A 4-year-old girl is brought to the emergency department for severe pain in her right arm for the past 2 hours. She was holding hands with her 7-year-old sister while they were running across the park, and the patient tripped and hit the ground. She has no previous history of hospitalizations or surgeries. Development has been normal for her age, and her immunizations are up to date. Her vital signs are within normal limits. On physical examination, the patient is holding her right arm close to her chest with her elbow slightly flexed and the forearm pronated. There is no tenderness, swelling, or erythema over the right elbow joint. Radial pulse is present. Attempts at passively supinating her forearm elicit pain and cause her distress.
Which of the following is the most appropriate next step in the management of this patient?
C) Hyperpronation of the right arm
Radial head subluxation, also known as nursemaid’s elbow, is a common pediatric elbow injury caused by sudden traction on a pronated or outstretched arm (e.g., a child getting yanked by the arm or tripping suddenly while holding onto someone). With the sudden pulling force on the elbow, the radial head slips under the annular ligament, causing the patient’s symptoms. This injury occurs in children less than 5 years old whose bones and ligaments are still developing. Diagnosis of radial head subluxation is done clinically. In the absence of significant trauma or any symptoms that point to neurovascular compromise, reduction can be done by hyperpronation of the affected forearm while applying slight traction. A faint clicking or popping sound may be heard once the radial head is slotted back into the joint.
Answer choice A: Apply ice packs on the right forearm and elevate arm while resting, is incorrect. Ice packs and elevation of the affected limb can lessen inflammation and pain caused by muscle sprains. However, this patient’s elbow pain is caused by subluxation of the radial head and will be treated adequately with immediate manual reduction.
Answer choice B: Cast on the right elbow, is incorrect. Casting the elbow is more appropriate in the presence of fractures. The patient’s history, clinical presentation, and lack of significant trauma make fractures unlikely in this patient.
Answer choice D: Splint on the right elbow, is incorrect. Splinting the elbow is more appropriate in the presence of fractures. The patient’s history and the lack of significant trauma make fractures unlikely in this patient.
Answer choice E: X-ray of the right elbow and forearm, is incorrect. Radial head subluxation is diagnosed clinically. The patient presents with the classic mechanism and presentation for subluxation, which makes other diagnoses less likely. Moreover, there is no evidence of significant neurovascular compromise. Therefore, ordering imaging is not appropriate for this patient.
Key Learning Point
Radial head subluxation is suspected in a pediatric patient with a history of sudden forceful traction on their arm who presents with pain and significant distress when the affected forearm is moved. It can be managed with manual reduction through hyperpronation of the forearm.
