Although most elbow dislocations are reduced uneventfully under procedural sedation, the risks of entrapping a fracture fragment or a nerve in the joint space during the procedure are such that immediate orthopedic consultation is recommended (see Chapter 130 Procedures , section on Closed Reduction) Open reduction may be needed in over 50% of cases A repeat neurologic and vascular examination should be completed after ED reduction to assess for median or ulnar nerve entrapment and arterial compromise Persistence of vascular compromise indicates the need for emergent orthopedic consultation Postreduction radiographs are necessary to evaluate for associated fractures that may not be evident when the elbow is dislocated The patient with a reassuring postreduction examination may be placed in a posterior splint with the elbow at 90 degrees and with the forearm in midpronation for to weeks Discharge instructions should include signs of compartment syndrome and symptoms of motor and sensory deficit that require emergent follow-up Radial Head Subluxation CLINICAL PEARLS AND PITFALLS Dependent swelling of the wrist or hand may be noted in the child with a more prolonged period of subluxation Recovery of function after reduction may be more prolonged in younger children and those with greater than to hours of subluxation If reduction fails to return function, one must consider alternative diagnoses including fractures of the bones around the elbow or the clavicle, which may present similarly Radial head subluxation occurs when the annular ligament either tears or slips over the radial head in the setting of longitudinal traction on the arm, and then when traction is released, the ligament remains interposed between the radial head and capitellum This injury, known more often by its moniker, the “nursemaid’s elbow,” is among the most common traumatic injuries to the upper extremity It occurs most often among children from a few months to years old In children older than years, the radial head becomes ossified and less spherical and the strength of the annular ligament changes, making subluxation less common Classically, the child will present with the injured elbow pronated, partially flexed, and held at the side with a history of refusal to use the arm after being pulled or lifted by that same arm Frequently, however, the history is of a fall or, in infants, that the arm was trapped beneath the torso as the child is rolled over Palpation of the elbow may elicit minimal or no pain at the radial head, but attempted supination, pronation, and elbow flexion usually elicits more discomfort Radiographs are not routinely recommended when the history and clinical presentation are classic, as the normal and affected elbows are usually indistinguishable radiographically Imaging should be obtained if the examination or history is atypical, or routine methods of reduction not succeed The two most commonly used reduction techniques are supination and flexion at the elbow, or hyperpronation with an extended forearm (see Chapters 38 Immobile Arm and 130 Procedures, section on Reduction of Nursemaid’s Elbow ) There are some data suggesting that the pronation approach may be more effective on first attempt and less painful When reduction succeeds, the child typically uses the arm normally within to 10 minutes There is no need for immobilization after first subluxation With recurrent subluxations, immobilization for a few weeks in a posterior splint with the elbow at 90 degrees and with the forearm supinated may be considered Note that even when efforts at closed reduction fail, spontaneous reduction almost invariably occurs Once alternative diagnoses have been excluded, persistently symptomatic patients with a suspected nonreduced radial head subluxation may be discharged in a sling or posterior splint with orthopedic follow-up Injuries of the Forearm Fractures of the Radial and Ulnar Shafts Goals of Treatment ED management should include pain control and immobilization with the arm in a position of comfort, until definitive orthopedic reduction can be achieved CLINICAL PEARLS AND PITFALLS Plastic deformations are more common in the ulna, and are difficult to identify without comparison films of the contralateral forearm Given the “ring” structure of the forearm and resulting transmission of force, the presence of an apparent single-bone fracture should prompt close inspection for possible dislocation at the proximal and distal radioulnar joints The potential for remodeling decreases with increasing fracture distance from the epiphysis and with the age of the child As a result, less angulation is acceptable in midshaft fractures than in more distal injuries, and in adolescents relative to younger children The incidence of neurovascular complications from forearm and wrist fractures is low Current Evidence Forearm shaft fractures are the third most common fracture in children, and many require sedated reduction in the ED to obtain anatomic or near-anatomic alignment per guidelines of anticipated remodeling by age and fracture location Unfortunately, an estimated 39% to 64% of these reduced complete shaft fractures of the ulna and radius remain unstable and will require subsequent repeat manipulation or surgical stabilization ( Fig 111.25 ) While closed reduction and casting remains the standard of care, a primary surgical approach may be preferential for certain patients and fracture types This consideration is based on the potential for failed reduction and/or increased risk of permanent loss of motion secondary to waning remodeling potential of certain patients due to age or unstable fracture location Commonly unstable fracture patterns at higher risk for failed closed reduction include proximal third fractures, ulna fractures with angulation greater than 15 degrees, comminuted patterns, Monteggia fractures, and fractures in older children For these patients, orthopedics should be consulted While the standard of care has not changed, emergency clinicians should be aware of these potential options to guide their discussions with patients FIGURE 111.25 Complete fractures of the midshafts of the radius and ulna in a 9-year-old boy Efforts at closed reduction failed; internal fixation was necessary Clinical Considerations Clinical recognition Radial and ulnar shaft fractures have a number of fracture patterns including greenstick, torus (buckle), plastic deformation, and complete The management of these fractures depends on the age, type of fracture, and degree of displacement If there is wrist or elbow pain and swelling associated with deformity suggestive of forearm fracture, the clinician must consider the possibility of Galeazzi or Monteggia fracture-dislocation pattern, respectively Triage considerations These patients often present with an obvious deformity The injured extremity should be splinted and analgesia provided while awaiting further evaluation A focused neurovascular assessment should be performed Clinical assessment In many instances, emergency clinicians can provide the satisfactory initial, if not definitive, management for many forearm injuries However, careful history and assessment for associated fracture or dislocation is important in understanding the full complexity of the injury and determining the type of imaging and consultation necessary The incidence of neurovascular injury is low in forearm fractures; nevertheless, the initial evaluation should include a thorough examination of circulation, sensory, and motor nerve function distal to the injury Monteggia fractures (ulnar shaft fracture with radial head dislocation) may be diagnosed on physical examination by palpation of the dislocated radial head ( Fig 111.26 ) These children will frequently have considerable pain and swelling at the elbow with limited flexion and forearm supination A palsy of the posterior interosseous nerve, a motor branch of the radial nerve resulting in weakness or ... 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