History and radiographic findings associated with clinically suspected radial head subluxations

Cg. Macias et al., History and radiographic findings associated with clinically suspected radial head subluxations, PEDIAT EMER, 16(1), 2000, pp. 22-25
Citations number
Categorie Soggetti
Journal title
ISSN journal
0749-5161 → ACNP
Year of publication
22 - 25
SICI code
Objectives: To determine: I) physician practices regarding the use of radio graphs for radial head subluxations (RHS), 2 the prevalence of missed fract ures in children with a clinical diagnosis of RHS, 3) the relative risk of a fracture with a nonclassic history for mechanism of injury for RHS, and 4 ) radiographic findings associated with RHS that are difficult to reduce. Methods: This study began with a physician survey that addressed the integr ation of radiographs into the management of RHS, me subsequently conducted a prospective randomized trial with a consecutive sampling of children less than 6 rears of age who presented to one of 2 urban pediatric emergency de partments and 2 suburban pediatric urgent care centers with a clinical diag nosis of RHS, After informed consent was obtained, reduction was undertaken with a maximum. of four attempts (two by hyperpronation and two by supinat ion/flexion), 15 minutes apart. Failure to reduce the RHS resulted in the p rocurement of a radiograph of the elbow. Bt the conclusion of the study, al l radiographs were evaluated by a radiologist blinded to the diagnosis. Pat ients receiving radiographs were contacted 2 weeks after discharge for veri fication of the diagnosis. Results: Eighty-four percent of 224 physicians returned completed surveys, Fifty-six percent reported using radiographs for failed reduction attempts. Zn the second phase of the study, 136 patients were enrolled prospectively : 127 were reduced successfully and 9 patients failed attempts at reduction . Of the nine patients receiving radiographs: four had fractures (prevalenc e of 2.9% with 95% confidence interval (CI) = 0.8-7.4), two had no radiogra phic findings and normal function on follow up, and three had isolated post erior fat pads on radiograph and normal function an follow-up. The relative risk of a fracture in children with a nonclassic history defined as any me chanism other than "pull" was 1.200 (95% CI = 0.441-3.264); the relative ri sk was 1.886 (95% CI = 0.680-5.231) when defining a nonclassic history as a ny mechanism other than "pull" or "fall." Conclusions: 1) Physicians tend to order radiographs for elbow injuries the r initially perceive to be radial head subluxations when attempts at reduct ion fail. 2) In our study, fractures in children who presented with the cla ssic flexed elbow/pronated wrist position were Fare. 3) The relative risk o f a fracture in children with a nonclassic history for mechanism of injury was not significant, 4) tin isolated finding of a posterior fat pad in a ch ild with RHS that is difficult to reduce was not associated with a fracture in our small sample of children with radiographic findings.