Upper-Extremity Impairment in Young Children☆,☆☆,★
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
References (9)
Radial head subluxation: Epidemiology and treatment of 87 episodes
Ann Emerg Med
(1990)"Nursemaid's elbow" in infants six months and under
J Emerg Med
(1985)- et al.
The epidemiology and treatment of radial head subluxation
Am J Dis Child
(1985) - et al.
The pulled elbow
BMJ
(1959)
Cited by (38)
Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis
2017, American Journal of Emergency MedicineCitation Excerpt :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.
Radial Head Subluxation: Factors Associated with Its Recurrence and Radiographic Evaluation in a Tertiary Pediatric Emergency Department
2016, Journal of Emergency MedicineCitation Excerpt :Some children may experience recurrent episodes of RHS, likely related to increased laxity in the annular ligament during childhood (4). On clinical presentation the child will usually exhibit pain with movement and refuse to use the affected forearm, holding it in a slightly flexed (15–20°) and partially pronated manner (5,6). Closed reduction is usually accomplished under one of three circumstances: supination and flexion (SF), hyperpronation and extension (HE), or the patient may undergo spontaneous reduction prior to manipulation.
Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in childhood nursemaid's elbow cases
2013, American Journal of Emergency MedicineCitation Excerpt :Nursemaid's elbow (NE) is a common diagnosis in young children, typically younger than 5 years, who present to emergency departments (EDs) with complaints related to refusing to use one of their arms [1,2].
Critical Procedures in Pediatric Emergency Medicine
2013, Emergency Medicine Clinics of North AmericaCitation Excerpt :History may be inconsistent with the classic “pulling” mechanism.106 In one study, approximately half of the presenting patients had a history of pulling as a possible mechanism, whereas the second most common mechanism was falling from bed.105 Patients will present with the arm adducted, mildly pronated, and minimally flexed.
Upper extremity trauma
2008, Pediatric Emergency MedicineReduction of radial-head subluxation in children by triage nurses in the emergency department: A cluster-randomized controlled trial
2014, CMAJ. Canadian Medical Association JournalCitation Excerpt :Although this was a cluster-randomized trial, the anticipated number of radial-head subluxation cases per day was less than 1, therefore the reduction of power due to clustering was expected to be inconsequential, and we did not include a variance inflation factor in the sample size calculation. Previous studies have reported that success rates for first reduction attempts are 74%–90%, and that 99% of radial-head subluxations are reduced by the time of discharge from the emergency department.1,4–6,8 We conservatively estimated that the reduction success rate for physicians would be 90%.
- ☆
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.‡.
- ☆☆
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