A and B. What is the next best step in management? Topic Review Topic
FIGURES: A   B        

1. Observation
2. MRI
3. Supination and flexion reduction maneuver
4. Supination reduction maneuver with long arm casting
5. Closed reduction and percutaneous pinning

PREFERRED RESPONSE ▶




Evidence



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