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Question

Difficulty: EasySurgical and Procedural Interventions

A father brings his 3-year-old son to the outpatient pediatric clinic because the child has been refusing to move his left arm for the past hour. The father explains that they were walking in the park when the boy stumbled; to prevent him from falling to the ground, the father quickly pulled the child up by the left hand. Immediately afterward, the child began crying and holding his arm against his side. On physical examination, the boy is alert but appears anxious. He is cradling his left arm close to his body with the elbow slightly flexed and the forearm pronated. There is no visible swelling, ecchymosis, deformity, or point tenderness over the clavicle, shoulder, elbow, or wrist. The child cries and resists only when the clinician attempts to supinate the left forearm. Which of the following is the most appropriate next step in management?

  1. Closed reduction via hyperpronation of the left forearmAnswer
  2. B
    Radiography of the left elbow
  3. C
    Magnetic resonance imaging of the left upper extremity
  4. D
    Arthrocentesis of the left elbow joint
  5. E
    Discharge home with a sling and outpatient orthopedic referral

Answer

Closed reduction via hyperpronation of the left forearm
The correct answer is closed reduction via hyperpronation of the left forearm. The child's presentation—sudden arm pain after an axial pull on the extended arm, resulting in a flexed and pronated posture without swelling or point tenderness—is the classic description of radial head subluxation (nursemaid's elbow). This condition occurs when the annular ligament slips over the head of the radius. Because it is a clinical diagnosis, the most appropriate immediate step in management is procedural reduction. Hyperpronation or the supination-flexion maneuver easily and quickly reduces the ligament, often resulting in immediate relief of pain and return of normal arm function.

Step-by-Step Solution

1
Identify the clinical presentation
The patient is a 3-year-old presenting with acute arm pain after axial traction, holding the arm in pronation and slight flexion with no focal swelling.
This is the classic history and physical examination finding for radial head subluxation (nursemaid's elbow).
2
Determine the necessity of diagnostic workup
No imaging or laboratory tests are needed.
The diagnosis is purely clinical, and X-rays are usually normal as the annular ligament is radiolucent. Imaging is only needed if there is focal tenderness, swelling, or if reduction fails.
3
Select the appropriate procedural intervention
Perform closed reduction via hyperpronation.
Hyperpronation (or the supination-flexion maneuver) is the standard, highly successful procedural intervention to reduce the slipped annular ligament back into its normal anatomical position.

Key Concept

Radial head subluxation (nursemaid's elbow) is a clinical diagnosis managed immediately with a procedural intervention (hyperpronation or supination-flexion) without the need for prior imaging.
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Topics

Surgical and Procedural Interventions

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