Introduction Overview Nursemaid's elbow is a common injury of early childhood that results in subluxation of the annular ligament due to a sudden longitudinal traction applied to the hand treatment is usually closed reduction with either a supination or a hyperpronation technique. Epidemiology incidence common demographics most common in children from 1 to 4 years of age average age is 28 months rare after 5 years of age slightly more common in females Pathophysiology mechanism of injury sudden, longitudinal traction applied to the hand with the elbow extended and forearm pronated may also be caused by a fall pathoanatomy annular ligament becomes interposed between radial head and capitellum in children 5 years of age or older, subluxation is prevented by a thicker and stronger distal attachment of the annular ligament Prognosis excellent when reduced in a timely manner Presentation History a click may be heard or felt by the person pulling the child's arm Symptoms child refuses to use the affected limb holds the elbow in slight flexion and the forearm pronated Physical Exam pain and tenderness localized to the lateral aspect of the elbow range of motion full flexion and extension pain with supination Imaging Radiographs not required in the setting of the classic presentation of history of traction injury child five years or younger consistent clinical exam when obtained, elbow radiographs are normal 25% will show radiocapitellar line lateral to center of capitellum Ultrasound indications helpful for confirming the diagnosis when necessary when the mechanism of injury is not evident when physical examination is inconclusive benefits no radiation to the patient can visualize soft tissues findings increase echo-negative area between capitellum and radial head sensitivity 64.9% and specificity 100% Differential Diagnosis Nursemaid elbow is a diagnosis of exclusion Differential diagnosis of a painful elbow with limited supination traumatic causes supracondylar fracture, olecranon fracture, radial neck fracture, lateral condyle fracture contusion infection septic arthritis congenital radial head dislocation forearm synostosis Treatment Nonoperative closed reduction of annular ligament subluxation indications for majority of cases must be certain no fracture is present prior to any manipulation Operative open reduction rarely required indications for chronic, symptomatic subluxations that cannot be reduced Techniques Closed reduction of radial head subluxation supination technique while holding the arm supinated the elbow is then maximally flexed the physician’s thumb applies pressure over the radial head and a palpable click is often heard with reduction of the radial head hyperpronation technique involves hyperpronation of the forearm while in the flexed position followup child should begin to use the arm within minutes after reduction immobilization is unnecessary after first episode Complications Recurrence may occur, especially if the child is younger than 3 years initially treat with cast application in flexion and neutral or supination
QUESTIONS 1 of 2 1 2 Previous Next (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? Review Topic QID: 3520 FIGURES: A 1 MRI 1% (13/1587) 2 Aspiration of the elbow joint with blood cultures 0% (2/1587) 3 Closed reduction via supination and flexion 94% (1487/1587) 4 Closed reduction via longitudinal traction 1% (20/1587) 5 Placement into long arm splint with no reduction required 4% (56/1587) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 730 FIGURES: A B 1 Observation 2% (36/2221) 2 MRI 2% (41/2221) 3 Supination and flexion reduction maneuver 89% (1969/2221) 4 Supination reduction maneuver with long arm casting 5% (119/2221) 5 Closed reduction and percutaneous pinning 2% (49/2221) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3
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