What is the best next step in managing a 3-year-old girl with left arm pain and suspected radial head subluxation after a traumatic injury, presenting with a flexed and pronated forearm?

From the Guidelines

The best next step in managing this 3-year-old girl with suspected radial head subluxation (nursemaid's elbow) is to perform a reduction maneuver. The most effective technique is supination-flexion, where the child's elbow is grasped with one hand while the other hand holds the wrist, then the forearm is quickly supinated (palm turned upward) and the elbow is flexed. This maneuver typically results in an audible or palpable "click" as the annular ligament returns to its normal position. No analgesia is typically required before the procedure as it causes only momentary discomfort and provides immediate relief when successful. After reduction, the child should regain normal arm movement within 5-10 minutes. If the first attempt is unsuccessful, a second attempt can be made, or alternatively, a pronation maneuver can be tried. If multiple reduction attempts fail or if there is significant swelling or deformity suggesting a different diagnosis, radiographs should be obtained to rule out fracture, as recommended by the American College of Radiology 1. Nursemaid's elbow occurs when a sudden pull on the arm causes the radial head to slip partially out from the annular ligament, which is more elastic in young children. Parents should be counseled about the high recurrence rate (approximately 30%) and advised to avoid pulling on the child's arms or lifting by the hands. It is also important to note that diagnostic imaging plays a key role in the assessment of acute elbow pain, and MRI can be useful in the assessment of ligamentous and tendinous injury, as well as rare triceps tears 1. However, in this case, the initial management should focus on reduction of the subluxation, and imaging should be reserved for cases where reduction is unsuccessful or where there is suspicion of a more serious injury.

From the Research

Diagnosis and Management of Radial Head Subluxation

The patient's presentation of left arm pain, flexed and pronated forearm, and lack of gross deformity or ecchymosis is consistent with radial head subluxation, also known as nursemaid's elbow 2, 3, 4, 5.

Key Findings and Recommendations

• The hyperpronation technique is more successful in reducing radial head subluxations compared to supination, with a higher success rate on the first attempt 3.
• A study found that 95% of patients randomized to hyperpronation were reduced successfully on the first attempt, compared to 77% of patients randomized to supination 3.
• The prevalence of missed fractures in children with a clinical diagnosis of radial head subluxation is rare, with a prevalence of 2.9% in one study 4.
• Physicians tend to order radiographs for elbow injuries they initially perceive to be radial head subluxations when attempts at reduction fail 4.

Next Steps in Management

• Attempt reduction using the hyperpronation technique, as it has been shown to be more successful than supination 3.
• If the initial reduction attempt is unsuccessful, consider repeating the attempt after 15 minutes, and if still unsuccessful, consider alternative methods such as supination/flexion 3, 4.
• If reduction is still unsuccessful after multiple attempts, consider obtaining radiographs to rule out fracture or other underlying conditions 4.