- Email: [email protected]
Response from Dr. Snyder
Letters to the Editor
155
c) reduction cannot be readily achieved with appropriate ‘‘handshake’’ or supination-flexation maneuvers. I prefer the “handshake” to the classic supinationflexion maneuver. It is quickly and easily accomplished, manipulation is therefore less planned or obvious, and parental anxiety regarding movement of the painful arm is reduced. It also gives the child little time to become tearful, anxious, and uncooperative as occurs with the slower and more deliberate set-up of the supinationflexion maneuver. The few failures I have had with the “handshake” are those in which supination-flexion maneuvers have also failed. All cases involved children in whom the elbow had been subluxed for 2 hours or more. In this instance, I attribute difficulty in reduction to increased soft tissue edema secondary to prolonged RHS. More forceful and exaggerated forearm pronation or supination and increased elbow flexion are required for successful reduction in this instance. Analgesia and
orthopedic consultation is warranted if the emergency physician is hesitant to apply more forceful manipulation despite the availability of classic history and presentation. RHS is a very common pediatric injury, readily discernible on the basis of history in the majority of cases. Radiographs should rarely be required. The “handshake” (pronation-flexion) method of reduction is quick, easy, and almost painless - parents often marvel at the rapid return of function, frequently having missed your “cure”!
0
cess. This data would seem to imply that the anatomy of radial head subluxation is such that any number of manipulations of the elbow will produce a closed reduction. Radial head subluxation continues to be a common but interesting emergency condition and we thank Dr. Lyver for sharing her experiences with us.
To the Editor
We would like to thank Dr. Lyver for her letter and interest in our study. Although Dr. Lyver has significant personal experience with children with radial head subluxation (RHS), we disagree with her premise that the “classic history of RHS is readily obtainable in almost all cases.” From our review we found just the opposite. Radial head subluxation does present without the classic history and was found to occur in 33% of our patients (1). This premise is also supported by a recent study by Schunk in which 49% of the children with RHS did not have any history of a pulled arm (2). We do agree with Dr. Lyver’s statements concerning the futility of extremity radiographs in these patients. As we noted, x-rays are rarely indicated in children with the characteristic presentation of minimal distress, no elbow swelling or deformity, and the arm held in the nuresmaid’s position (semiflexion and supination). Dr. Lyver describes an interesting reduction technique “the handshake” pronation-flexion maneuver, which appears to work well for her. All reductions in our study were done successfully with a supinationflexion technique, while in Schunk’s review the supination-flexion technique had an 80% success rate while a supination-extension technique had a 68% rate of suc-
? ?Response from Dr. Snyder I appreciate Dr. Lyver’s comments on the issue of radial head subluxation (RHS). I was also surprised by the large
Marion B. Lyver, MD, FRCP(C) Active Staff Department of Emergency Medicine Joseph Brant Memorial Hospital Burlington, Ontario
Alfred Sacchetti, MD,FACEP Our Lady of Lourdes Medical Center Camden, New Jersey Edward Ramoska, MD, FACEP Methodist Hospital Philadelphia, Pennsylvania Cheni Glascow, RN, CEN Methodist Hospital Philadelphia, Pennsylvania REFERENCES 1. Sacchetti A, Ramoska
AE, Glascow C. Nonclassic history in children with radial head subluxations. J Emerg Med. 1990;8: 151-3. 2. Schunk, JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990;19:1019-23.
number of children receiving radiographs (23/45 or 51%) in the article by Sacchetti (1). In my study (2), the vast majority of patients with RHS did not receive radiographs, and no child received postreduction radio-
156
The Journal of Emergency
Medicine
graphs. It took nearly two years to identify 20 RHS patients with radiographs. I agree that patients with a classic history and physical examination do not require radiographs, My interest was in the interpretation of radiographs when they were obtained, because no study has ever shown that radiographs are indeed normal, as is often stated in many textbooks. In reviewing the literature, I found an occasional reference to the pronation method of reduction, but never any description of the actual maneuver. It appears the pronation-flexion maneuver has been quite successful in your hands. My experience has been that the supination maneuvers are also effective in nearly every case. Quan (3) described a 90% reduction rate with supination maneuvers only. It is interesting that you have experienced failures when the elbow has been subluxed for 2 hours or more. In fact, Quart (3) noted exactly the reverse. They had a 100% reduction rate for RI-IS of 2 hours or longer duration, and an 85% success rate for RI-IS of less than 2 hours duration. It is unclear to me whether there is a “window of opportunity” beyond which swelling results in a more difficult reduction. Many children who are not successfully reduced in the emergency department or pediatrician’s office will spontaneously reduce and regain function of their arm before they return for re-evaluation at 24 to 48 hours. Your letter states that a classic history of RI-IS is readily available in almost all cases. The literature seems to show variation in the reporting of this classic history. Quan (3) noted a classic history in 93% (63/67)
of cases. In my study (2), 65% (13/20) had a classic history of a pulling mechanism. Of the remaining 35% (7/20) 5 mechanisms were unknown, 1 was felt to be a direct blow, and 1 child had been doing somersaults. While doing somersaults, this child may have suffered a “self induced” RHS, which you refer to in your letter. An atypical history was present in 33% of patients in Sacchetti’s (1) study and 50% of patients in a recent study by Schunk (4). Without this typical history, it still seems reasonable to attempt reduction without radiographs if no atypical features are present on physical examination (i.e., swelling, deformity, erythema, point tenderness).
0
testicular torsion. When the time came to send for the patient from the ward, the nurse responsible asked me “is this a male or a female?“! 3) On preparing to clean and drape a patient for circumcision, the scrub sister asked me “which side?“! 4) Following a distal pancreatectomy in which the spleen was included, the operative notes recorded “Distal pancreatectomy and left splenectomy” ! From these you may wonder as to the quality of medical and nursing care in South Africa, but I can assure you that most of these were committed towards the end of a long tiring day and are probably repeated around the world.
Medical Howlers
1) On a recent ward round, the junior staff showed me a patient who had previously sustained blunt abdominal trauma. He had a number of admissions, mainly for abdominal discomfort and swelling, and was now readmitted. Clinically, he was in no distress but had ascitic fluid present. Thinking that the patient may have a pancreatic “fracture” or disruption, I asked the resident to perform an aspiration of the ascitic fluid and to ask for an amylase estimation. Later, while in the tea-lounge of OR, I asked him what had happened with the patient and what the results showed. Completely nonplussed, he replied that the patient had to attend to some business and was due to return at a later date. As to the aspirate, he had not seen the results but was sure that when he had done the aspiration that amylase was obviously present! 2) Recently I booked a 12-year-old for repair of
Howard Snyder, MD Associate Residency Director Department of Emergency Medicine Albany Medical Center Hospital Albany, New York
REFERENCES Sacchetti A, Ramoska EE, Glascow C. Nonclassic history in children with radial head subluxations. J Emerg Med. 1990;8: 151-4. Snyder HS. Radiographic changes with radial head subluxation in children. J Emerg Med. 1990;8:265-9. Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J JIis Child. 1985;139:1194-7. Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990;19:101%23.
Charles Perrott, FCS(SA) Block 1 Suite D Medicity, Payn Street PIBTBRMARIlZBURG South Africa
155
c) reduction cannot be readily achieved with appropriate ‘‘handshake’’ or supination-flexation maneuvers. I prefer the “handshake” to the classic supinationflexion maneuver. It is quickly and easily accomplished, manipulation is therefore less planned or obvious, and parental anxiety regarding movement of the painful arm is reduced. It also gives the child little time to become tearful, anxious, and uncooperative as occurs with the slower and more deliberate set-up of the supinationflexion maneuver. The few failures I have had with the “handshake” are those in which supination-flexion maneuvers have also failed. All cases involved children in whom the elbow had been subluxed for 2 hours or more. In this instance, I attribute difficulty in reduction to increased soft tissue edema secondary to prolonged RHS. More forceful and exaggerated forearm pronation or supination and increased elbow flexion are required for successful reduction in this instance. Analgesia and
orthopedic consultation is warranted if the emergency physician is hesitant to apply more forceful manipulation despite the availability of classic history and presentation. RHS is a very common pediatric injury, readily discernible on the basis of history in the majority of cases. Radiographs should rarely be required. The “handshake” (pronation-flexion) method of reduction is quick, easy, and almost painless - parents often marvel at the rapid return of function, frequently having missed your “cure”!
0
cess. This data would seem to imply that the anatomy of radial head subluxation is such that any number of manipulations of the elbow will produce a closed reduction. Radial head subluxation continues to be a common but interesting emergency condition and we thank Dr. Lyver for sharing her experiences with us.
To the Editor
We would like to thank Dr. Lyver for her letter and interest in our study. Although Dr. Lyver has significant personal experience with children with radial head subluxation (RHS), we disagree with her premise that the “classic history of RHS is readily obtainable in almost all cases.” From our review we found just the opposite. Radial head subluxation does present without the classic history and was found to occur in 33% of our patients (1). This premise is also supported by a recent study by Schunk in which 49% of the children with RHS did not have any history of a pulled arm (2). We do agree with Dr. Lyver’s statements concerning the futility of extremity radiographs in these patients. As we noted, x-rays are rarely indicated in children with the characteristic presentation of minimal distress, no elbow swelling or deformity, and the arm held in the nuresmaid’s position (semiflexion and supination). Dr. Lyver describes an interesting reduction technique “the handshake” pronation-flexion maneuver, which appears to work well for her. All reductions in our study were done successfully with a supinationflexion technique, while in Schunk’s review the supination-flexion technique had an 80% success rate while a supination-extension technique had a 68% rate of suc-
? ?Response from Dr. Snyder I appreciate Dr. Lyver’s comments on the issue of radial head subluxation (RHS). I was also surprised by the large
Marion B. Lyver, MD, FRCP(C) Active Staff Department of Emergency Medicine Joseph Brant Memorial Hospital Burlington, Ontario
Alfred Sacchetti, MD,FACEP Our Lady of Lourdes Medical Center Camden, New Jersey Edward Ramoska, MD, FACEP Methodist Hospital Philadelphia, Pennsylvania Cheni Glascow, RN, CEN Methodist Hospital Philadelphia, Pennsylvania REFERENCES 1. Sacchetti A, Ramoska
AE, Glascow C. Nonclassic history in children with radial head subluxations. J Emerg Med. 1990;8: 151-3. 2. Schunk, JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990;19:1019-23.
number of children receiving radiographs (23/45 or 51%) in the article by Sacchetti (1). In my study (2), the vast majority of patients with RHS did not receive radiographs, and no child received postreduction radio-
156
The Journal of Emergency
Medicine
graphs. It took nearly two years to identify 20 RHS patients with radiographs. I agree that patients with a classic history and physical examination do not require radiographs, My interest was in the interpretation of radiographs when they were obtained, because no study has ever shown that radiographs are indeed normal, as is often stated in many textbooks. In reviewing the literature, I found an occasional reference to the pronation method of reduction, but never any description of the actual maneuver. It appears the pronation-flexion maneuver has been quite successful in your hands. My experience has been that the supination maneuvers are also effective in nearly every case. Quan (3) described a 90% reduction rate with supination maneuvers only. It is interesting that you have experienced failures when the elbow has been subluxed for 2 hours or more. In fact, Quart (3) noted exactly the reverse. They had a 100% reduction rate for RI-IS of 2 hours or longer duration, and an 85% success rate for RI-IS of less than 2 hours duration. It is unclear to me whether there is a “window of opportunity” beyond which swelling results in a more difficult reduction. Many children who are not successfully reduced in the emergency department or pediatrician’s office will spontaneously reduce and regain function of their arm before they return for re-evaluation at 24 to 48 hours. Your letter states that a classic history of RI-IS is readily available in almost all cases. The literature seems to show variation in the reporting of this classic history. Quan (3) noted a classic history in 93% (63/67)
of cases. In my study (2), 65% (13/20) had a classic history of a pulling mechanism. Of the remaining 35% (7/20) 5 mechanisms were unknown, 1 was felt to be a direct blow, and 1 child had been doing somersaults. While doing somersaults, this child may have suffered a “self induced” RHS, which you refer to in your letter. An atypical history was present in 33% of patients in Sacchetti’s (1) study and 50% of patients in a recent study by Schunk (4). Without this typical history, it still seems reasonable to attempt reduction without radiographs if no atypical features are present on physical examination (i.e., swelling, deformity, erythema, point tenderness).
0
testicular torsion. When the time came to send for the patient from the ward, the nurse responsible asked me “is this a male or a female?“! 3) On preparing to clean and drape a patient for circumcision, the scrub sister asked me “which side?“! 4) Following a distal pancreatectomy in which the spleen was included, the operative notes recorded “Distal pancreatectomy and left splenectomy” ! From these you may wonder as to the quality of medical and nursing care in South Africa, but I can assure you that most of these were committed towards the end of a long tiring day and are probably repeated around the world.
Medical Howlers
1) On a recent ward round, the junior staff showed me a patient who had previously sustained blunt abdominal trauma. He had a number of admissions, mainly for abdominal discomfort and swelling, and was now readmitted. Clinically, he was in no distress but had ascitic fluid present. Thinking that the patient may have a pancreatic “fracture” or disruption, I asked the resident to perform an aspiration of the ascitic fluid and to ask for an amylase estimation. Later, while in the tea-lounge of OR, I asked him what had happened with the patient and what the results showed. Completely nonplussed, he replied that the patient had to attend to some business and was due to return at a later date. As to the aspirate, he had not seen the results but was sure that when he had done the aspiration that amylase was obviously present! 2) Recently I booked a 12-year-old for repair of
Howard Snyder, MD Associate Residency Director Department of Emergency Medicine Albany Medical Center Hospital Albany, New York
REFERENCES Sacchetti A, Ramoska EE, Glascow C. Nonclassic history in children with radial head subluxations. J Emerg Med. 1990;8: 151-4. Snyder HS. Radiographic changes with radial head subluxation in children. J Emerg Med. 1990;8:265-9. Quan L, Marcuse EK. The epidemiology and treatment of radial head subluxation. Am J JIis Child. 1985;139:1194-7. Schunk JE. Radial head subluxation: epidemiology and treatment of 87 episodes. Ann Emerg Med. 1990;19:101%23.
Charles Perrott, FCS(SA) Block 1 Suite D Medicity, Payn Street PIBTBRMARIlZBURG South Africa