A 2-year-old girl is brought to the urgent care clinic by her father due to a sudden refusal to use her right arm. Thirty minutes ago, the father grabbed the child's right hand to prevent her from stepping into the street while they were walking. The child immediately cried and has since kept her arm close to her side. On physical examination, the child is calm while sitting on her father's lap but cries if her right arm is touched. Her right arm is held closely against her trunk with the elbow slightly flexed and the forearm pronated. There is no visible swelling, bruising, erythema, or obvious deformity of the clavicle, shoulder, elbow, or wrist. Which of the following is the most appropriate next step in management?
- AAnteroposterior and lateral radiographs of the right elbow
- BImmobilization with a long-arm cast
- Attempted closed reduction with hyperpronationAnswer
- DUltrasonography of the right elbow joint
- EReassurance and discharge with weight-based ibuprofen
Answer
Attempted closed reduction with hyperpronation
The patient's clinical presentation is classic for radial head subluxation, also known as nursemaid's elbow. This injury typically occurs in children aged 1 to 4 years when axial traction is applied to an extended and pronated arm (e.g., pulling a child by the hand). The annular ligament slips over the head of the radius and becomes entrapped in the radiohumeral joint. The child typically presents holding the arm close to the body with the elbow slightly flexed and the forearm pronated. Because there is no visible swelling, bruising, or bony deformity, fracture is highly unlikely. The most appropriate next step in management is immediate closed reduction, most commonly achieved via hyperpronation of the forearm, which has a higher success rate and is often less painful than the traditional supination-flexion technique.
Step-by-Step Solution
Key Concept
Radial head subluxation (nursemaid's elbow)