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c. Obtain post reduction x-rays when possible.
- Patient education:
a. General: Avoid the motion that contributed to the injury.
b. Medications: Control pain and inflammation with NSAIDs on regular basis (ibuprofen 800 mg tid x 7
days or diclofenac sodium 150 mg am and hs x 7 days) - Follow-up actions:
a. Consultation criteria: Failure of all the above maneuvers suggests the requirement for reduction
under anesthesia or surgical stabilization. Acute indications for surgery include open or irreducible
dislocations, those associated with vascular injuries, and fractures, or entrapment of bony/ligamentous
fragments in the joint space.
Radial head subluxation (RHS):
- Assessment: Usually there is no history of significant trauma. Be mindful to pick up clues of non
accidental trauma in all injured children! Parents may admit that the toddler has received a sudden tug or
pull on the arm, usually by an adult. The injury appeared to cause instant pain, and the child holds the
arm motionless. Although comfortable at rest, the arm is splinted limply at the side with mild flexion in
the elbow and pronation of the forearm. Examination reveals no deformity, discoloration, crepitation, or
swelling present. There is little palpable tenderness present. However, the child is likely to begin crying
and splinting the arm with any forced movement, especially supination. Further exam of the arm should
be entirely normal. - Differential Diagnosis: Elbow fractures; combined fracture/dislocation; muscular contusion.
- Diagnostic tests: X-ray the elbow
- Procedure:
a. Advise the parents that you believe the child’s elbow is slightly “out of joint” and that this is a common
and not serious problem but may hurt the child for a few moments until it snaps back into place.
b. To elicit parental assistance, ask the mother or father to hold the child comfortably in their lap.
c. Place your thumb directly over the head of the radius on the “tender spot” and press down gently while
you smoothly supinate the forearm and extend the elbow. Then, fully flex the elbow as you continue to
press against the radial head in the supinated forearm.
d. You will recognize a “click” or “”thunk” under the pressing thumb which will indicate that the radial head
has slipped back into normal position. The child is also likely to begin using the limb normally.
e. Advise the parents that you think the problem is resolved
f. Return when the child is calm and reevaluate the elbow. - Post Treatment: Avoid repeating the mechanism that caused it. There is no reason to immobilize
of the arm. - Patient education:
a. General: Advise the parents that the dislocation is a common problem and admonish them to handle
the child gently. If problem is recurrent, consider the potential of abuse.
b. Medications: Acetaminophen, dose according to age, if child is “fussy”
c. Prevention: Do not lift child by outstretched arms
d. Recurrence or no improvement: return ASAP for recurrence - Follow-up actions:
Consultation criteria: Consider potential of abuse if multiple recurrences. Examine for other evidence
to support suspicion.
Hip Dislocations (Anterior and Posterior):
- Assessment: Posterior dislocations of the hip result from direct blows to the front of the knee or upper
tibia, typically in an unrestrained passenger in a motor vehicle. If the leg is adducted at the time of impact,
the pure dislocation is more common. If the leg is abducted, then posterior wall acetabular fractures
are more likely. Typical appearance of patient with a posterior hip dislocation is with the hip flexed,
adducted, internally rotated, and resistant to movement in marked pain. If a fracture is present, this
posture is less likely. Anterior dislocations result from forced abduction and external rotation. They
are quire rare (only 5% of all hip fractures) and tend to present showing the abduction and external
rotation.