This patient has nursemaid's elbow, subluxation of the radial head. The appropriate course of action is closed reduction via flexion and supination of the forearm.
Nursemaid's elbow is a common occurrence in children ages 1 to 4. It classically occurs when children are pulled by a single arm in the opposite direction of their momentum (e.g. a child being yanked back when they run towards something). The annular ligament in young children is looser than in older children and this allows for partial dislocation (subluxation) of the radial head. The subluxation is easily reduced either by flexion and supination, or by hyperpronation.
Boyette and London described the phenomenon of nursemaid's elbow in 1948. They note that the factors suggestive of nursemaid's elbow include: consistent with history, lack of deformity at site of injury, point tenderness over the head of the radius, abnormal resting position of the extremity, and loss of function.
Macias et al. conducted an RCT comparing hyperpronation to supination/flexion for reduction of subluxation of the radial head. They found that hyperpronation resulted in fewer attempts at reduction, was more successful than flexion/supination, and frequently succeeded when flexion/supination failed.
Illustration A shows a common cause for the development of nursemaid's elbow. Illustration B shows the how the radial head subluxes out of the annular ligament. Video V shows the technique of reducing nursemaid's elbow.
Answer 1: Casting is not necessary, and will not promote reduction of the subluxation.
Answer 2: Although action is required, reduction can be achieved without surgery.
Answer 4: While supination of the forearm is appropriate, extension will not help reduce the subluxation.
Answer 5: This patient needs an intervention to resolve the subluxation of her radial head, expectant management is not appropriate here.
BOYETTE DP, LONDON AH Jr. Subluxation of the head of the radius; nursemaid's elbow. J Pediatr. 1948 Mar;32(3):278-81. PubMed PMID: 18907149.
PMID:18907149 (Link to Abstract)
Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998 Jul;102(1):e10. PubMed PMID: 9651462.
PMID:9651462 (Link to Abstract)