A 3-year-old girl is brought to the emergency department for acute onset of right elbow pain. She was playing in the snow and started crying when her father pulled her by the arm to take her inside. On examination, the girl keeps her hand in a pronated position, refuses to use her hand, and cries when her elbow is moved. There is no swelling or deformity. Palpation of the radial head elicits mild tenderness. A click is felt when the forearm is hyperpronated, and the child stops crying and starts to use her arm. What is the most likely etiology of this child's symptoms?

Question

A 3-year-old girl is brought to the emergency department for acute onset of right elbow pain.  She was playing in the snow and started crying when her father pulled her by the arm to take her inside.  On examination, the girl keeps her hand in a pronated position, refuses to use her hand, and cries when her elbow is moved.  There is no swelling or deformity.  Palpation of the radial head elicits mild tenderness.  A click is felt when the forearm is hyperpronated, and the child stops crying and starts to use her arm.  What is the most likely etiology of this child's symptoms?

Quizplus · Accepted Answer

11ec25c8_d2c6_22c0_bc81_6161a5726325_MD0003_00 Radial head subluxation (nursemaid's elbow) is one of the most common elbow injuries in children age 1-5. It occurs when infants or children are lifted or pulled by the hand or arm. Pulling causes axial traction on the forearm, which causes the radial head to slip through parts of the annular ligament. Physical examination should show no swelling or angular deformity (the radial head may be mildly tender). The child typically keeps the affected arm in a pronated position; attempted forearm supination will be resisted and cause the child to cry out in pain. axial traction While pressure is applied at the radial head, forearm hyperpronation or supination plus flexion usually reduces the annular ligament with an audible click. Either maneuver should restore full, normal use of the extremity. The response to reduction is diagnostic of this condition. forearm hyperpronation supination plus flexion (Choice A) Lateral epicondylitis ("tennis elbow") is caused by repetitive contraction of the extensor muscles at the lateral epicondyle. Tenderness is elicited over the lateral epicondyle, and pain is felt with passive wrist flexion and resisted wrist extension. (Choice B) Medial epicondylitis ("golfer elbow") manifests as localized tenderness over the medial epicondyle, pain with resisted wrist flexion, and pain with passive wrist extension. (Choices C and F) Fractures are very common in children and manifest with significant pain, deformity, and swelling of the injured bone. A fracture is unlikely in this child, who resumes arm use after forearm supination/flexion. (Choice D) Panner disease is an osteochondrosis of the capitulum. The typical patient is an adolescent who is actively engaged in sports that involve throwing. Common complaints include chronic dull pain, crepitation, and loss of pronation and supination. Educational objective: Radial head subluxation occurs when infants or children are lifted or pulled by the hand or arm. The child typically keeps the hand in a pronated position and refuses attempted forearm supination. Reduction by forearm hyperpronation or supination plus flexion is diagnostic and therapeutic. References: Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. (http://www.ncbi.nlm.nih.gov/pubmed/16651912) Manipulative interventions for reducing pulled elbow in young children. (http://www.ncbi.nlm.nih.gov/pubmed/22258973)

A 3-Year-Old Girl Is Brought to the Emergency Department for Acute