Michael Hughes MD
Pediatric Elbow Injury Frequency & Treatment
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Average 4.3 of 31 Ratings
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?
Aspiration of the elbow joint with blood cultures
Closed reduction via supination and flexion
Closed reduction via longitudinal traction
Placement into long arm splint with no reduction required
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The clinical scenario above describes a nursemaids elbow. This injury occurs commonly in children under 5 years of age as a result of a quick pull on an extended and pronated arm and results in subluxation of the annular ligament. Figure A is a lateral radiograph showing normal ossification pattern in a pediatric elbow, without any obvious fracture or dislocation. A lateral radiograph of a nursemaid's elbow will show a normal collinear relationship between capitellum & central axis of the radius. Reduction typically includes elbow flexion and supination while placing a finger on the radial head to feel the snap of the reducing annular ligament.
Krul et al studied manipulative techniques for reduction of nursemaid elbows. Although elbow flexion with forearm supination is the commonly taught technique for reduction, their review mentioned several studies that showed that forearm pronation during reduction may cause less pain and actually be more effective than supination. They concluded further high-quality studies need to be done on this reduction technique.
Illustration A shows the elbow flexion and forearm supination technique used to reduce the subluxated radial head.
Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW
Cochrane Database Syst Rev. 2012 1:CD007759. PMID: 22258973 (Link to Abstract)
Krul, COCHD 2012
J Am Med Assoc. 1959 Apr 11;169(15):1734-6. PMID: 13640927 (Link to Abstract)
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Average 3.0 of 19 Ratings
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?
Supination and flexion reduction maneuver
Supination reduction maneuver with long arm casting
Closed reduction and percutaneous pinning
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.
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.
Average 3.0 of 27 Ratings
Shows nursemaid elbow reduction