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Observation
2%
71/3091
MRI
62/3091
Supination and flexion reduction maneuver
87%
2694/3091
Supination reduction maneuver with long arm casting
6%
175/3091
Closed reduction and percutaneous pinning
3%
78/3091
Select Answer to see Preferred Response
Based on clinical findings and radiographs provided, the patient should undergo a supination maneuver without casting to acutely treat this radial head subluxation or “nursemaid’s elbow”. The mechanism causing radial head subluxation is pronation and traction, causing a tear of the annular ligament. The ligament becomes interposed between the radial head and the capitellum as the traction is released. Reduction of the radial head occurs with supination of the forearm and flexion of the elbow to ~60-90 degrees. Immobilization is not necessary. Figures A and B show AP and lateral radiographs of a patient with a nursemaid's elbow; no radiographic abnormality is seen, which is classic for this condition. Illustration A is a schematic detailing the mechanism of annular ligament tear. Release of traction is what often catches the ligament with the radiocapitellar joint space and limits motion. Incorrect answers 1: Observation alone is not appropriate as the radial head is subluxated and needs to be reduced 2: While an MRI can be obtained, it may be more beneficial if the radial head is irreducible and delineation of the surrounding soft tissue injury or occult fracture is wanted. 3: While the reduction maneuver is that of supination, casting should not be completed as to avoid stiffness. Casting may be indicated if recurrent subluxation has occurred to allow for adequate healing of the annular ligament. 5: Elbow pinning is not required to keep the annular ligament reduced.
3.7
(32)
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