A 3-year-old girl is brought to the emergency department by her mother due to refusal to u… — USMLE Step 2 CK

A 3-year-old girl is brought to the emergency department by her mother due to refusal to use her left arm. The mother reports that an hour ago, they were walking on a slippery sidewalk when the child lost her balance. To prevent her from falling to the ground, the mother instinctively pulled up firmly on the child's left hand. Following this, the child immediately began crying and has since refused to bend her elbow or reach for toys. Vital signs include a temperature of $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), pulse of $105/\text{min}$ , and blood pressure of $90/60\text{ mm Hg}$ . On physical examination, the child is calm when left undisturbed but holds her left arm adducted against her side with the elbow slightly flexed and the forearm pronated. There is no erythema, ecchymosis, or focal point tenderness upon palpation of the clavicle, shoulder, humerus, elbow, or wrist. As part of the initial triage protocol, point-of-care laboratory studies are obtained and reveal a leukocyte count of $7,200/\text{mm}^3$ , an erythrocyte sedimentation rate of $6\text{ mm/hr}$ , and a C-reactive protein of $0.3\text{ mg/dL}$ . Which of the following is the most appropriate next step in management?

Hyperpronation of the left forearmCevap
B
Radiography of the left elbow
C
Application of a long-arm cast
D
Intravenous administration of oxacillin
E
Notification of child protective services

Cevap

Hyperpronation of the left forearm is the most appropriate next step in management.

This patient's presentation is pathognomonic for radial head subluxation, commonly known as Nursemaid's elbow. It typically occurs in children aged 1 to 4 years when axial traction is applied to a pronated and extended arm (such as being pulled by the hand to prevent a fall). This traction causes the annular ligament to slip over the head of the radius and become trapped in the radiohumeral joint. Children present holding the affected arm close to their body, with the elbow slightly flexed and the forearm pronated. Crucially, there is no focal swelling, deformity, or point tenderness. When the history and physical examination are classic, the most appropriate next step is immediate manual reduction. Hyperpronation of the forearm (while applying pressure to the radial head) is the preferred technique, as it has a higher first-attempt success rate and is often perceived as less painful than the traditional supination-flexion maneuver.

Adım Adım Çözüm

Analyze the mechanism of injury and physical examination findings.

The patient experienced axial traction on an extended arm, followed by acute pseudoparalysis with the arm held flexed and pronated. There is no focal tenderness or swelling.

This establishes a classic clinical picture of radial head subluxation (Nursemaid's elbow).

Evaluate the need for diagnostic workup versus immediate intervention.

Given the classic presentation and absence of focal point tenderness or signs of infection (normal vitals and inflammatory markers), imaging or extensive workup is unnecessary.

Unnecessary imaging delays care and causes undue distress; clinical diagnosis warrants immediate therapeutic intervention.

Select the appropriate therapeutic maneuver.

Closed reduction via hyperpronation (or supination-flexion) is selected.

Hyperpronation is highly effective and often less painful than the supination-flexion maneuver for reducing the subluxed annular ligament.

Anahtar Kavram

Radial head subluxation (Nursemaid's elbow) is a common pediatric injury diagnosed clinically and treated with immediate manual reduction, typically by hyperpronation.

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