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A mother brings her 4-year old daughter Sarah to the emergency department. She explains that at school the previous day, her daughter was reported to trip over a class-mate and fall. The mother explains that they went to a walk-in clinic last night, x-rays were completed and they were sent home in a sling. Her mother feels unsatisfied with the care she received and reports that Sarah is no longer using her left arm and was in pain last night.
General appearance: Overall well looking 4-year old girl, easily distractable, limp left arm
Vitals: HR: 115 beats/min, BP: 97/66, RR: 22/min, T: 37.0 C
HEENT: Unremarkable
CVS: Normal S1, S2, II/VI systolic ejection murmur
Pulmonary: Chest clear to auscultation
Abdo: Soft and nontender.
Neuro: Screening exam normal.
Focused MSK exam: Upon attempt to closer examine her arm, she becomes anxious and guards her arm. The left arm is in 20 degrees partial flexion and the forearm partially pronated. She is resistant to any movement of the wrist, fingers or arm. There is no pain shrugging the shoulders. There is no erythema, swelling or signs of trauma in any region of the left arm. Neurovascular status is intact.
Based on the history and physical exam, what is the most likely diagnosis?
Responses:
choose the best one answer
Explanation:
This is the classic presentation of the Nursemaid's Elbow or radial head subluxation/dislocation. The mechanism of injury is usually a sudden jerk or axial traction on a pronated and extended forearm with the elbow in extension. A portion of the annular ligament slips over the head of the radius and slides into the radiohumeral joint, where it becomes trapped. This results in displacement of the annular ligament. Once the child gets older, the annular ligament has become thicker unlikely to tear or be displaced.
Common mechanisms of injury are:
- A toddler holding the hand of an adult is suddenly pulled in the opposite directions.
- A toddler being held by the wrist is pulled over an obstacle.
- Falling directly on the elbow.
It is unlikely that this child has a fracture due to the overall well appearance of the child, no erythema and no swelling. An ulnar dislocation is unlikely as there would be a deformity observable on inspection.
Panner disease is osteochondrosis of the lateral portion of the distal humeral epiphysis. It is usually present in adolescents that are involved in throwing activities. Patients present with pain, loss of motion and crepitus over the joint.
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