Rosen & Barkin's 5-Minute Emergency Medicine Consult (488 page)

• Child refuses to use arm.
  
• Elbow is slightly flexed, with forearm held close to the trunk.
  
• Pain with flexion of the elbow
  
• Pain with forearm supination or pronation
  
• Absence of point tenderness
  
• Minimal to no swelling
  

• Child not using affected arm
  
• 50% report the classic history of pulling the arm.
  
• Can also be due to a fall, minor trauma to the elbow, or twisting of the forearm
  
• In children <6 mo, can be due to the child rolling onto the arm.
  

• Affected arm is held close to the body.
  
• Arm is usually pronated.
  
• Elbow is either fully extended or slightly flexed.
  
• Child will not use the elbow.
  
• Can be mildly tender over anterolateral radial head, but the rest of the elbow is nontender.
  
• Painless passive range of motion
  
• Painful with supination
  

Clinical diagnosis:

• Classic history, passive position of arm, and physical exam are sufficient for diagnosis.
  

Radiographs:

• Not routinely indicated
  
• Obtain to exclude or diagnose other injuries if any of the following are present:
  
  • Point tenderness
    
  • Soft tissue swelling
    
  • Deformity
    
  • Ecchymosis of the elbow
    
  • Failed reduction
    
  • Child continues to favor extremity after reduction maneuver.
    

• Humerus, radius, or ulna fracture
  
• Elbow dislocation
  
• Joint infection
  
• Osteomyelitis
  
• Tumor
  

TREATMENT

Cautions:

• Place ice on the injured elbow to reduce pain and swelling.
  
• Immobilize in a sling or splint to facilitate transport and prevent further injury.
  
• Assess distal neurovascular status.
  

Assess distal motor, sensory, and vascular function.

• 2 common reduction techniques:
  
  • Supination/flexion:
    
    • More commonly used
      
  • Hyperpronation/extension:
    
    • Nurses and caretakers perceive this method to be less painful
      
    • More successful
      
• Supination/flexion technique:
  
  • Grasp child’s hand in handshake position and apply mild axial traction.
    
  • Stabilize injured elbow with the other hand with the thumb over the radial head exerting moderate pressure.
    
  • In 1 smooth, swift motion, fully supinate the forearm and flex the elbow.
    
• Hyperpronation/extension technique:
  
  • Grasp child’s hand in handshake position and apply mild axial traction.
    
  • Stabilize injured elbow with the other hand with the thumb over the radial head exerting moderate pressure.
    
  • Hyperpronate the arm and extend if arm is not already extended.
    
• Placing the examiner’s thumb over the radial head may allow palpation of a click.
  
• Child may cry during the reduction, but is frequently pain free using the arm shortly thereafter. Period of immobility may be some what prolonged if reduction delayed
  
• Attempt reduction a 2nd time if the child does not use arm 15 min after 1st attempt.
  
• 1 of the attempts should be the hyperpronation method.
  
• Consider opposing technique for 2nd reduction attempt.
  
• Radiographic studies indicated if the 2nd reduction attempt is unsuccessful, evaluate for fractures.
  
• Perform postreduction neurovascular assessment.
  

• Usually unnecessary
  
• Acetaminophen: 10–15 mg/kg PO q4h; do not exceed 5 doses/24 hr
  
• Ibuprofen 10 mg/kg PO q6–8h
  

FOLLOW-UP

None

• Discharge after child regains full, unrestricted use of the arm.
  
• Patient instructions:
  
  • Inform parents not to pull or lift the child by the hand, wrist, or forearm.
    
  • Recurrence rate of 27–39% until the child reaches 5 yr of age.
    

Unsuccessful reduction:

• If radiologic evaluation is also negative, child should be referred to an orthopedist.
  
• Place arm in a sling or a posterior splint for outpatient follow-up.
  
• No long-term sequelae have been reported with short delay in reduction
  

• None required for successful reduction
  
• Orthopedics within 24 hr for unsuccessful reduction
  

• Suspect nursemaid’s elbow with a classic history.
  
• Radiographs are not necessary unless the elbow is focally tender or swollen or history does not suggest nursemaid’s elbow.
  
• Reduction attempt should include the hyperpronation method.
  
• 2 unsuccessful reductions should prompt radiographic evaluation.
  
• Unsuccessful reductions should be referred to the orthopedist after the arm is placed in a sling or posterior splint.
  

• Bachman D, Santora S. Orthopedic trauma. In: Fleisher GR, Ludwig S, Henretig FM, et al. eds.
  Textbook of Pediatric Emergency Medicine
  . 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1525.
  
• Chasm RM, Swencki SA. Pediatric orthopedic emergencies.
  Emerg Med Clin North Am.
  2010;28(4):907–926.
  
• Green DA, Linares MY, Garcia Peña BM, et al. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation.
  Pediatr Emerg Care
  . 2006;22:235–238.
  
• Rudloe TF, Schutzman S, Lee LK, et al. No longer a “nursemaid’s” elbow: Mechanisms, caregivers, and prevention.
  Pediatr Emerg Care.
  2012;28(8):771–774.
  

CODES

832.2 Nursemaid’s elbow

BASICS

• Typical presentation of a 3rd cranial nerve (CN) palsy:
  
  • Eyelid drooping
    
  • Blurred or double vision
    
  • Light sensitivity
    
  • May also have other neurologic signs/symptoms:
    
    • Hemiplegia
      
    • Ataxia
      
    • Tremor
      
• CN III controls elevation, adduction and depression of the eye. This nerve also raises the lid and mediates pupillary constriction and lens accommodation:
  
  • Medial rectus:
    
    • Moves eye medially toward nose (adduction)
      
  • Superior rectus:
    
    • Moves eye upward
      
    • Rotates top of eye toward nose
      
    • Slight adduction
      
  • Inferior rectus:
    
    • Moves eye inferiorly
      
    • Rotates top of eye away from nose
      
    • Slight adduction
      
  • Inferior oblique:
    
    • Rotates top of eye away from nose
      
    • Slight elevation and abduction
      
  • Levator palpebrae superioris:
    
    • Raises eyelid
      
• CN IV innervates the superior oblique:
  
  • Moves eye down when looking medially
    
  • Rotates eye internally
    
• CN VI innervates the lateral rectus:
  
  • Moves eye laterally (abduction)
    
  • Lesions categorized as:
    
  • Complete vs. incomplete
    
  • Pupil involving vs. pupil sparing
    
• Complete: Total loss of CN III function (“down and out”):
  
  • Compressive lesions:
    
    • Aneurysms
      
    • Tumors
      
    • Brainstem herniation with compression
      
    • Increased intracranial pressure
      
• Incomplete: Partial loss of CN III function:
  
  • Vascular infarction of vasa vasorum
    
• Pupil involving:
  
  • 95–97% of compressive lesions (aneurysm, tumor, etc.) involve the pupil
    
  • Parasympathetic fibers sit peripherally in CN III
    
• Pupil sparing:
  
  • Ischemic injury to nerve
    
  • Diabetics, uncontrolled hypertension
    

• Intracranial or orbital tumor
  
• Aneurysm (particularly posterior communicating artery)
  
• Trauma
  
• Intracranial hemorrhage
  
• Diabetes mellitus
  
• Migraine headache
  
• Infection, meningitis
  
• Arteriovenous malformation or fistula
  
• Cavernous sinus thrombosis
  
• Neuropathy (e.g., myasthenia gravis, Guillain–Barré)
  
• Collagen vascular diseases (e.g., sarcoidosis)
  
• Idiopathic