Upper-Extremity Impairment in Young Children,☆☆,

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Abstract

Study objective: To determine the spectrum of disorders in children younger than 6 years with upper-extremity injury or immobility and to identify clinical findings associated with specific disorders. Design: Prospective patient series. Setting: Urban pediatric emergency department. Participants: Children younger than 6 years seen during a 6-month period with injury or immobility of an upper extremity. Results: We identified 178 episodes of immobility or injury of an upper extremity. Radial head subluxation (RHS) was the most frequent diagnosis (63%; 99 definite and 13 probable), followed by fracture (22%) and soft-tissue injury (STI; 13%). One patient each had humeral osteomyelitis and neurologic impairment. The mean age of children with RHS was significantly less than that of children with fractures (27±12 months versus 39±19 months, P<.01); the only diagnoses in children younger than 4 months old were infection and neurologic impairment. Multivariate regression analysis showed point tenderness and swelling correlated with fractures (P<.05). Decreased arm movement, absence of swelling, and a pull as the mechanism of injury correlated with RHS (P<.05). However, arm traction occurred in only 55% of the children with RHS (95% confidence interval=.46 to .64). By 1 week after the evaluation, all children without fractures had recovered, except one each with a sprain, osteomyelitis, and neurologic impairment. Conclusion: Most children with arm injury or immobility have bony or soft-tissue trauma, the majority being RHS. Clinical findings varied between diagnoses and may aid the clinician in deciding whether attempted reduction of RHS is indicated or whether radiographs are warranted first. Nontrauma diagnoses are unusual but should be considered, particularly in the child younger than 6 months old. Appropriate immobilization and follow-up are important for the management of children without a clear diagnosis at the initial evaluation. [Schutzman SA, Teach S: Upper-extremity impairment in young children. Ann Emerg Med October 1995;26:474-479.]

Section snippets

INTRODUCTION

Pediatricians and emergency physicians frequently must evaluate children with upper-extremity injuries or immobility. The assessment of the young patient is especially challenging because the preverbal child cannot relate a history, has difficulty localizing pain, and often is frightened and uncooperative, hindering adequate physical examination. The child with a history and physical examination classic for radial head subluxation (RHS, aka nursemaid's elbow) or the child with a gross deformity

MATERIALS AND METHODS

Approval for this study was received from the Children's Hospital Committee on Clinical Investigations. Children younger than 6 years seen during a 6-month period in an urban pediatric emergency department with the complaint of injury or immobility of an upper extremity were identified prospectively. Excluded were those with lacerations or burns and those referred with fractures documented radiographically. The treating physician completed a questionnaire with information regarding the history,

RESULTS

One hundred seventy-eight episodes of arm injury or immobility in 173 children (96 of them girls) were identified during the 6-month period. Five children each had two episodes of RHS. The most frequent final diagnosis was RHS (63%; 99 definite and 13 probable), followed by fracture (22%) and nonspecific STI (13%). One patient each had humeral osteomyelitis and neurologic impairment. There were 20 fractures of the radius or ulna, 15 of the humerus (supracondylar and shaft), and 5 involving the

DISCUSSION

Young children with injury or immobility of an upper extremity commonly visit physicians' offices and EDs for evaluation and can be considered to have the upper-extremity equivalent of a limp. At our institution, children younger than 6 years with this symptom (excluding those with lacerations, burns, and those referred with documented fractures) accounted for 8 of 1,000 ED visits. As with limping children, evaluation of these patients is challenging, given the frequent limitations of the

CONCLUSION

Despite a broad range of causes of injury or immobility of an upper extremity in young children, 99% had RHS, fracture, or nonspecific STI. Historical and physical findings varied significantly between the traumatic diagnoses, which may aid the clinician in the differentiation, particularly as to whether radiography is warranted before attempted reduction. However, no one group of clinical characteristics accurately identified all children with a specific diagnosis. Because only 55% of those

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    The applied forces and resulting arm movements permit subluxation of the radial head by partially tearing or entrapping the annular ligament between the radial head and capitellum [3,5]. The most frequent causal mechanism is when an adult abruptly pulls while holding the hand of a child [3,5,6]. Clinical presentation suggestive of nursemaid's elbow includes typical mechanism of injury, limb in incomplete extension with a pronated wrist, and the child not wanting to use the arm or protecting it at their side.

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From the Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, Massachusetts*; and the Division of Emergency Medicine, Buffalo Chiildren's Hospital, Buffalo, New York..

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Address for reprints: Sara A Schutzman, MD, Division of Emergency Medicine, Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115, 617-735-6624, Fax 617-735-6625

Reprint no. 47/1/67075

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