A 2-year-old girl is brought to the emergency department due to sudden refusal to move her right arm for the past hour. Her mother says that this started immediately after she grabbed her daughter by the right wrist to prevent her from falling out of a chair, but there was no other trauma. The patient is an active girl who likes to run and play at the beach and playground. She takes no medications and her vaccinations are up to date. The girl lives with her parents, who work at home as writers. She does not attend day care or have other caregivers. Temperature is 36.7 C (98 F) and pulse is 94/min. On physical examination, the girl holds her right arm close to her body with the forearm pronated. No swelling or focal point tenderness of her upper extremities is elicited, but she winces when supination of her right arm is attempted. Radial pulse is 2+ bilaterally, and there is no pallor, cyanosis, or ecchymosis. Which of the following is the most appropriate next step in management of this patient?

Question

A 2-year-old girl is brought to the emergency department due to sudden refusal to move her right arm for the past hour.  Her mother says that this started immediately after she grabbed her daughter by the right wrist to prevent her from falling out of a chair, but there was no other trauma.  The patient is an active girl who likes to run and play at the beach and playground.  She takes no medications and her vaccinations are up to date.  The girl lives with her parents, who work at home as writers.  She does not attend day care or have other caregivers.  Temperature is 36.7 C (98 F) and pulse is 94/min.  On physical examination, the girl holds her right arm close to her body with the forearm pronated.  No swelling or focal point tenderness of her upper extremities is elicited, but she winces when supination of her right arm is attempted.  Radial pulse is 2+ bilaterally, and there is no pallor, cyanosis, or ecchymosis.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0bd_d7d4_8f63_91b1ad50fe03_MD0005_00 This child's sudden refusal to move the arm immediately after her forearm was pulled is classic for radial head subluxation. This injury, also known as nursemaid's elbow or annular ligament displacement, typically occurs in children age 6 months to 5 years. Another common mechanism of injury includes swinging a child by the arms. The sudden pulling force causes the annular ligament to slide over the radial head and become entrapped in the radiohumeral joint. annular ligament Children with this injury typically hold the arm close to their body with the forearm pronated and the elbow extended. Radiographs are not necessary to make the diagnosis when the history and examination findings are classic, as in this case. Treatment consists of reduction by hyperpronation or supination/flexion. In the hyperpronation method, the child's arm is held at the elbow, pressure is applied to the radial head, and the forearm is hyperpronated. In the supination/flexion method, the elbow is supported similarly while the patient's forearm is quickly supinated and fully flexed at the elbow in a continuous motion. Hyperpronation has a significantly higher chance of successful reduction than supination, although practitioners may use whichever method they are most comfortable performing. Following reduction, the child should be able to move the arm normally in a few minutes. hyperpronation supination/flexion (Choices B and C) Radial head subluxation can be reduced at the bedside without casting or immobilization. Reduction can be performed as an outpatient or by an emergency department provider without operative repair. (Choice D) MRI can be used to diagnose ligament and tendon disorders (sprains, partial/complete tears), cartilage lesions, occult fractures, and osteomyelitis. It is not indicated for the diagnosis of radial head subluxation. (Choice E) X-rays should be considered if there is a history of trauma or fall on an outstretched arm. X-rays should also be ordered to evaluate for fracture if there is focal tenderness or swelling. The patient's history of arm disuse after a pulling motion is unlikely to cause a fracture. Educational objective: Radial head subluxation, or nursemaid's elbow, classically presents as sudden refusal to move an arm after a pulling force is exerted on the forearm. Examination shows a child who holds the affected arm close to the body with the forearm pronated. Hyperpronation of the affected forearm is the treatment of choice. References: Investigation on 2331 cases of pulled elbow over the last 10 years. (http://www.ncbi.nlm.nih.gov/pubmed/24987508) Manipulative interventions for reducing pulled elbow in young children. (http://www.ncbi.nlm.nih.gov/pubmed/22258973)

A 2-Year-Old Girl Is Brought to the Emergency Department Due