American College of Emergency PhysiciansACEP Continuing Med PEERcert+ Question
This PEERcert+ question is from the Trauma and Bleeding module.
A 3-year-old boy with no past medical history was playing outside and started to run into the street. His father quickly grabbed the boy’s hand, pulling him out of the way of an oncoming car. Immediately, the child started to cry. When he is brought in for evaluation, the boy is well appearing with no obvious signs of trauma, but he refuses to move his left arm. What is the best next step in management?
A. Obtain an x-ray of the left arm
B. Pronate the forearm and then flex the elbow
C. Recommend RICE treatment (rest, ice, compression, elevation)
D. Supinate the forearm and then flex the elbow
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The Correct Answer: Supinate the forearm and then flex the elbow
The child’s presentation is consistent with a nursemaid’s elbow — subluxation of the radial head. This injury is usually caused by applying traction to an extended arm. Immediate reduction is the best next management step when a nursemaid’s elbow is suspected in a patient without other trauma. Supination of the forearm and flexion of the elbow or hyperpronation of the forearm are ways to reduce this subluxation. The physician’s thumb can be placed on the patient’s radial head to feel the click of the radial head back into place. The measure of successful reduction is the ability to move the arm and improvement in pain. Post reduction, it is common for a child to not immediately move the arm. One trick is to return to the patient’s bedside with a popsicle or lollipop and have the child reach with the reduced arm to grab it.