Radial head subluxation is an extremely common injury (nursemaid's elbow) with a peak incidence between 1 and 4 years of age. It has been recognized for centuries. While a history of linear traction upon a hand or wrist is frequently elicited, it is not uncommon to receive a history of an incidental fall in which the arm, elbow, and forearm were impacted between the ground and the child's trunk. Occasionally there is no history of trauma, and the parents note only nonuse of the affected limb.
The child maintains the arm partially flexed at the elbow and in forearm pronation. Typically, the arm is kept close to the trunk. The child usually is found seated in the parent's lap and appears quite contented and playful but declines to actively move the affected arm.
A slow and pleasant approach to the child's examination demonstrates no tenderness to palpation of the clavicle, shoulder, humerus, elbow, forearm, wrist, or hand. By carefully avoiding movements involving the elbow and forearm, the physician will note painless passive range of motion of the shoulder, hand, and wrist. In contrast, even modest attempts to supinate the forearm or to flex or extend the elbow elicit pain and anguish.
There is seldom clinical doubt if the child's age, mechanism of injury, body positioning, and examination (nonuse as opposed to tenderness to palpation) are consistent with the diagnosis. Radiographs in such a situation are superfluous, since there are no radiographic abnormalities associated with this condition and since the examination effectively excludes other entities. Radiographs should be considered, however, if the child exhibits point tenderness, soft tissue swelling, or ecchymosis of the elbow.
Reduction is usually easily accomplished. The physician's thumb is placed over the child's radial head. The child's hand is grasped by the physician. Beginning with the child's elbow in extension and the forearm in pronation, three simultaneous maneuvers are rapidly accomplished: (1) downward pressure on the child's radial head by the physician's thumb, (2) passive full supination of the child's forearm, and (3) passive full flexion of the child's elbow. A "click" is often but not always palpated by the physician's thumb as reduction is accomplished. The child cries out for a few seconds but is usually and easily soon distracted. Observation for up to 15 min typically demonstrates a full return to normal function and use, especially if the physician notes the click. If function and use have not normalized within 15 min, a repeated attempt at reduction is recommended. Alternative diagnoses should be considered if the child's arm does not return to normal function and use following a second reduction attempt. Radiographic studies may then be indicated.
For children who recover full, unrestricted use after one or two reduction maneuvers, further therapy is unnecessary. A sling may be offered to the child whose function and use have improved but are not complete. The toddler will often discard the sling within minutes or hours, however. Parents should be gently reminded to avoid lifting the child by the hand, wrist, or forearm and should be informed of the increased risk of recurrence until the child reaches 5 to 6 years of age.
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