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.